TITLE 25.HEALTH SERVICES

Part 1. TEXAS DEPARTMENT OF HEALTH

Chapter 37. MATERNAL AND INFANT HEALTH SERVICES

Subchapter H. SUDDEN INFANT DEATH SYNDROME

25 TAC §§37.171 - 37.173

The Texas Department of Health (department) adopts new §§37.171 - 37.173 concerning sudden infant death syndrome (SIDS) and reimbursement to counties for autopsies performed upon children younger than 12 months of age for whom SIDS is the primary cause of death. Sections 37.171 and 37.172 are adopted with changes to the proposed text as published in the December 3, 1999, issue of the Texas Register (24 TexReg 10714). Section 37.173 is adopted without change, and therefore will not be republished.

Family Code, Chapter 264, requires that the medical examiner or justice of the peace of a county in which a child younger than six years of age dies must hold an inquest to determine whether the death was unexpected or the result of abuse or neglect. The investigation must include an autopsy. Health and Safety Code, §673.002, as amended by the 76th Legislature, requires the department to define SIDS and to reimburse counties $500 for the cost of autopsies performed upon children younger than 12 months of age, if the primary cause of death is SIDS. Reimbursement by the department is subject to the availability of funds.

The following comments were received concerning the proposed sections. Following each comment is the department's response and any resulting change(s).

Comment: Concerning the subchapter as a whole, one commentor stated that the use of undefined elements of medical history and death scene investigation provides a financial disincentive to find a cause of death other than SIDS, such as a vaccine reaction, because no payment is available for any diagnosis other than SIDS.

Response: The department disagrees that the law or proposed rules provide an incentive to determine that SIDS is the cause of death. The department makes a $500 payment directly to the county which is responsible for conducting the autopsy, not to the physician who performs the autopsy and makes a diagnosis based on the criteria stated in the definition. The physician who conducts the autopsy remains professionally and legally responsible for the diagnosis whether or not the county is reimbursed by the department. No change was made as a result of this comment.

Comment: Concerning the subchapter as a whole, one commentor stated that SIDS is not really a diagnosis, but is often used when insufficient effort or and testing results in failure to isolate a cause of death.

Response: SIDS is a recognized diagnosis of exclusion. Although research continues, the cause of death for some infants simply cannot be established. The county may be reimbursed for the cost of an autopsy only if the primary cause of death is SIDS, and all other known causes of death have been ruled out through the medical history, death scene investigation, and a complete autopsy. The physician must determine whether a particular event or condition was the primary cause of death or was merely coincidental with the death, utilizing all three sources of information. No change made as a result of this comment.

Comment: Concerning the subchapter as a whole, one commentor stated "those who make the reports have no clear directives or incentive to implicate a vaccine as a contributing factor."

Response: The department does not believe the legislature intended to provide an incentive for declaring SIDS, vaccines, or any other factor to be the primary cause of an infant's death. A physician's determination that SIDS is the primary cause of death of a child younger than 12 months of age should be based on the recognized criteria, and all relevant information should be considered when making any diagnosis. No change was made as a result of this comment.

Comment: Concerning §37.171, one commentor stated that the phrase "children 12 months old or younger" in the proposed rules would include children who are 12 months and 29 days old. Since children over one year of age would not be considered infants, the commentor recommends that the age criterion be changed to "children younger than 12 months of age".

Response: The department agrees and has amended the section accordingly.

Comment: Concerning §37.172, one commentor stated that the lack of definitions for the terms "death scene investigation" and "medical history" could financially reward those who fail to determine the actual cause of a child's death due to lack of effort.

Response: The department has no authority to review the professional competence of physicians or the activities of law enforcement officials when they seek to determine the cause of death of children under 12 months of age. Health and Safety Code §673.002 establishes only a reimbursement mechanism for autopsies, if the primary cause of death is found to be SIDS. Although the physician responsible for the diagnosis should be familiar with the information concerning death scene investigation contained in "Morbidity and Mortality Weekly Report" (Volume 45, No. RR-10, June 21, 1996) published by the Centers for Disease Control and Prevention, the law does not require the department to adopt rules which mandate the elements of a death scene investigation. The department will continue to work with all county judges and with medical examiners and other pathologists to provide educational material concerning information which should be obtained from a medical history and during a death scene investigation. No change was made as a result of this comment.

Comment: Concerning §37.172(1), one commentor stated that the procedures used by different physicians for a "complete autopsy" may vary. The commentor suggested that "autopsy" should be defined as "a post mortem examination of the body a of a person, including X-ray and an examination of the internal organs and structures after dissection, including gross and histologic examination and other laboratory studies as indicated, to determine the cause of death or the nature of any pathological changes that may have contributed to the death."

Response: The proposed definition of "autopsy" is the same as that in the Code of Criminal Procedure, Article 49.01(1), and certainly would not preclude any physician from obtaining some or all the additional evidence specified by the commentor as the basis for a determination of the cause of death of a child younger than 12 months of age. No change was made as a result of this comment.

Comment: Concerning §37.172(4), one commentor stated that the child's social history, including but not limited to the Child Protective Services family history, is vitally important to the final determination of the cause of death. The commentor suggested that SIDS be defined as "death of an infant which remains unexplained after all known caused have been ruled out through a complete autopsy, death scene investigation and medical and social history including but not limited to Child Protective Services family history of the infant."

Response: The department acknowledges the importance of a complete and accurate history in determining the cause of an infant's death. The department agrees with the commentor's suggestion and has amended the section accordingly.

The comments on the proposed rules received by the department were submitted by the Texas Child Fatality Review Team State Committee and by Parents Requesting Open Vaccine Education. The comments were neither for nor against the rules in their entirety; however, they raised questions, offered comments for clarification purposes, and suggested clarifying language concerning specific provisions in the rules.

The new sections are adopted under the Health and Safety Code, §673.002, which requires the department to adopt rules defining SIDS and establishing a method for obtaining reimbursement for the cost of autopsies for children younger than 12 months of age whose primary cause of death is SIDS; and §12.001, which provides the Texas Board of Health with the authority to adopt rules for the performance of every duty imposed by law on the board, the department, and the commissioner of health.

§37.171.Purpose.

The purpose of these sections is to define sudden infant death syndrome (SIDS) and to establish a payment mechanism for autopsies for children younger than 12 months of age who die unexpectedly and whose primary cause of death is SIDS.

§37.172.Definitions.

The following words and terms pertain explicitly to this subchapter and shall have the following meanings, unless the context clearly indicates otherwise.

(1)

Autopsy - A post mortem examination of the body of a person, including X-rays and an examination of the internal organs and structures after dissection, to determine the cause of death or the nature of any pathological changes that may have contributed to the death.

(2)

Infant - A child who is younger than 12 months of age.

(3)

Parent - A natural parent, step parent, adoptive parent, legal guardian, or other legal custodian of a child.

(4)

Sudden infant death syndrome (SIDS) - Death of an infant which remains unexplained after all known causes have been ruled out through a complete autopsy, death scene investigation, and medical and social history including, but not limited to, Child Protective Services family history of the infant.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002397

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 23, 2000

Proposal publication date: December 3, 1999

For further information, please call: 458-7236


Chapter 229. FOOD AND DRUG

The Texas Department of Health (department) adopts the repeal of §§229.401 - 229.412 and new §§229.401 - 229.412 concerning the licensing of tattoo and certain body piercing studios. New §§229.403, 229.407 and 229.408 are adopted with changes to the proposed text as published in the December 3, 1999, issue of the Texas Register (24 TexReg 10736). The repeal of §§229.401 - 229.412 and new §§229.401 - 229.402, 229.404 - 229.406, and 229.409 - 229.412 are adopted without changes and therefore those sections will not be republished.

Specifically, the new sections cover general provisions; definitions; licensing fees, procedures, and exemptions; physical facilities; personnel responsibilities; client qualifications, disclosure, and records; sterilization; care of the new tattoo and body piercing; tattooing and body piercing instruments and jewelry; report of infection or allergic reactions; disposal of infectious waste; and refusal, revocation, or suspension of license and enforcement provisions.

The new sections contain new language and incorporate language that were previously located in §§229.401 - 229.412, which have been repealed. Sections 229.401 - 229.412 have been repealed for the purpose of reorganization and implementing Senate Bills (SB) 61 and 932 which were enacted during the 76th Texas Legislature, Regular Session, 1999. The new sections clarify existing requirements for tattoo studios and includes new language for certain body piercing studios. The new sections establish new licensure fees for certain body piercing studios and clarify existing licensure requirements for tattoo studios. The new sections provide for standards of sterilization, sanitation, record keeping, and aseptic technique. In addition, the new sections address requirements for those persons under the age of 18 wishing to receive a tattoo or body piercing. Finally, the new sections clarify the department's inspection authority and enforcement options available under Health and Safety Code, Chapter 146, (Tattoo and Certain Body Piercing Studios), and Chapter 431, (Texas Food, Drug, and Cosmetic Act).

The following comments were received by the department concerning the proposed sections. Following each comment is the department's response and any resulting change(s).

Comment: Concerning §229.408(c)(1), one commenter stated that antibacterial or antimicrobial soaps can both be used to cleanse the area.

Response: The department agrees that this was the intent of the regulation and has added "or antimirobial" to §229.408(c)(1) to clarify that intent.

Comment: Concerning §§229.401 - 229.412, one commenter commended the department on comprehensive rules which will protect the public health.

Response: The department agrees with the commenter. No change was made as a result of this comment.

Comment: Concerning §229.405(c), two commenters stated that body piercing artists should wear sterile surgical gloves rather than single-service examination gloves.

Response: The department disagrees with the two commenters because the use of single- service medical examination gloves is used universally throughout the medical and tattoo industry for these types of procedures or operations. No change was made as a result of this comment.

Comment: Concerning §229.405(i), one commenter stated that the department should require each artist performing body piercing procedures to receive mandatory, certified training in the prevention of the transmission in blood borne pathogens as well as having a four-year degree in a medical field.

