TITLE 25.HEALTH SERVICES

Part 1. TEXAS DEPARTMENT OF HEALTH

Chapter 13. HEALTH PLANNING AND RESOURCE DEVELOPMENT

Subchapter E. ADVISORY COMMITTEE

25 TAC §13.51

The Texas Department of Health (department) adopts the repeal of §13.51, concerning the Hospital Data Advisory Committee (committee) without changes to the proposal as published in the January 31, 2003, issue of the Texas Register (28 TexReg 819). The committee has provided advice to the Texas Board of Health (board) and the department on hospital reporting requirements and on interpretation and evaluation of the data received.

In 1993, the Texas Legislature passed Senate Bill 383 (now codified in the Government Code, Chapter 2110) which requires that each state agency adopt rules on advisory committees. The rules must state the purpose of the committee, describe the tasks of the committee, describe the manner in which the committee will report to the agency, and establish a date on which the committee will be automatically abolished unless the governing body of the agency affirmatively votes to continue the committee's existence.

In 1995, the board established a rule relating to the Hospital Data Advisory Committee. The rule states that the committee will automatically be abolished on May 1, 2003, and the board has determined that the committee should be abolished on that date. Issues relating to the type of advice previously provided by the committee are better addressed through the establishment of ad hoc workgroups.

Government Code, §2001.039, requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). The department has reviewed §13.51 and has determined that reasons for adopting the rule no longer continue to exist.

The department published a Notice of Intention to Review §13.51 in the Texas Register on December 27, 2002 (27 TexReg 12382). No comments were received due to publication of this notice.

There were no comments received concerning the repeal during the 30-day comment period.

The repeal is adopted under the Health and Safety Code, §11.016, which allows the board to establish advisory committees; the Government Code, Chapter 2110, which sets standards for the evaluation of advisory committees by the agencies for which they function; and the Health and Safety Code, §12.001, which provides the board with authority to adopt rules for the performance of every duty imposed by law upon the board, the department, and the commissioner of health.

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 4, 2003.

TRD-200302217

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: January 31, 2003

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


Chapter 91. CANCER

Subchapter A. CANCER REGISTRY

25 TAC §91.4

The Texas Department of Health (department) adopts an amendment to §91.4, concerning cancer incidence reporting requirements without changes to the proposed text as published in the January 31, 2003, issue of the Texas Register (28 TexReg 820). The amended section clarifies cancer incidence information that persons are required to report to the department.

The department reviewed the rule to ensure that covered entities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would continue to report the same information they currently report after the federal HIPAA privacy standards (45 Code of Federal Regulations (CFR), Parts 160 and 164) become effective on April 14, 2003. The amended section clarifies the rule to ensure there will be no change in the information reported under this section, and to further ensure that HIPAA covered reporting entities will comply with the letter and the spirit of the HIPAA privacy standards.

The amended section elucidated discrepancies between the rule and the information the department currently receives. The amended section makes no change in the information a person is currently required to report to the department and ensures that persons required to report will have continuing authority to disclose protected health information (PHI) to the department after the implementation date of the federal privacy standards.

The department received the following comment concerning the proposed section.

Comment: Concerning §91.4(b)(1)(H), a commenter recommended that wording be added to include advanced practice nurses by changing the word "physician" to "practitioner or advanced practice nurse" since advanced practice nurses (APN) are also legally authorized to order laboratory exams.

Response: The department disagrees with the suggested change. The department is authorized by the Health and Safety Code, §82.008 to collect cancer data from health care facilities, clinical pathology laboratories or health care practitioners. A health care practitioner is defined as a physician or dentist by §82.002. No change was made as a result of this comment.

One comment was received from the Coalition for Nurses In Advanced Practice and was generally in favor of the rule, however, it offered one suggested change.

The amended section is adopted under the Health and Safety Code, §82.006, which authorizes the board to adopt rules necessary to implement the Cancer Registry; and §12.001, which provides the board with the authority to adopt rules for the performance of each duty imposed by law on the board, the department, and the commissioner.

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 4, 2003.

TRD-200302218

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: January 31, 2003

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


Chapter 99. OCCUPATIONAL DISEASES

25 TAC §99.1

Texas Department of Health (department) adopts an amendment to §99.1, concerning reporting requirements to the department, with changes to the proposed text as published in the January 31, 2003, issue of the Texas Register (28 TexReg 823), as a result of comments received during the 30-day comment period.