Response: The department disagrees with the commenter. The language in this section does require that an artist performing tattoo or body piercing procedures to have the education, training, and experience to practice aseptic technique and to prevent the transmission of blood borne pathogens; however, the law provides no authority for the department to require a four-year degree or certification for this training. No change was made as a result of this comment.

Comment: Concerning §229.402, one commenter stated that the state should require that the jewelry used for piercing be made of surgical implant grade, such as 316L or M series.

Response: The department agrees with the commenter. Jewelry as defined in §229.402(22) states the following: "Any personal ornament inserted into a pierced area, which must be made of surgical implant grade stainless steel (minimum of 316L or 316LVM), solid 14k or 18k gold, niobium, titanium (minimum of 6A14V), or platinum, which is free of nicks, scratches, or irregular surfaces and has been properly sterilized prior to use." No change was made as a result of this comment.

Comment: Concerning §229.403(a), three commenters stated that a license should be required for each body piercer.

Response: The department disagrees with the commenter. The law requires that we license the studio not the individual artist who is employed at the studio. No change was made as a result of this comment.

Comment: Concerning §229.403(f), one commenter stated that ear piercing should fall under these regulations.

Response: The department disagrees with the commenter. The law exempts from licensing, those body piercers who only pierce an individual's earlobe. No change was made as a result of this comment.

Comment: Concerning §§229.401 - 229.412, one commenter requested that the rules for body piercing be separated from the rules for tattooing.

Response: The department disagrees with the commenter. SB 61 amended Health and Safety Code, Chapter 146, to include regulations concerning certain body piercing studios. Sections 229.401 - 229.412 are being repealed for the purpose of reorganization and implementing SB 61 and 932. The law does not allow for body piercing and tattoo regulations to be separate. No change was made as a result of this comment.

Comment: Concerning §229.403(f), one commenter stated that all ear piercing should be exempt from the licensing requirements.

Response: The department disagrees with the commenter. The law only allows for the exemption of licensing for those piercing the earlobe. No change was made as a result of this comment.

The commenters were: Body Rights of Austin, DR Powers Tattoo Studio, Association of Professional Piercers, Kenneth Magness, Ear Piercing Manufacturers of the United States, and one department staff member.

The department is making the following changes due to staff comments to clarify the intent and improve the accuracy of the section; and as a correction to the proposed text as printed in the Texas Register .

Change: Concerning §229.403(a), the department determined that two licensing applications for tattoo and body piercing studios were needed for accounting purposes. Clarifying language has been deleted/added to stipulate fee requirements in §229.403(a). Additionally, language has been added to §229.403(c) to clarify that two separate applications are required to be submitted.

Change: Concerning §229.407(a), one of the "section" symbols was removed to read §229.409(a)-(c).

Subchapter V. MINIMUM STANDARDS FOR LICENSURE OF TATTOO STUDIOS

25 TAC §§229.401 - 229.412

The repeals are adopted under the Health and Safety Code, §146.010(a) and §146.015(a), which provides the department with the authority to adopt necessary regulations pursuant to the enforcement of this Chapter; and §12.001, which provides the Texas Board of Health (board) with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health; Health and Safety Code, Chapter 146, Tattoo and Certain Body Piercing Act, and the Health and Safety Code, Chapter 12.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002398

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 23, 2000

Proposal publication date: December 3, 1999

For further information, please call: 458-7236


Subchapter V. MINIMUM STANDARDS FOR LICENSURE OF TATTOO AND CERTAIN BODY PIERCING STUDIOS

25 TAC §§229.401 - 229.412

The new sections are adopted under the Health and Safety Code, §146.010(a) and §146.015(a), which provides the department with the authority to adopt necessary regulations pursuant to the enforcement of this Chapter; and §12.001, which provides the Texas Board of Health (board) with the authority to adopt rules for the performance of every duty imposed by law on the board, the department and the commissioner of health; Health and Safety Code, Chapter 146, Tattoo and Certain Body Piercing Act, and the Health and Safety Code, Chapter 12.

§229.403.Licensing Fees. Procedures, and Exemptions.

(a)

License fees. All tattoo and body piercing studios shall obtain a license annually except as indicated below from the Texas Department of Health (department) and shall pay an annual, non-refundable license fee for each place of business operated as follows:

(1)

$450 per tattoo only studio or temporary location license for a specified length of time not to exceed seven days;

(2)

$600 for a tattoo and body piercing studio or temporary location license for a specified length of time not to exceed seven days - the fee to be paid as follows: $450 for the tattoo portion; and $150 for the body piercing portion; and

(3)

$200 per body piercing only studio or temporary location license for a specified length of time not to exceed seven days.

(b)

License forms. License forms may be obtained from the Drugs and Medical Devices Division, Texas Department of Health, 1100 West 49th Street, Austin, Texas, 78756-3182.

(c)

License application. An application shall be submitted for each tattoo studio and a separate application shall be submitted for each body piercing studio. The initial license application for each studio or temporary location shall be signed and verified, shall be made on the license application furnished by the department, and shall contain the following information:

(1)

the full or legal name under which the studio or temporary location is conducted;

(2)

the address of the studio or temporary location that is to be licensed. Sufficient descriptive information must be included if the studio or temporary location is located in a portion of the building with other license holders;

(3)

if a proprietorship, the name and residence address of the proprietor; if a partnership, the names and residence addresses of all partners; if a corporation, the date and place of incorporation and name and address of its registered agent in the state; or if any other type of association, then the names of the principals of such association;

(4)

for each studio or temporary location, the name(s) and residence address(es) of the responsible individual(s) thereof;

(5)

the name(s) of the studio's or temporary location's artist(s);

(6)

the usual days and hours of operation of each studio or temporary location; and

(7)

a description of all services to be provided at the studio or temporary location.

(d)

Issuance of license. The department may issue a license to the owner of a studio or temporary location after determining that the studio or temporary location is in compliance with applicable statutes, rules, and zoning codes.

(1)

The initial studio license shall be valid for one year from the date of issuance which becomes the anniversary date. The temporary location license is valid for a specified period not to exceed seven days.

(2)

The renewal studio license shall be valid for one year from the anniversary date.

(3)

The license shall be displayed in a prominent place in the studio or temporary location.

(e)

Renewal of license - applicable to studios only.

(1)

Each year, the license holder shall renew its license in accordance with the requirements of this section.

(2)

The license holder shall renew the license by filing an application for renewal on the form prescribed by the department accompanied by the required licensure fee. A licensee must file for renewal before the expiration date of the current license. A person who files a renewal application after the expiration date must pay an additional $100 as a delinquency fee.

(3)

Failure to submit the renewal application annually shall subject the studio to the enforcement provisions of the Tattoo and Certain Body Piercing Studio Act and also to the provision of §229.412 of this title (relating to Refusal, Revocation or Suspension of License and Enforcement Provisions).

(A)

Amendment of license. A license must be amended when the name, ownership, or location of the licensed studio is changed. Such changes require submission of the fees as outlined in subsection (a) of this section.

(B)

Notification of change of location of studio.

(i)

Not fewer than 30 days in advance of the change, the licensee shall notify the commissioner or the commissioner's designee in writing of the licensee's intent to change the location of a licensed studio. The notice shall include the address of the new location, and the name and residence address of the individual in charge of the studio at the new location.

(ii)

Notice will be deemed adequate if the licensee provides the intent and verification notices to the commissioner or the commissioner's designee within the established time frames of clause (i) of this subparagraph by certified mail, return receipt requested, mailed to the Drugs and Medical Devices Division, Texas Department of Health, 1100 West 49th Street, Austin, Texas, 78756.

(iii)

Not later than the tenth day after the change of location is complete, the license holder shall notify the department in writing and shall verify the information submitted under clause (i) of this subparagraph.

(f)

Exemption from licensure. Persons who engage only in the following are exempt from the licensing requirements of this section:

(1)

a studio or temporary location located within a medical facility which is licensed under other law, or an office or clinic of a person licensed by the Texas State Board of Medical Examiners;

(2)

a person who performs only ear piercing; or

(3)

a facility in which only ear piercing is performed.

§229.407.Sterilization.

(a)

A studio or temporary location is required to utilize instruments that have been prepared as described in §229.409(a)-(c) of this title (relating to Tattooing and Body Piercing Instruments and Jewelry). The studio or temporary location shall use sterilization equipment that is approved by the United States Food and Drug Administration for the purpose of sterilization, and adequate in size to accommodate necessary utensils and instruments. A copy of the manufacturer's recommended procedures for operation of the sterilization unit(s) must be available for inspection by an authorized agent.

(b)

Each person responsible for the sterilization of instruments shall be able to demonstrate to the department's authorized agent the correct sterilization procedures and the proper operation of autoclave and/or dry heat sterilization equipment.

(c)

After each use, the reusable instruments shall be cleansed to remove blood and tissue residue before sterilization as described in §229.409(n) of this title.

(d)

Instruments requiring sterilization shall be packed in packages approved for the sterilization unit. Instruments shall be packed individually, or as a set provided such set is intended to be used for a single procedure. Each package shall be labeled with the date of sterilization and the initials of the person sterilizing the instruments. Packaged sterilized instruments shall be kept in a sterile condition and stored in a clean dust-tight container when not in use.

(e)

Each package of instruments sterilized shall be monitored for sterilization by the use of chemical/heat sensitive indicators.

(f)

Each studio or temporary location shall maintain sterilization records. The information shall be permanently recorded and made available for examination by an authorized agent in the studio for at least two years from the date of the last entry. These permanent records shall be maintained at the studio and shall include the following:

(1)

date of sterilization;

(2)

quantity and type of instruments to be sterilized; and

(3)

name or initials of the individual sterilizing the instruments.

(g)

Sterilized instruments stored in an approved manner and not used within 30 days after sterilization shall no longer be considered sterile and shall be resterilized before use, unless the studio or temporary location utilizes presterilized instruments sterilized by the manufacturer. If presterilized instruments are used, the artist shall obtain documentation from the manufacturer that describes the method of sterilization utilized by the manufacturer and the manufacturer's recommendations for storage and maintenance of sterility. This documentation shall be available for inspection by an authorized agent. The artist shall follow the manufacturer's instructions for storage and maintenance of sterility.

(h)

One of the following methods of sterilization shall be used.

(1)

Autoclave - steam under pressure:

(A)

121 degrees Celsius (250 degrees Fahrenheit) and a pressure of at least 15 pounds per square inch for not less than 30 minutes after the chamber of the autoclave has reached the required temperature and pressure; or

(B)

as specified in the manufacturer's operator's manual.

(2)

Dry heat sterilization:

(A)

160 degrees Celsius (320 degrees Fahrenheit) for not less than one hour under atmospheric pressure after the sterilizer has reached the required temperature; or

(B)

as specified in the manufacturer's operator's manual.

§229.408.Care of the New Tattoo and/or Body Piercing.

(a)

Each time tattooing or body piercing is performed the client (and if applicable, the parent, managing conservator, or guardian) shall receive oral and written instructions on the care of the area tattooed or pierced. The client shall sign a written statement in the permanent client record acknowledging that the client has received a copy of the written care instructions, and that the client has read and understands the instructions.

(b)

The written care instructions for tattooing shall contain at least the following items:

(1)

for at least two weeks, the need to minimize exposure to the sun, and to discourage swimming in fresh, salt, or chlorinated water;

(2)

the need to properly cleanse the tattooed area;

(3)

the need to apply antibiotic ointment or cream;

(4)

the need to use sterile bandage(s) or other sterile dressing(s) when necessary;

(5)

the name of the artist, and the name, address, and telephone number of the studio or temporary location; and

(6)

the instructions for the client to consult a health care practitioner at the first sign of infection or an allergic reaction, and to report any diagnosed infection, allergic reaction, or adverse reaction resulting from the application of the tattoo to the artist and to the Texas Department of Health, Drugs and Medical Devices Division, at 1-888-839-6676.

(c)

The written care instructions for body piercing shall contain at least the following items:

(1)

the need to properly cleanse the pierced area by using antibacterial or antimicrobial soap for the external skin and or an antiseptic or carbamide peroxide mouthwash for the oral cavity;

(2)

for at least the first two to six weeks, the need to minimize exposure to the sun, and to discourage swimming in fresh, salt, or chlorinated water;

(3)

the need to use sterile bandage(s) or other sterile dressing(s) when necessary;

(4)

the name of the artist, and the name, address, and telephone number of the studio or temporary location; and

(5)

the instructions for the client to consult a health care practitioner at the first sign of infection or an allergic reaction, and to report any diagnosed infection, allergic reaction, or adverse reaction resulting from the body piercing to the artist and to the Texas Department of Health, Drugs and Medical Devices Division, at 1-888-839-6676.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002399

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 23, 2000

Proposal publication date: December 3, 1999

For further information, please call: (512) 458-7236


Part 2. TEXAS DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION

Chapter 401. SYSTEM ADMINISTRATION

Subchapter D. CONTRACTS MANAGEMENT FOR COMMUNITY-BASED SERVICES

25 TAC §401.351

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts amendments to §401.351 (relating to Methods of Procurement) of Chapter 401, Subchapter D, concerning contracts management for community-based services, with changes to the proposed text as published in the January 28, 2000, issue of the Texas Register (25 TexReg 527).

The amendments allow local authorities of TDMHMR to procure qualified contractors of any community service through open enrollment in order to establish and maintain a provider network.

Language was added to (3)(D)(ii) clarifying that the contractor or its designated staff complete (rather than participate in) orientation conducted or approved by the local authority.

Written public comment on the proposal was received from the Burke Center in Lufkin.

Regarding the requirement to approve for inclusion in its provider network all applicants whose applications are complete and who meet all requirements specified in the request for applications in (3)(C)(ii), the commenter expressed concern that the local authority would not have discretion to turn down an applicant. The commenter stated that "the only means by which a local authority could create some wiggle-room for themselves (sic) would be in how they (sic) write the RFA (request for applications) criteria." The commenter suggested allowing the local authority to determine the criteria for approving applicants. The department responds that the local authority has the ability to determine award criteria by describing the eligibility requirements in the RFA. Since open enrollment is not a competitive procurement method, all applicants who fulfill the eligibility requirements must be awarded a contract. If the local authority wants to choose providers on a competitive basis, then it should use the request for proposal method of procurement.

Regarding (3)(B)(ii), the commenter expressed concern about the absence of language relating to conflicts of interest. The commenter asked if the department intended for such requirement to be included in the criteria for approval in (3)(B)(ii)(VII). The department responds that §401.344(b) and (f) contain the subchapter's provisions relating to conflict of interest and standards of conduct.

Regarding (1), (3), and (3)(A), the commenter stated that the rule did not provide adequate direction in determining which method of procurement to use. Additionally, the commenter stated that the rule seemed to provide two contradictory ways to determine if a local authority should use open enrollment. The commenter related that the term "may" in paragraph (3) implied use of open enrollment was permissive, while language in subparagraph (3)(A) stated that open enrollment "is used" to procure qualified contractors for inclusion in the provider network. The commenter requested that language be added or modified "to guide local authorities as to how to make the procurement method choice and when it is mandatory that a particular method be used" or at least state "that it is solely at the local authority's discretion as to which method to use." The department responds that the local authority has the sole discretion to determine which method provides the best value to the authority. Additionally, the needs of the community identified in the authority's local plan should guide the authority in its determination of procurement method. For example: An authority's local plan indicates a need for improved access to and choice of psychiatrists. The authority may determine that open enrollment provides best value in procuring multiple psychiatrists who are located in all parts of the authority's service area. Or the authority may determine that a request for proposals provides best value because there are several psychiatrist groups in the service area who will compete for the contract which will allow the authority to possibly negotiate a lower rate in exchange for exclusivity. The indicators that could be used to determine best value are so varied it would be impossible to articulate specific criteria to determine use of either procurement method.

This section is adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Board of Mental Health and Mental Retardation (board) with broad rulemaking authority, and §534.052(a), which requires the board to adopt rules it considers necessary and appropriate to ensure the adequate provision of community-based mental health and mental retardation services through a local mental health or mental retardation authority.

§401.351. Methods of Procurement.

The state authority shall procure community-based services to be provided by another organization through either the method described in paragraph (1) or paragraph (2) of this section. All local authorities shall procure community-based services to be provided by another organization through one of the methods described in this section.

(1)

Request for proposal (RFP). A contract may be procured using the request for proposal method in accordance with this subsection.

(A)

Determination of method. A contract must be procured through the RFP method unless a determination is made that the sole source method is permissible under this section or that open enrollment will be used. The RFP method is typically applicable to those situations where funds of greater than $1,000 are available to the contracting entity for the provision of a service without reference to a particular person with a mental disability.

(B)

Solicitation.

(i)

The contracting entity must make a reasonable effort to give notice of the intent to contract for services to each potential provider in the authority's local service area. An RFP must be published in a local newspaper or professional association newsletter, or solicited through announcements by direct mail to all known providers by the contracting entity at least 10 days, but not more than 60 days, prior to the due date of submission of proposals. An RFP must contain, but is not limited to, the following information:

(I)

the community-based service to be purchased;

(II)

the approximate number of persons with a mental disability to be served pursuant to the contract;

(III)

the geographic area to be served pursuant to the contract;

(IV)

applicable funding limitations;

(V)

method of payment;

(VI)

the contract term;

(VII)

any limitations on who may submit a proposal and any limitations in the services;

(VIII)

the procedure for requesting a procurement package; and

(IX)

the date by which proposals must be submitted.

(ii)

A contracting entity must provide a procurement package to each entity that requests one. No requirement that restricts competition by unreasonably eliminating or limiting participation in the procurement process may be included in the procurement package. A procurement package must contain:

(I)

a detailed description of the community-based services to be purchased, including all information included in the RFP;

(II)

a detailed description of information to be included in a proposal;

(III)

instructions for the submission of questions concerning the procurement by potential offerors;

(IV)

instructions for the submission of proposals;

(V)

requirements that a potential offeror must fulfill to participate in the procurement process, including assurances that:

(-a-)

the offeror has made no attempt nor will make any attempt to induce any person or firm to submit or not submit a proposal;

(-b-)

the offeror has arrived at the proposal independently without consultation, communication, or agreement for the purposes of restricting competition;

(-c-)

the offeror and its officers or employees have no relationship now or will have no relationship during the contract period that interferes with fair competition or that is a financial or other conflict of interest, real or apparent; and

(-d-)

no member of the offeror's staff or governing authority has participated in the development of specific criteria for award of the contract, nor will participate in the selection of the proposal to be awarded the contract.

(VI)

the criteria for evaluation of proposals.

(iii)

A proposal must include, but is not limited to, the following information:

(I)

the offeror's name, address, telephone number, and type of legal entity;

(II)

the offeror's credentials for providing the community-based service, including applicable certifications, licenses, and/or evidence of compliance with applicable TDMHMR community standards;

(III)

information concerning the factors set forth in subparagraph (C)(iii) of this paragraph.

(iv)

Changes to a procurement package may be made by the contracting entity prior to the date designated for submission of proposals, provided all offerors that have obtained a procurement package are notified of the change and are provided fair opportunity to respond.

(v)

Except as provided in the Texas Open Records Act, Texas Government Code, Chapter 552, all information submitted in a proposal is confidential until a contract has been awarded.

(vi)

Any amendments to a proposal must be made by the offeror in writing and must be received prior to the submission date for proposals.

(vii)

The contracting entity must document all transactions concerning contracts.

(viii)

The contracting entity may validate any information in a proposal by using outside sources or materials.

(C)

Award.

(i)

For a proposal to be considered for award, the offeror must follow all instructions and meet all requirements specified in the procurement package.

(ii)

Clarification or confirmation of information submitted in a proposal may be obtained if such information is necessary to complete the award process; however, no offeror may be given information which would give that offeror an unfair competitive advantage.