The program reviewed the rule to ensure that covered entities under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would continue to report the same information they currently report after the federal HIPAA privacy standards (45 Code of Federal Regulations (CFR), Parts 160 and 164) which became effective on April 14, 2003. The HIPAA privacy standards contain sections that allow HIPAA covered entities to use and disclose protected health information (PHI), which is individually identifiable health information, without the authorization of the individual, if the use and disclosure is required by law or rule, the use and disclosure complies with the law or rule and is limited to the requirements of the law or rule (45 CFR §164.512(a), and for public health activities (45 CFR §164.512(b)). The amendment corrects any discrepancies between the rule and the information the department currently receives. The amended section will make no change in the information a person is currently required to report to the department. The amendment to the section will ensure that persons required to report will have continuing authority to disclose PHI to the department after the implementation date of the federal privacy standards.

Three comments were received during the comment period. All the comments are from the Coalition for Nurses in Advanced Practice (CNAP). The comments suggest using the term "health professionals" in those paragraphs that address reporting. The "health professionals" language is a defined term in Health and Safety Code, §84.002. Some health professionals, notably advanced practice nurses and physician assistants may diagnose and treat patients with occupational diseases. Especially among medically underserved populations, these health professionals are frequently in separate locations from that of a collaborating physician. Therefore it is appropriate to require all practitioners who treat the patient to report the occupational conditions identified by the department. These comments clarify and update the reporting requirements section of this rule.

Comment: Concerning §99.1(b)(1), a commenter suggested to add "or other health professional acting within the scope of the professional license," after "physician" and before "based upon."

Response: The department agrees and has corrected the wording in the section.

Comment: Concerning §99.1(c)(1), a commenter suggested to insert "or health professional," after "physician" and before "holding".

Response: The department agrees and has corrected the wording in the section.

Comment: Concerning §99.1(c)(3), a commenter suggested to add "health professional" in the first sentence after "physician" and before "or laboratory director." The commenter also suggested to add "health professional" after "physician" and before "or laboratory director" in the second sentence.

Response: The department agrees and has corrected the wording in the section. This change more accurately reflects the wording of Health and Safety Code, §84.004, which requires all health professionals to report.

The amendment is adopted under Health and Safety Code, §84.003 which allows the Board of Health (board) to adopt rules that require the reporting of occupational diseases; and Health and Safety Code, §12.001, which provides the board with the authority to adopt rules for the performance of each duty imposed by law on the board, the department, and the commissioner.

§99.1.General Provisions.

(a) Purpose. This section implements the Texas Occupational Conditions Reporting Act, Health and Safety Code, Chapter 84, House Bill 2091, 69th Legislature, 1985, which authorizes the Texas Board of Health to adopt rules concerning the reporting and control of occupational conditions.

(b) Definitions. The following words and terms, when used in these sections, shall have the following meanings unless the context clearly indicates otherwise.

(1) Case--A person in whom an occupational condition is diagnosed by a physician or other health professional acting within the scope of the professional license, based upon clinical evaluation, interpretation of laboratory and/or roentgenographic findings, and an appropriate occupational history.

(2) Commissioner--The commissioner of health.

(3) Department--The Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756.

(4) Local health authority--The chief administrative officer of a public health district or a local health department, or the physician who is to administer state and local laws relating to public health.

(5) Occupational conditions--Those diseases, abnormal health conditions or laboratory findings that are caused by or are related to exposures in the workplace.

(6) Reportable occupational condition--Any occupational disease, condition or laboratory finding for which an official report is required. See subsection (d) of this section.

(7) Report of occupational condition--The notification to the appropriate authority of the occurrence of a specific occupational disease in a human, including all information required by the procedures established by the Board of Health.

(8) Suspected case--A case in which an occupational condition is suspected, but the final diagnosis is not yet made.

(c) Reporting requirements.

(1) It is the duty of every physician or health professional holding a license to practice in the State of Texas to report promptly to the local health authority each patient she or he shall examine and who has or is suspected of having any reportable occupational condition. The local health authority may authorize a staff member to transmit reports.

(2) It is the duty of every person who is in charge of a clinical or hospital laboratory, blood bank, mobile unit, or other facility in which a laboratory examination of any specimen derived from a human body yields microscopical, cultural, serological, chemical, or other evidence suggestive of a reportable condition to report promptly that information to the local health authority.

(3) The reporting physician, health professional, or laboratory director shall make the report in writing. A local health authority may authorize one or more employees under his or her supervision to receive the report from the physician, health professional, or laboratory director by telephone; use of this alternative, if authorized, is at the option of the reporter. The local health authority shall implement a method of verifying the identity of the telephone caller when that person is unfamiliar to the employee.

(4) The local health authority shall collect the reports and transmit the information at weekly intervals to the Environmental Epidemiology and Toxicology Division, Bureau of Epidemiology, Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756. Transmission may be made by mail, courier, or electronic transfer.

(A) If by mail or courier, the reports shall be placed in a sealed envelope addressed to the attention of the Environmental Epidemiology and Toxicology Division, Bureau of Epidemiology, Texas Department of Health, 1100 West 49th Street, Austin, Texas, 78756, and marked "Confidential Medical Records."