(iii)

The award of a contract is made by determining the lowest and best proposal. The determination shall include consideration of any relevant information included in the RFP, including:

(I)

price;

(II)

the ability of the offeror to perform the contract and to provide the required services;

(III)

whether the offeror can perform the contract or provide the services within the period required, without delay or interference;

(IV)

the offeror's history of compliance with the laws relating to its business operations and the affected services and whether it is currently in compliance;

(V)

whether the offeror's financial resources are sufficient to perform the contract and to provide the services;

(VI)

whether necessary or desirable support and ancillary services are available to the offeror;

(VII)

the character, responsibility, integrity, reputation, and experience of the offeror;

(VIII)

the quality of the facilities and equipment available to or proposed by the offeror;

(IX)

the ability of the offeror to provide continuity of services; and

(X)

the ability of the offeror to meet all applicable written policies, principles, and regulations.

(iv)

Negotiation may be conducted either to complete the procurement process or to complete an evaluation of an acceptable proposal. When only one proposal has a reasonable chance of being awarded, contract staff and the potential contractor/subcontractor will negotiate the contract requirements as necessary to complete the procurement process. When more than one acceptable proposal is received, negotiation is used to further evaluate competitive proposals and to select one or more for award. In this situation, no potential contractor/subcontractor is given information that will give the contractor/subcontractor a competitive advantage over the other potential contractors/subcontractors.

(v)

An RFP may be canceled without award for any reason or for no reason.

(vi)

Each offeror who submits an acceptable proposal but is not awarded a contract is entitled to timely notification in writing that the proposal is no longer being considered.

(vii)

Upon written request, an unsuccessful offeror is entitled to receive information concerning why its proposal was not accepted.

(2)

Sole source. A contract may be procured using the sole source method in accordance with this section.

(A)

Determination of method. The sole source method is typically applicable in those situations where funds are available for the provision of services and certain conditions exist which indicate that the RFP method is not appropriate.

(i)

A contract may be procured using the sole source method, only if:

(I)

it is documented that only one source can or will provide the needed services;

(II)

the contract is with another governmental entity;

(III)

there exists an emergency situation in which a delay may result in harm to person(s) with a mental disability who is to receive the community-based service;

(IV)

the contract is for less than $1,000 for a one-year period; or

(V)

no acceptable proposal was received through a substantially similar RFP within the previous 12 months.

(ii)

A contract procured using the sole source method pursuant to clause (i)(III) of this subparagraph, may be for a term of only six months or for the balance of the fiscal year, whichever is greater.

(iii)

A contract procured using the sole source method pursuant to clause (i)(IV) of this subparagraph may not be divided in order to qualify for the sole source method.

(iv)

The contracting entity must justify and document awarding a sole source contract. Documentation must accurately and concisely substantiate the necessity for a sole source contract on the basis of one or more of the reasons listed in clause (i) of this subparagraph.

(B)

Award. The procedure for awarding contracts using the sole source method is established by the contracting entity.

(3)

Open enrollment. A local authority may use open enrollment to establish and maintain a provider network in accordance with this subsection.

(A)

Determination of method. Open enrollment is used by a local authority to procure qualified contractors for inclusion in the local authority's provider network.

(B)

Solicitation.

(i)

At least once every two years the local authority must publish in a local newspaper or professional association newsletter a request for applications notice to procure qualified contractors for inclusion in the local authority's provider network. In addition, the local authority must continuously and prominently display such request for applications notice at the local authority's administrative office(s). The request for applications notice must include:

(I)

the types of community services, including brief descriptions, for which the local authority intends to contract;

(II)

the geographic area to be served under the contracts;

(III)

the procedure for obtaining the request for applications for inclusion in the local authority's provider network; and

(IV)

the date and time by which applications must be submitted, if any.

(ii)

A local authority must provide the request for applications to each entity that requests one. A request for applications must include:

(I)

a detailed description of each type of community service for which the local authority intends to contract, including all information included in the request for applications notice;

(II)

the amount of payment for each type of community service for which the local authority intends to contract and the method used to determine that amount;

(III)

a detailed description of the information to be included in an application;

(IV)

instructions for the submission of applications;

(V)

eligibility requirements an applicant must fulfill to be included in the local authority's provider network (e.g., credentials for providing the community service(s), such as applicable certifications, licenses; evidence of compliance with relevant TDMHMR rules; evidence of accessibility; evidence of providing quality services; evidence of financial solvency; and evidence of liability insurance);

(VI)

assurances that:

(-a-)

the applicant is not currently held in abeyance or barred from the award of a federal or state contract;

(-b-)

the applicant is not currently delinquent in its payments of any franchise tax owed to the state of Texas; and

(VII)

the criteria for approval.

(iii)

An application must include the following information:

(I)

the applicant's name, address, telephone number, and type of legal entity;

(II)

the type(s) of community service(s) that the applicant intends to provide;

(III)

assurances that the applicant meets the requirements described in subparagraph (B)(ii)(VI) of this paragraph;

(IV)

evidence that the applicant fulfills the eligibility requirements described in subparagraph (B)(ii)(V) of this paragraph; and

(V)

a statement that the applicant agrees to provide the specified community service(s) at the amount of payment described in the request for applications.

(C)

Approval process for inclusion on a local authority's provider network.

(i)

The local authority may obtain clarification or confirmation of information submitted in an application.

(ii)

The local authority must approve for inclusion on its provider network all applicants whose applications are complete and who meet all requirements specified in the request for applications.

(D)

Provider network contracts. All contracts for a specific type of community service provided through a provider network must contain the same contract conditions, provisions, and requirements, including:

(i)

the requirement that the contractor immediately notify the local authority of any change, or potential change, in its status that could affect its inclusion on the network;

(ii)

the requirement that, before services can be delivered to consumers, the contractor or its designated staff complete orientation conducted or approved by the local authority relating to the local authority's policies and procedures;

(iii)

the statement that the contractor is prohibited from:

(I)

offering any gift with a value in excess of $10 to potential consumers; and

(II)

soliciting potential consumers through direct-mail or by telephone.

(iv)

the requirement that the local authority maintain and make available to consumers and potential consumers, current information about each contractor of community services participating in its network that:

(I)

represents all participating contractors fairly;

(II)

is organized and relevant to consumers and potential consumers; and

(III)

includes results from consumer satisfaction surveys; and

(v)

the requirement that the local authority allow consumers to choose freely any participating contractor of a specific type of community service within its network, without influence by any local authority staff or representative.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002352

Charles Cooper

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2000

Proposal publication date: January 28, 2000

For further information, please call: (512) 206-5216


Chapter 403. OTHER AGENCIES AND THE PUBLIC

Subchapter B. CHARGES FOR COMMUNITY-BASED SERVICES

25 TAC §403.46, §403.48

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts amendments to §403.46 and §403.48 of Chapter 403, Subchapter B, concerning charges for community-based services. Section 403.48 is adopted with changes to the proposed text as published in the December 31, 1999, issue of the Texas Register (24 TexReg 11895). Section 403.46 is adopted without changes and will not be republished.

Language in §403.48(c)(2) has been modified to state: "If the local MHMR authority has a contract with the person's insurance carrier, then the local MHMR authority shall charge the person in accordance with such contract. For services not covered by the person's insurance carrier, the local MHMR authority shall charge the person his or her maximum monthly fee in accordance with this subchapter. Payments collected from a person pursuant to a contract between the person's insurance carrier and the local MHMR authority are separate from, and may not be included as part of, the person's maximum monthly fee for services that are not covered by the person's insurance carrier." Proposed language in new subsection (h) of §403.48 concerning the Children's Health Insurance Plan (CHIP) has been deleted because modified language in §403.48(c) addresses charges for services when a person has third party coverage.

Written comment on the proposal was received from the Texas Council of Community MHMR Centers, Austin; MHMR of Tarrant County, Fort Worth; Denton County MHMR Center, Denton; and Texas Interagency Council on Early Childhood Intervention, Austin.

Regarding §403.48(c)(2), one commenter asked why TDMHMR would want to promulgate a rule giving a local MHMR authority permission to comply with requirements of a contract it has with an insurance carrier and over which TDMHMR has no jurisdiction. The department acknowledges that it does not have jurisdiction regarding the provisions of a contract between a local MHMR authority and an insurance carrier. However, pursuant to the Texas Health and Safety Code, §534.067, the department does have jurisdiction regarding the establishment of a uniform fee collection policy for all local MHMR authorities. The department has been made aware of inconsistent implementation of the policy due to the lack of clear direction. The clarifying language ensures uniformity in situations in which the authority has a contract with the person's insurance carrier. In other words, the policy recognizes such contracts as a method of maximizing contributions.

Regarding §403.48(h), the same commenter stated that CHIP is not a TDMHMR-administered program and, for community MHMR centers/local MHMR authorities, the program will become one more payor source alternative to TDMHMR, such as Medicaid, Medicaid managed care, and private insurance, which centers/authorities bill for services as long as the centers/authorities are enrolled by the payor as a provider. The commenter also stated that collection of any co-payments and deductibles will be subject to the provisions in the provider agreement between the center/authority and the payor. The commenter suggested deleting provisions relating to CHIP in (h)(1) and (h)(2) since the responsibility for the action described falls to the CHIP contractor based on the requirements of the Health and Human Services Commission (HHSC). The department agrees with the commenter and responds that language specific to CHIP has been deleted.

Regarding §403.48(h)(3), the commenter asked that TDMHMR investigate the intent of §1.06 (cost-sharing) of HHSC's draft CHIP contract, which states "...the co-payments and deductibles outlined in this section are the only amounts that a provider may collect from a CHIP-eligible family." The commenter expressed concern that the statement does not make clear whether it applies only to CHIP-reimbursed services or to any service the CHIP provider delivers that is not reimbursable by CHIP. Regarding the same section of the draft contract, which states "Federal law prohibits charging co-payments or deductibles to members of Native American Tribes," the commenter asked if such requirement is specific to CHIP or to other federally funded services as well. The department responds that the draft contract language that states, "... the only amounts that a provider may collect from a CHIP eligible family," references only those services that are reimbursable by CHIP. If a local MHMR authority that is a provider of CHIP services delivers non-CHIP-reimbursable services, then the authority charges the family a maximum monthly fee in accordance with the subchapter. Regarding members of Native American Tribes, the department responds that the contract provision is specific to CHIP.

Regarding §403.48(h)(4), the commenter suggested adding "and/or deductibles" after co-payment. The commenter also stated that the department may consider adding the provision to §403.48(c) relating to third party coverage. The department responds that language addressing the commenter's concerns has been added to §403.48(c)(2). The department notes that provisions specific to CHIP have been deleted.

Regarding §403.48(h), the commenter suggested adding the sentence "Local MHMR authorities may not expend local authority funds to meet co-payment and deductible requirements of CHIP-enrolled persons." The commenter also stated that the department may consider adding the provision to §403.48(c) relating to third party coverage. The department responds that promulgating such a policy would be the responsibility of HHSC.

Regarding §403.48(h), the commenter suggested adding language to the rule which describes HHSC's currently undefined policy regarding an agency's ability to serve or deny services to persons eligible for CHIP enrollment, but who refuse to enroll or pay deductibles or co-payments. The commenter requested that the department actively work to ensure that persons requiring crisis services can obtain them from the local authority regardless of CHIP enrollment or any other payor enrollment status. The department responds that promulgating such a policy would be the responsibility of HHSC. Concerning the provision of crisis services without regard to payor status, the department notes that local mental health authorities must comply with the department's rules governing mental health community services standards (Chapter 412, Subchapter G), which do not allow for the provision of crisis services to be contingent on a person's payor status.

The same commenter stated that in the few years since the department's fee collection policy was originally promulgated many more members of the priority population have payor sources alternative to the department and Medicaid. The commenter suggested that the policy be modified to reflect the new environment for community MHMR services. The department agrees with the commenter and responds that it is in the process of revising the fee collection policy to reflect the new reimbursement environment for community MHMR services.

Regarding §403.48(c), one commenter asked if it was permissible to charge the person his or her maximum monthly fee (MMF) based upon the estimated third party coverage payment amount for that month. The commenter stated that third party payors can take between 45 and 90 days to process and pay for services. The commenter also asked which month is credited the MMF payment when delay of a third party payment causes the collection of the person's MMF to be delayed. The department responds that it is permissible to charge the person his or her maximum monthly fee (MMF) based upon the estimated third party coverage payment amount for that month. Regarding which month is credited the MMF payment, the department responds the month in which the services were delivered is the month that is credited.

Regarding extraordinary expenses in §403.46(a), the commenter requested a more specific definition and examples. The department responds that extraordinary expenses are described in §403.45(b)(2) to include major medical or health-related expenses; major casualty losses due to fire, theft, flood, etc.; and child care expenses for the previous year or projections for the next year. Additionally, the training program developed by the department (as required in §403.50) addresses extraordinary expenses. Within the Implementation Manual, on the top of page 3 of the How to Perform Financial Assessment and Determine Fees for Members of the Priority Population in Non-Emergencies , Version 2, dated August 13, 1996, states: "Ask the person to name extraordinary expenses (§403.45): - (1) major medical or health related expenses (2) major casualty losses due to fire, fire, theft, flood, etc. (3) child care expenses for the previous year or projections for the next year. Note: These are the only allowable extraordinary expenses."

Regarding §403.48(c)(2), the commenter requested clarification and asked if the provision meant that it is permissible to collect co-payments even if they amount to more than the person's MMF. The department responds that if the local MHMR authority has a contract with the person's insurance carrier that allows the authority to collect co-payments, then it is permissible for the authority to collect co-payments even if they amount to more than the person's MMF.

Regarding §403.48(h), the commenter requested confirmation that a local MHMR authority can only collect the CHIP co-payment for CHIP reimbursable services; can only collect MMFs for non-reimbursable CHIP services; and, if there is a balance left after collecting the CHIP co-payment and the CHIP payment, cannot collect a MMF to offset the balance. The department responds by confirming the commenter's statements. The department notes that the cost of a CHIP-reimbursed service should equal the family's co-payment and the payment from CHIP.

Regarding §403.48(h), another commenter stated that the provisions in proposed subsection (h) "assumes that the children with MH will receive services only from a local MHMR community center. In some if not a lot of cases, the parents will want to and/or will utilize several local non-MHMR MH services. The local community center will not have the ability to access (the information as to) whether the annual maximum co-pay has been paid if payments are made to multiple providers. Further, it is unclear whether MHMR should deny services to any child if the co-pay is not recovered prior to the child receiving services. That would be the only way to ensure state GR (general revenue) is not used to cover actual costs of providing CHIP services." The department responds that the organization administering CHIP is responsible for ensuring CHIP providers have current information regarding when a person has paid his or her maximum out-of-pocket expense. Regarding denying services if the co-pay is not collected, the department responds that developing such a policy would be the responsibility of HHSC.

Regarding §403.48(c)(2), one commenter stated that collecting co-payment should not be permissive, but should be mandatory as stated in subsection (h) for CHIP co-payments. The commenter also requested that language be added to (c)(2) which requires, in cases in which the person's insurance carrier refuses to pay out-of-network, that the person utilize a provider within the network of his or her insurance carrier or pay the full standard rate for the service. The department responds that language in (c)(2) has been modified to require the local MHMR authority to charge a person in accordance with the contract it has with the person's insurance carrier. Regarding cases in which the person's insurance carrier refuses to pay out-of-network, the department responds that such situations will be addressed in the policy's next revision.

One commenter expressed concern that local MHMR authorities would implement the proposed amendments by collecting co-payments or deductibles from CHIP families for the provision of Early Childhood Intervention services. The commenter stated that state and federal regulations do not permit families to share the cost of Early Childhood Intervention services; therefore, providers of Early Childhood Intervention services, which include most or all local MHMR authorities, are prohibited from collecting co-payments or deductibles. The department responds that §403.42 describes the subchapter's application. Specifically, §403.42(b)(1) states that the "subchapter does not apply to programs and services that are prohibited by statute or regulation from charging fees to persons served (e.g., Early Childhood Intervention Program)..."

These sections are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board (board) with broad rulemaking authority; the Texas Health and Safety Code, §534.052(a), which requires the board to adopt rules it considers necessary and appropriate to ensure the adequate provision of community-based mental health and mental retardation services through a local mental health or mental retardation authority under Chapter 534, Subchapter B; and the Texas Health and Safety Code, §534.067, which requires TDMHMR to establish a uniform fee collection policy for all local mental health and mental retardation authorities.

§403.48. Billing Procedures.

(a)

Monthly services charge. All services provided during a month, and the rates for those services, are listed on the person's monthly services charge. If the total charges:

(1)

exceed the person's maximum monthly fee, then the charges are discounted to equal the maximum monthly fee and the person is billed the maximum monthly fee;

(2)

are less than the person's maximum monthly fee, then the person is billed for the charges listed on the monthly services charge.

(b)

Medicaid recipients.

(1)

For Medicaid recipients, the Medicaid program is billed for Medicaid-covered services rendered according to federal and state regulations and procedures. Medicaid reimbursement is considered full payment.

(2)

Medicaid recipients receiving non-Medicaid-covered services are charged a maximum monthly fee in accordance with this subchapter.

(c)

Third-party coverage.

(1)

If a person has third-party coverage and executes an assignment of benefits, then the local MHMR authority will bill the third-party payor. The local MHMR authority will subtract the third-party payment from the person's monthly service charge, and the remaining balance, if any, is what the person will pay up to the person's maximum monthly fee.

(2)

If the local MHMR authority has a contract with the person's insurance carrier, then the local MHMR authority shall charge the person in accordance with such contract. For services not covered by the person's insurance carrier, the local MHMR authority shall charge the person a maximum monthly fee in accordance with this subchapter. Payments collected from a person pursuant to a contract between the person's insurance carrier and the local MHMR authority are separate from, and may not be included as part of, the person's maximum monthly fee for services that are not covered by the person's insurance carrier.

(d)

Statements.

(1)

Persons who have been determined as having the ability to pay are sent monthly or quarterly statements that include:

(A)

an itemized list, at least by date and by type, of all services received;

(B)

the standard rate for each service;

(C)

the total charge for the period;

(D)

the amount that is being discounted, if any; and

(E)

the amount to be paid.

(2)

Unless requested by the person, statements are not sent to persons with an ability to pay if they maintain a zero balance (i.e., the person does not currently owe any money).

(3)

Statements may not be sent to persons who have been determined as having an inability to pay.

(4)

When the person's interdisciplinary or multidisciplinary team has determined that being charged for services and receiving statements will result in a reduction in the functioning level of the person or the person's refusal or rejection of the needed services, then charges will cease and statements will no longer be sent. This determination requires clinical documentation and must be reassessed at least annually by the team.

(e)

Receipts. Receipts must be provided for all cash payments.

(f)

Punitive action. Financial penalties may not be imposed on a person nor may a person be denied services as punitive action. Actions such as missed appointments without canceling or consistently losing medications by a person should be addressed by the person's interdisciplinary or multidisciplinary team.

(g)

Debt collection. Local MHMR authorities must make reasonable efforts to collect debts before an account is referred to a debt collection agency. Local authorities must document their efforts at debt collection.

(1)

Local MHMR authorities must incorporate into a written agreement or contract for debt collection provisions that state that both parties shall:

(A)

maintain the confidentiality of the information and not disclose the identity of the person or any other identifying information; and

(B)

not harass, threaten, or intimidate persons and their families.

(2)

Local MHMR authorities will enforce the provisions contained in paragraph (1) of this subsection.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002353

Charles Cooper

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2000

Proposal publication date: December 31, 1999

For further information, please call: (512) 206-5216


Chapter 414. PROTECTION OF CONSUMERS AND CONSUMER RIGHTS

Subchapter A. CLIENT-IDENTIFYING INFORMATION

25 TAC §§414.3, 414.4, 414.7, 414.10, 414.11, 414.16

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts amendments to §§414.3, 414.4, 414.7, §414.10, 414.11, and 414.16 of Chapter 414, Subchapter A, concerning client-identifying information. Sections 414.3, 414.4, and 414.7 are adopted with changes to the proposed text as published in the February 4, 2000, issue of the Texas Register (25 TexReg 674). Sections 414.10, 414.11, and 414.16 were adopted without changes and will not be republished.