(B) If by electronic transmission, including facsimile transmission by telephone, it shall be in a manner and form authorized by the commissioner or his or her designee in each instance. Any electronic transmission of the reports must provide at least the same degree of protection against unauthorized disclosure as those of mail or courier transmission. The commissioner or his or her designee shall, before authorizing such transmission, establish guidelines for establishing and conducting such transmission.

(5) When an occupational condition is reported to a local health authority, and the person diagnosed as having the condition resides outside his or her area of local health jurisdiction, the local health authority receiving the report shall notify the appropriate local health authority where the person or persons reside. The department shall assist the local health authority in providing such notifications if requested.

(d) Reportable conditions and information to be reported.

(1) The reportable occupational conditions are: asbestosis, silicosis, blood lead levels in persons 15 years of age or older, and acute pesticide poisoning.

(2) Reports for asbestosis and silicosis shall include all information collected by the reporting person and required to complete the most recent version of the department's Asbestosis and Silicosis Case Report Form F09-11626.

(3) Reports for blood lead levels in persons 15 years of age and older shall include all information collected by the reporting person and required to complete the most recent version of the department's Adult Blood Lead Report Form F09-11624.

(4) Reports for acute pesticide poisoning shall include all information collected by the reporting person and required to complete the most recent version of the department's Pesticide Poisoning Report Form F09-11625.

(e) General control measures for reportable occupational conditions. The commissioner or his or her duly authorized representative shall, as circumstances may require, proceed as follows:

(1) investigation shall be made for the purpose of verifying the diagnosis, ascertaining the source of the causative agent, obtaining an occupational and employment history and discovering unreported cases;

(2) collection of specimens of the body tissues, fluids, or discharges and of materials directly or indirectly associated with the case, as may be necessary in confirmation of the diagnosis, and their submission to a laboratory for examination;

(3) obtaining samples of air or materials from the current or former business or place of employment of a case, as may be necessary to ascertain if a public health hazard exists. If a hazard is found the commissioner or his/her designee shall make appropriate recommendations concerning the hazard.

(f) Confidential nature of case reporting.

(1) All case reports received by the local health authority or the Texas Department of Health are confidential records and not public records. These records will be held in a secure location and accessed only by authorized personnel.

(2) The department may use information obtained from reports or health records for statistical and epidemiological studies which may be public information as long as an individual is not identifiable.

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 4, 2003.

TRD-200302216

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: January 31, 2003

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


Chapter 128. PERMITS FOR CONTACT LENS DISPENSERS

The Texas Department of Health (department) adopts the repeal of §§128.1 - 128.10 and new §§128.1 - 128.15, concerning the regulation of persons filling contact lens prescriptions without changes to the proposed text as published in the December 6, 2002, issue of the Texas Register (27 TexReg 11401), and the sections will not be republished.

Government Code, §2001.039, requires that each state agency review and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). The sections have been reviewed and the department has determined that reasons for adopting the sections continue to exist in that rules on this subject are needed; however the need to reorganize and modify the existing sections warrants the repeal and new sections.

Each section was edited and restructured to correct grammatical errors; update legal citations; and delete repetitive, ambiguous, obsolete, unenforceable, and unnecessary language. The new sections improve draftsmanship and make the rules more accessible, understandable, and usable. Much of the adopted language is former language; however, the sections were reorganized in a more logical manner resulting in the language appearing as new in the adopted sections.

New §128.1 (relating to Introduction) explains the overall purpose of the rules and identifies the topics covered in the rules.

A definition for business entity is included in new §128.2 (relating to Definitions). The term was not formerly defined; however, the definition is necessary to assist applicants in determining the amount of the annual permit fee.

New §128.3 (relating to Fees) and §128.4 (relating to Petition for Rulemaking) is language that was formerly included in another section. New §128.3 is adopted for easy reference in determining applicable fees required for obtaining and maintaining a contact lens permit. New §128.4 is adopted for a more logical placement of the information.

New §128.5 (relating to Sale or Delivery of Contact Lenses) is adopted to clearly describe the requirements for the sale or delivery of contact lenses in Texas.

New §128.6 (relating to Display of Permit) is language that was formerly included in the rules, but in a different sequence.

New §128.7 (relating to Application Requirements and Procedures) is adopted to clearly describe the application process; and to remove the obsolete requirement for applicants to obtain letters from the Comptroller of Texas attesting to compliance with the Tax Code, Chapter 171 (Franchise Tax).

New §128.8 (relating to Application Processing) is adopted to identify the time periods and procedures for issuing a contact lens permit.

New §128.9 (relating to Renewal of Permit) is adopted to clearly set out the permit renewal process and to include language relating to the suspension of a permit for failure to comply with a court order providing for the possession of or access to a child.