The amendments implement the provisions of the Texas Family Code, §153.3721 (added by the 76th Legislature, HB 2455), which provides a joint conservator the right to access the medical records of the child; the Texas Health and Safety Code, §614.017 (amended by the 76th Legislature, HB 3256), which defines "special needs offender" and describes the entities that may exchange client-identifying information of special needs offenders without consent for disclosure; the Texas Code of Criminal Procedure, §46.04 (added by the 76th Legislature, HB 245), which states that a person who files a motion under the article waives confidentiality of all mental health and medical records relevant to the person's competency; the Texas Insurance Code, Article 21.58A (amended by the 76th Legislature, SB 569), which restricts a utilization review agent from receiving or reviewing a professional's process or progress notes; the Texas Health and Safety Code, §611.004 (amended by the 76th Legislature, SB 1217), which clarifies to whom and for what purpose a professional may disclose confidential information relating a person detained in a correctional facility; and the Texas Health and Safety Code, §574.083 (amended by the 76th Legislature, SB 358), which allows the release to a law enforcement official confidential information that relates to a court-committed client who is absent from a mental health facility.

Language was added to the definition of "special needs offender" in §414.3 to state that the individual has mental illness or mental retardation. Language was also added to §414.4(b) clarifying that the Texas Department of Protective and Regulatory Services conducts investigations into allegations of exploitation of clients as well as abuse and neglect of clients. Language was added to §414.7(c)(4) to clarify that the utilization review agent being referenced is defined in the Texas Insurance Code, Article 21.58A, §2.

Written comment on the proposal was received from MHMR of Tarrant County, Fort Worth; Advocacy, Inc., Austin; The Gulf Coast Center, Alvin; Center for Health Care Services, San Antonio; Texas Health Choice, L.C., Dallas; Parent Association for the Mentally Retarded of Texas (PART), Austin; and the parent of a state school resident, Garland.

Regarding the definition of "professional" in §414.3(15), one commenter suggested adding examples of who is considered a professional, such as physician, licensed practitioner of the healing arts (LPHA), and qualified mental health professional (QMHP). The commenter stated that his organization considered all three of the cited examples to be professionals, but that his organization's legal counsel considered only physicians and LPHAs to be professionals. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Although amendments were proposed within the definitions section, the department did not propose amendments to the definition of "professional" and therefore, may not adopt a modification to it. The department notes that it agrees with the legal counsel of the commenter's organization concerning who is considered a professional. A person who is an LPHA, as defined in TDMHMR rules governing Medicaid Rehabilitative Services (25 TAC §419.453), has the authority to practice medicine or is licensed or certified by the state in the determination, diagnosis, evaluation, or treatment of any mental or emotional condition or disorder. A person who is a QMHP, as defined in TDMHMR rules governing Mental Health Community Services Standards (25 TAC §412.303), is not required have the authority to practice medicine or be licensed or certified by the state. While the QMHP definition includes people who are so authorized, licensed, or certified, it also includes people who are not.

Regarding release of client-identifying information to a law enforcement official to facilitate the return of a client to a mental health facility in §414.7(g), one commenter requested that the department disseminate a policy interpretation that provides guidance for its facility administrators in determining the scope and type of the client-identifying information that would be necessary for law enforcement to facilitate the client's return. The department responds that it is preparing a policy interpretation document for distribution to its facility administrators as requested by the commenter.

Regarding who may consent to the release of confidential information for a deceased client who received MHMR services in §414.10(c), the same commenter suggested clarifying the term "client's personal representative" by adding "court appointed." The commenter acknowledged that the department did not propose amendments to the subsection. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (c), it may not adopt modifications to it. The department notes that it will consider the commenter's concern when the rules are next proposed.

Regarding who may consent to the release of confidential information for a deceased client who received chemical dependency services in §414.11(c), the commenter expressed concern that the policy for clients who receive chemical dependency services is not consistent with the policy for clients who receive MHMR services. The commenter also expressed concern "about the term used, legally authorized representative, which may be much more broad than is intended in this situation." The commenter acknowledged that the department did not propose amendments to the subsection. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (c), it may not adopt modifications to it. The department notes that it will consider the commenter's concern when the rules are next proposed.

Regarding the time frame of three working days for a professional to determine whether a client's access to parts of his or her record would not be in the client's best interest in §414.12(a) and (b), one commenter requested that the time frame be extended to 10 working days. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.12, it may not adopt modifications to it. The department notes that it will consider the commenter's concern when the rules are next proposed.

Regarding §414.12(a), (b), and (b)(5), one commenter requested that time frames be included for the actual release of requested information to clients. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.12, it may not adopt modifications to it. The department notes that it will consider the commenter's concerns when the rules are next proposed.

The same commenter recommended creating a new section to contain time frames for releasing information to other entities such as healthcare providers, insurance companies, and the courts. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose a new section containing time frame for release of information, it may not adopt such. The department notes that it will consider the commenter's concerns when the rules are next proposed.

Regarding use of the terms "managing conservator," "joint managing conservator," and "possessory conservator" in §414.10(b) and §414.11(b), one commenter requested that the three terms be defined. The department responds that the definitions are unnecessary because an individual's claim to be the managing conservator, joint managing conservator, or possessory conservator could be substantiated only by court documents, not by interpretation of a definition.

Regarding use of the term "utilization review agent" in §414.7(c)(4), one commenter requested that the term be defined. The commenter stated that confusion may arise between the utilization review personnel of a local authority and that of insurance carriers and health maintenance organizations. The department responds by adding language clarifying that the utilization review agent being referenced is defined in the Texas Insurance Code, Article 21.58A, §2.

Regarding the phrase "professional's process or progress notes" in §414.7(c)(4), one commenter from a local authority stated that the phrase was too vague and could imply information in the client's chart. The department responds that §414.7(c) relates to releasing client-identifying information without consent when required in situations other than court proceedings. This means certain information in the client's chart may be required to be released. Under the Texas Insurance Code, a utilization review agent may require submission of a patient's medical record summary. However, an agent may not require, as a condition of treatment approval or for any other reason, the review of a professional's process or progress notes. The department suggests seeking legal counsel for specific direction in complying with this section.

Regarding §414.10(b)(3), one commenter requested that "guardian of the person" be added as someone who can consent to the release of confidential information. The department responds that adding "guardian of the person" to the paragraph would be inappropriate because courts do not appoint guardians of the person to competent minors who are between 16 and 18 years of age.

One commenter stated that the subchapter leaves the client without protection. The commenter expressed concern that the subchapter did not state that confidential information will be released only to those individuals in the organization (i.e., law enforcement) who need the information to do their jobs. The department responds that §414.7(g) states the facility administrator may release confidential information to "a law enforcement official ," meaning a single individual, if the administrator determines that the information is needed to facilitate the client's return. A facility administrator cannot possibly know who within the law enforcement agency will be assigned the task of returning the client to the facility. The department notes that the provision is consistent with §574.083(h) of the Texas Health and Safety Code (added by the 76th Legislature, SB 358).

The same commenter also expressed concern that the subchapter did not require a recipient of the confidential information to use the information strictly for the purpose for which it was obtained and to ensure the recipient did not further distribute the information. The department responds that the subchapter is limited to issues related to disclosing confidential information, but agrees with the commenter that provisions relating to the use of confidential information should be included. The department notes that it will consider the commenter's concern when the rules are next proposed.

Regarding reference to a surrogate decision-making committee in the definition of "legally authorized representative" (LAR) in §414.3(12)(E), two commenters requested the addition of the phrase "this can only be used if the client does not have an LAR." The department responds that the addition of such a phrase to the definition of LAR would not make sense because the phrase qualifies a specific and limited condition using the term (LAR) that is being defined.

Regarding the definition of "professional" in §414.3(12), two commenters suggested deleting the phrase "or a person reasonably believed by the client to be so." The commenters stated that merely believing a person to be a professional does not make the person a professional. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Although amendments were proposed within the definitions section, the department did not propose amendments to the definition of "professional" and therefore, may not adopt a modification of it. The department notes that the phrase referenced by the commenters is consistent with the Texas Health and Safety Code, §611.001(2)(C). Additionally, the phrase allows for broader protections of client-identifying information by requiring people who are not authorized to practice medicine, licensed, or certified (but who are believed by the client to be so authorized, licensed, or certified) to comply with the provisions.

Regarding §414.5(a), two commenters suggested adding as the second sentence, "Client-identifying information will not be given to the local authority if client is in a state school without LAR's consent unless the client has been referred to the community and the LAR agreed in writing." The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.5, it may not adopt modifications to it. The department notes that the Texas Health and Safety Code, §533.009(a), allows for the exchange of client-identifying information between department facilities, community centers, local authorities, and contract providers without consent. Additionally, §414.7(d) requires notification of the client or LAR when confidential information is being exchanged.

Regarding §414.6, two commenters suggested adding language to ensure a client's LAR is informed of the elements contained in the section. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.6, it may not adopt modifications to it. The department notes that it will consider the commenters' concerns when the rules are next proposed.

Regarding §414.7(b)(5), two commenters suggested adding language clarifying that the provision only applies if the client is capable of giving legally adequate consent and does not have an LAR. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (b), it may not adopt modifications to it. The department notes that the provision is consistent with the Texas Health and Safety Code, §611.006(a)(5) and adding language suggested by the commenters is unnecessary since the client's competency is implied. A client who is capable of giving legally adequate consent would not have or need an LAR.

Regarding §414.7(c)(3), two commenters suggested deleting "program evaluations, or research" because of the commenters' claim that the department misused the provision in order to conduct a particular research study from 1993-1995. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (c)(3), it may not adopt modifications to it. The department notes that the provision is consistent with the Texas Health and Safety Code, §611.004(a)(3).

Regarding §414.7(c)(6), two commenters asked why the department deleted the requirement to obtain consent for disclosure in the rules' last revision. The commenters requested that the requirement be included in this revision. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (c)(6), it may not adopt modifications to it. The department notes that, as stated in the preamble of the subchapter's previous adoption, the phrase was deleted because it conflicted with the prefacing language in subsection (c) which states, "client-identifying information may be disclosed without consent ..." Although §611.004(c) of the Texas Health and Safety Code (on which the rule's language is based) states that confidential information "may be released only with the patient's proper consent" in an official legislative inquiry, the provision conflicts with a more recently adopted statute, Texas Government Code, §552.008(b), which allows persons participating in an official legislative inquiry to receive confidential information provided they sign a confidentiality agreement.

Regarding §414.7(c)(9)and §414.8(c)(2), two commenters suggested adding language to clarify that confidential information could be released to Advocacy, Inc. only with the LAR's consent or if the client doesn't have an LAR. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to the two subsections, it may not adopt modifications to them. The department notes that 42 USC §10806 and §6042(a)(2)(I) (Protection and Advocacy of Individuals with Mental Illness and Protection and Advocacy of Individuals with Developmental Disabilities) allows Advocacy, Inc. access to client-identifying information without consent in certain situations, including some situations in which a client has an LAR.

Regarding §414.7(d), two commenters suggested deleting the subsection that allows department facilities, community centers, local authorities, and contract providers to exchange client-identifying information without consent. The commenters stated that they believed there was no valid reason for releasing such information without consent from the client or the LAR. The department responds that the Texas Health and Safety Code, §533.009(a), allows for the exchange of client-identifying information between department facilities, community centers, local authorities, and contract providers without consent. Paragraphs (1)-(3) of §414.7(d), which describes the department's requirements pertaining to such exchange of information, implements §533.009(b) of the Texas Health and Safety Code, which requires the department to adopt rules to carry out the purpose of the code's section.

Regarding §414.8(c)(1)(C), two commenters suggested deleting "research" and "evaluation purposes" because of the commenters' claim that the department misused the provision in order to conduct a particular research study from 1993-1995. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.8, it may not adopt modifications to it. The department notes that the provision is consistent with federal regulations, specifically 42 CFR, Part 2, §2.53.

Regarding allowing department facilities (including state-operated community services) and department personnel to exchange client-identifying information without consent in §414.8(d), two commenters stated that consent should be required. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.8, it may not adopt modifications to it. The department notes that the provision is consistent with federal regulations, 42 CFR Part 2, §2.12(c)(3).

Regarding §414.8(e), two commenters requested that the subsection be deleted stating the superintendent or director of a department facility does not have the professional ability or legal right to determine that a minor under the age of 16 years lacks the capacity to make rational decisions or consent to notification of his or her legally authorized representative. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.8, it may not adopt modifications to it. The department notes that the provision is consistent with federal regulations, 42 CFR Part 2, §2.14(b).

Regarding a competent minor between 16 and 18 years of age receiving voluntary mental health services being able to unilaterally authorize and consent to disclosure of client-identifying information in §414.10(b)(3), two commenters requested that the subsection be deleted. The commenters stated that they did not believe such a minor is legally able to authorize and consent to disclosure of client-identifying information. The department responds that since a competent minor between 16 and 18 years of age is legally able to request and receive voluntary admission to an inpatient mental health facility (Texas Health and Safety Code, §572.001), such a minor is legally able to authorize and consent to disclosure of client-identifying information.

Regarding who can consent to the release of confidential information of a deceased client who received mental retardation services in §414.10(c), two commenters requested adding language that required seeking consent from the LAR before allowing the client's personal representative to consent. The commenters stated that the parallel subsection for deceased clients who received chemical dependency services (§414.11(c)) required consent from the LAR and wondered why the department was providing more protection to clients receiving chemical dependency services and their LARs in the section and throughout the subchapter. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (c), it may not adopt modifications to it. The department notes that the provision is consistent with the Texas Health and Safety Code, §595.003(a)(4)(B).

Regarding a competent minor who voluntarily admitted himself or herself for chemical dependency treatment being able to consent to the disclosure of client-identifying information in §414.11(b)(1), two commenters requested that the subsection be deleted. The commenters stated that they did not believe such a minor is legally able to authorize and consent to disclosure of client-identifying information. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to subsection (b)(1), it may not adopt modifications to it. The department notes that the provision is consistent with federal regulations, 42 CFR Part 2, §2.14(b).

Regarding §414.12(c)(1), two commenters requested clarification that the reasonable fee being referenced is for copies of the client's records and not access to the client's records. The department responds that before a state agency is able to adopt a rule, the rule must first be proposed in the Texas Register in accordance with Chapter 2001 of the Texas Government Code. Since the department did not propose amendments to §414.12, it may not adopt modifications to it. The department notes that the reasonable fee is for both access and copies. (The department does not require charging clients any type of fee for access to their records; however, state statute allows for such action.) The department also notes that charging a fee is permissive and not required.

Regarding §414.15, two commenters stated that the exhibits should be attached to the policy. The department responds that it attaches copies of the exhibits when it distributes hard copies of the adopted subchapter.

These sections are adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Board of Mental Health and Mental Retardation (board) with broad rulemaking authority; the Texas Health and Safety Code, §576.005, which mandates the confidentiality of records of a mental health facility that directly or indirectly identify a present, former, or proposed patient; and the Texas Health and Safety Code, §595.002, which requires the board to adopt rules that it considers necessary to facilitate compliance with Chapter 595.

§414.3. Definitions.

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

(1)

Adult - A person:

(A)

who is 18 years of age or older; or

(B)

who is under 18 years of age and:

(i)

is or has been legally married; or

(ii)

whose disabilities of minority have been legally removed.

(2)

Chief executive officer or CEO - The superintendent/director of a facility or the executive director of a local authority or contract provider.

(3)

Client - A person who, voluntarily or involuntarily, is seeking or receiving, or who has received mental health, mental retardation, or chemical dependency services from a facility, local authority, or contract provider.

(4)

Client-identifying information - The name, address, social security number, or any information by which the identity of a client can be determined either directly or by reference to other publicly available information. The term includes, but is not limited to, a client's medical record, graphs, or charts; statements made by the client, either orally or in writing, while receiving services; photographs, videotapes, etc.; and any acknowledgment that a person is or has been a client of a facility, local authority, or contract provider. The term does not include a client-identifying number. The statutes, regulations, and rules requiring that client-identifying information be kept confidential apply regardless of the means or methods utilized for the storage and retrieval of such information.

(5)

Competent - A term used to describe a person who has the ability to comprehend the effect and consequences of giving an authorization for disclosure of client-identifying information and who has not been adjudicated incompetent by a court, or for whom an order of restoration has been executed and recorded subsequent to the client's having been adjudicated incompetent.

(6)

Contract provider - An individual, entity, or organization that contracts with the department, a facility, or local authority to provide mental health, mental retardation, and/or chemical dependency services.

(7)

Consent - The authorization to disclose client-identifying information given by a person with such authority as described in §414.10 of this title (relating to Who Can Give Consent for Disclosure: Clients Receiving MHMR Services) or §414.11 of this title (relating to Who Can Give Consent for Disclosure: Clients Receiving Chemical Dependency Services).

(8)

Department - The Texas Department of Mental Health and Mental Retardation.

(9)

Facility - A state hospital, state school, state center, Central Office of the Texas Department of Mental Health and Mental Retardation.

(10)

Incompetent - A term used to describe a person who:

(A)

has been adjudicated incompetent by a court and for whom no subsequent order of restoration has been executed or recorded; or

(B)

does not, as determined by the professional, have the ability to comprehend the effect or consequences of giving an authorization for disclosure of client-identifying information.

(11)

Legal counsel - At a facility or state-operated community services, staff of the department's legal services office; at a local authority (that is not a state-operated community services) or a contract provider, the attorney(s) in its service.

(12)

Legally authorized representative - A legally authorized representative means:

(A)

a parent, legal guardian, or conservator if the client is a minor, or a legal guardian if the client has been adjudicated incompetent to manage the client's personal affairs;

(B)

an agent of the patient authorized under the Advance Directives Act, Texas Health and Safety Code, Chapter 166;

(C)

an attorney ad litem appointed for the client;

(D)

a parent, spouse, adult child, or personal representative (executor or administrator of the client's estate) if the client is deceased; or

(E)

a surrogate decision-making committee or surrogate decision-maker, as appropriate, pursuant to the Texas Health and Safety Code, Chapter 597, Subchapter C, and Chapter 405, Subchapter J of this title (relating to Surrogate Decision-Making for Community-Based ICF/MR and ICF/MR/RC Facilities).

(13)

Local authority - An entity to which the Texas Mental Health and Mental Retardation Board delegates its authority and responsibility within a specified region for the planning, policy development, coordination, resource development and allocation, and for supervising and ensuring the provision of mental health services to persons with mental illness and/or mental retardation services to persons with mental retardation in one or more local service areas.

(14)

Minor - A person under 18 years of age:

(A)

who is not and never has been legally married; and

(B)

whose disabilities of minority have not been legally removed.

(15)

Professional - A person authorized to practice medicine in any state or nation, or a person licensed or certified by the State of Texas in the determination, diagnosis, evaluation, or treatment of any mental or emotional condition or disorder, or a person reasonably believed by the client to so be.

(16)

Qualified service organization - An individual, partnership, corporation, governmental agency, or any other legal entity that:

(A)

provides services for chemical dependency programs, such as data processing, bill collecting, dosage preparation, laboratory analyses, or legal, medical, accounting, or other professional services, or services to prevent or treat child abuse or neglect, including training on nutrition and child care and individual and group therapy; and

(B)

has entered into a written agreement with a program under which that entity:

(i)

acknowledges that in receiving, storing, processing, or otherwise dealing with any client records from the programs, it is fully bound by the provision of this subchapter; and

(ii)

if necessary, will resist in judicial proceedings any efforts to obtain access to client records except as permitted by state and federal law and this subchapter.

(17)

Special needs offender - An individual with mental illness or mental retardation for whom criminal charges are pending or who after conviction or adjudication is in custody or under any form of criminal justice supervision.

(18)

State-operated community services (SOCS) - Community residential and nonresidential programs operated by the Texas Department of Mental Health and Mental Retardation.

(19)

Subpoena - A command to appear at a certain time and place to give testimony about a certain matter.

(20)

Subpoena duces tecum - A command to produce or bring items (e.g., books, papers, documents, records) at a certain place and time.

§414.4. Statutes and Federal Regulations Governing Disclosure.

(a)

State statutory provisions governing disclosure of client-identifying information concerning clients receiving mental health and mental retardation services are contained primarily in §576.005 and Chapter 611 of the Texas Health and Safety Code.

(b)

The provisions for disclosure of client-identifying information concerning clients receiving mental retardation services are contained in the Persons with Mental Retardation Act, Texas Health and Safety Code, Chapter 595. The provisions described in §576.005 and Chapters 595 and 611 of the Texas Health and Safety Code should be interpreted together in reaching a determination regarding the disclosure of client-identifying information concerning clients receiving mental retardation services.

(c)

Texas Human Resources Code, Chapter 48, establishes authority for the Texas Department of Protective and Regulatory Services (TDPRS) to have access to client records necessary to conduct investigations into allegations of abuse, neglect, and exploitation of clients.

(d)

Texas Civil Statutes, Article 4512g-1, allows for the release of information concerning the mental health treatment of a sex offender (as defined by Code of Criminal Procedure, Article 42.12, Section 9) to a criminal justice agency or local law enforcement authority.

(e)

The Secretary of the United States Department of Health and Human Services has promulgated extensive regulations governing the disclosure of records of clients receiving chemical dependency services as described in 42 Code of Federal Regulations Part 2.

(f)

The Secretary of the United States Department of Education has promulgated extensive regulations governing the disclosure of educational records of school-age children as described in 45 Code of Federal Regulations 99ff. State statutory provisions governing the disclosure of a client's educational records are described in the Texas Health and Safety Code, §595.005(c). Any questions concerning the disclosure of such educational records should be referred to legal counsel.

(g)

The Texas Open Records Act, Texas Government Code, Chapter 552, provides that all information collected, assembled, or maintained by governmental bodies, and agencies operating in part or whole with state funds, pursuant to law or ordinance in connection with the transaction of official business is public information and available to the public during normal business hours; however, the act does set out certain exceptions. One such exception is information deemed confidential by law, such as records which directly or indirectly identify a client, former client, or prospective client.

(h)

The Texas Health and Safety Code, §614.017, allows for the exchange of client-identifying information of special needs offenders between the state agencies responsible for providing continuity of care if it furthers the purposes of the Texas Council on Offenders with Mental Impairments, Texas Health and Safety Code, Chapter 614.

(i)

The Texas Code of Criminal Procedure, Article 46.04(j), waives confidentiality of all client-identifying information of a person challenging his or her competency under Article 46.04.

§414.7. When Consent for Disclosure is not Required: Clients Receiving MHMR Services.

(a)

When consent has been previously given. Consent to disclosure of client-identifying information is not required if:

(1)

proper consent has been obtained previously and has not been revoked;

(2)

the duration of the consent has not expired; and

(3)

the specifications of the consent (what is to be released, to whom, for what purpose) are the same.

(b)

When required by certain judicial and administrative proceedings. Client-identifying information may be disclosed without consent in:

(1)

a judicial or administrative proceeding brought by the client or the client's legally authorized representative against a professional, including malpractice proceedings;

(2)

a license revocation proceeding in which the client is a complaining witness and in which disclosure is relevant to the claim or defense of a professional;

(3)

a judicial or administrative proceeding in which the client waives his or her right in writing to the privilege of confidentiality of information or when the client's legally authorized representative, acting on the client's behalf, submits a written waiver to the confidentiality privilege;

(4)

a judicial or administrative proceeding to substantiate and collect on a claim for mental or emotional health services rendered to the client;

(5)

a judicial proceeding if the judge finds that the client, after having been informed that communications would not be privileged, has made communications to a professional in the course of a court-order examination, except that those communications may be disclosed only with respect to issues involving the client's mental or emotional health;

(6)

a judicial proceeding affecting the parent-child relationship;

(7)

any criminal proceeding subject to a subpoena issued by the court;

(8)

a judicial or administrative proceeding regarding the abuse or neglect, or the cause of abuse or neglect, of a resident of an institution, as defined by the Texas Health and Safety Code, §242.002(6);

(9)

a judicial proceeding relating to a will, if the client's physical or mental condition is relevant to the execution of the will;

(10)

an involuntary commitment proceeding for court-ordered treatment or for a probable cause hearing under Chapter 462, 574, or 593 of the Texas Health and Safety Code; or

(11)

a judicial or administrative proceeding where the court or agency has issued an order or subpoena.

(c)

When required in other than court proceedings. Client-identifying information may be disclosed without consent:

(1)

to government agencies if required or authorized by law (for example, to the Texas Department of Protective and Regulatory Services in cases of client/child abuse; to a member of a child fatality review team who is investigating the death of a child in accordance with the Texas Family Code, Chapter 264);

(2)

to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the client to the client or others or there is a probability of immediate mental or emotional injury to the client;

(3)

to qualified personnel for management audits, financial audits, program evaluations, or research, except that personnel who receive the information may not directly or indirectly or otherwise disclose the identity of a client in a report or in any other manner;

(4)

to persons, corporations, or governmental agencies involved in the paying or collecting of fees for mental or emotional health services provided by a professional. However, pursuant to the Texas Insurance Code, Article 21.58A(o), a utilization review agent (as defined by the Texas Insurance Code, Article 21.58A, §2) may not receive or review a professional's process or progress notes;

(5)

to other professionals and personnel under the professionals' direction who are participating in the diagnosis, evaluation, and treatment of the client;

(6)

to persons participating in an official legislative inquiry regarding state hospitals or state schools in accordance with the Texas Government Code, §552.008 (this exception only applies to records created by employees of the state hospitals or state schools);

(7)

to medical personnel to the extent necessary to meet a bona fide medical emergency;

(8)

to personnel legally authorized to conduct investigations concerning complaints of abuse or denial of rights of clients;

(9)

to Advocacy, Incorporated, in the investigation of a complaint by or on behalf of a client in accordance with 42 USC §10806 or §6042(a)(2)(I) (Protection and Advocacy of Individuals with Mental Illness and Protection and Advocacy of Individuals with Developmental Disabilities). Excepted from this disclosure without consent are records subject to attorney/client privilege, e.g., records of an investigation conducted at the request of a departmental attorney in preparation for potential litigation;

(10)

to an employee or agent of the treating professional who requires the mental health care information to provide mental health care services or in complying with statutory, licensing, or accreditation requirements, if the professional has taken appropriate action to ensure that the employee or agent:

(A)

will not use or disclose the information for any other purposes; and

(B)

will take appropriate steps to protect the information;

(11)

to satisfy a request for medical records of a deceased or incompetent person pursuant to §4.01(e), Medical Liability and Insurance Improvement Act, Texas Civil Statutes, Article 4590i; and

(12)

to designated persons or personnel of a correctional facility in which the client is detained if the disclosure is for the sole purpose of providing treatment and health care to the client in custody.

(d)

When used between facilities, local authorities, community centers, and contract providers. Client-identifying information may be disclosed without consent when it is used between department facilities, local authorities, community centers, and contract providers only if:

(1)

the client or legal guardian has been informed that the records may be exchanged at the time of or prior to release;

(2)

the client or legal guardian is informed of the purpose of the release, e.g., to facilitate continuing care for the client; and

(3)

this advisement is documented in the client's record, dated, and signed by the client or legal guardian and staff.

(e)

When used by an attorney ad litem. Client-identifying information may be disclosed without consent to the attorney ad litem representing the client in legal process.

(f)

When used for continuity of care of special needs offenders. In accordance with the Texas Health and Safety Code, §614.017, to provide continuity of care for a special needs offender (as defined), client-identifying information (i.e., identity; needs; treatment; social, criminal and vocational history; supervision status and compliance with conditions of supervision; and medical and mental health history) concerning the offender may be disclosed and received without consent among the following entities, or a person with an agency relationship with one of the following entities, or a person who contracts with one or more of the following entities:

(1)

the institutional division of the Texas Department of Criminal Justice;

(2)

the pardons and paroles division of the Texas Department of Criminal Justice;

(3)

the community justice assistance division of the Texas Department of Criminal Justice;

(4)

the state jail division of the Texas Department of Criminal Justice;

(5)

the Texas Department of Mental Health and Mental Retardation;

(6)

the Texas Juvenile Probation Commission;

(7)

the Texas Youth Commission;

(8)

the Texas Rehabilitation Commission;

(9)

the Texas Education Agency;

(10)

the Criminal Justice Policy Council;

(11)

the Texas Commission on Alcohol and Drug Abuse;

(12)

the Commission on Jail Standards;

(13)

the Texas Department of Human Services;

(14)

the Texas Department on Aging;

(15)

the Texas School for the Blind and Visually Impaired;

(16)

the Texas Department of Health;

(17)

the Texas Commission for the Deaf and Hard of Hearing;

(18)

community supervision and corrections departments;

(19)

personal bond pretrial release offices established under Article 17.42, Code of Criminal Procedure;

(20)

local jails regulated by the Commission on Jail Standards; and

(21)

the office of the Texas Council on Offenders with Mental Impairments.

(g)

When used to assist law enforcement in the return of a court-committed client who is absent from a mental health facility (as defined in the Texas Health and Safety Code, §571.003) or a facility. The facility administrator may release to a law enforcement official information about the client if the administrator determines that the information is needed to facilitate the return of the client to the mental health facility or the facility.

This agency hereby certifies that the adoption has been reviewed by legal counsel and found to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on April 3, 2000.

TRD-200002354

Charles Cooper

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2000

Proposal publication date: February 4, 2000

For further information, please call: (512) 206-5216