New §128.10 (relating to Changes of Name or Address) is adopted to explain the process for changing the name or address of the permit holder.

New §128.11 (relating to Filing Complaints and Complaint Investigations) is adopted to reflect the process for filing a complaint and conducting an investigation of the complaint.

New §128.12 (relating to Disciplinary Actions) is adopted to reflect the department's authority to deny an application, suspend or revoke a permit, place a permit on probation, or impose administrative penalties.

New §128.13 (relating to Informal Disposition) and §128.14 explain the process for informal settlement conferences and formal hearings.

The two commenters were the Texas Optometry Board and the Texas Optometric Association, Inc. The commenters were neither for nor against the proposed rules in their entirety; rather, they offered comments and questions regarding specific points in the rules.

Comment: One commenter requested that additional language be added to the end of §128.5(c), specifically "Any such request shall be dated and if such request is made by facsimile or electronic method the facsimile or electronic mail shall contain the actual time of transmittal." The commenter stated that this would help provide documentary evidence to the Optometry Board or Medical Board regarding whether or not a doctor has responded in a timely fashion to an agent's request on behalf of a patient.

Response: The department disagrees. The additional language is not required by either the Texas Optometry Act, Occupations Code Chapter 351 or the Contact Lens Prescription Act, Occupations Code Chapter 353, nor is a corresponding requirement related to prescription release included in the rules of the Texas Optometry Board, 22 TAC §279.2 relating to contact lens prescriptions. No change was made as a result of the comment.

Comment: The commenter requested that language allowing a physician or optometrist to provide a prescription by telephone or other electronic means to a contact lens dispenser be removed, or if it remains, that additional requirements be included related to reducing the additional transmittal methods to writing, requirements for ascertaining the authenticity of the prescription, and requirements for maintaining the records and for return of the prescription to the customer when not all the lenses have been dispensed, as well as more specific language describing "other electronic means".

Response: The department disagrees. The proposed language tracks the language of the Texas Optometry Act, which permits a physician or optometrist to authorize the dispensing of lenses by these methods. The rules as proposed already require that prescriptions be maintained and returned to the patient in accordance with the Act. Any additional restrictions on methods of prescription release necessary for a physician or optometrist should properly be addressed in the rules of the appropriate licensing board. No change was made as a result of the comment.

Comment: One commenter requested that language be included which requires that "licensed dispensers be readily available to prescribing doctors should the prescribing doctor have a question concerning the request for a prescription."

Response: The department disagrees. The proposed language would place additional requirements on the contact lens dispenser not mandated by the Act, which sets out clear guidelines related to the release of prescriptions to consumers or their agents by physicians and optometrists. No change was made as a result of the comment.

25 TAC §§128.1 - 128.10

The repeals are adopted under the Occupations Code, Chapter 353, which provides the Board of Health (board) with the authority to adopt rules; and Health and Safety Code, §12.001, which provides the board with authority to adopt rules to implement every duty imposed by law on the board, the department, and the commissioner of health.

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 4, 2003.

TRD-200302222

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


25 TAC §§128.1 - 128.15

The new sections are adopted under the Occupations Code, Chapter 353, which provides the Board of Health (board) with the authority to adopt rules; and Health and Safety Code, §12.001, which provides the board with authority to adopt rules to implement every duty imposed by law on the board, the department, and the commissioner of health.

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 4, 2003.

TRD-200302223

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Chapter 169. ZOONOSIS CONTROL

Subchapter E. DOG AND CAT STERILIZATION

25 TAC §169.101

The Texas Department of Health (department) adopts an amendment to §169.101, concerning the Animal Friendly Advisory Committee (committee). Section 169.101 is adopted without changes to the proposed text as published in the January 31, 2003, issue of the Texas Register (28 TexReg 888). The section is amended to change the process for filling vacancies in the offices of presiding officer and assistant presiding officer; include additional requirements regarding statements by members; and clarify the components that the committee must include in an annual report to the commissioner.

Government Code, §2001.039, requires that each state agency conduct a review of its rules every four years and consider for readoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedures Act). Section 169.101 has been reviewed and the department has determined that reasons for adopting the section continue to exist in that a rule on this subject is needed.

The department published a Notice of Intention to Review for §169.101 as required by Government Code, §2001.039 in the Texas Register on May 19, 2000 (25 TexReg 4598). The department received no comments due to the publication of the notices.

No comments were received on the proposal during the comment period.

The amendment is adopted under Health and Safety Code, Chapter 828, "Dog and Cat Sterilization," §828.015, which provides the Texas Board of Health (board) with the authority to appoint a committee to provide advice on the dispensing of grant money in the animal friendly license plate account to eligible organizations for the purpose of providing low-cost dog and cat sterilization to the general public; and §12.001, which provides the 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.

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 4, 2003.

TRD-200302215

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: January 31, 2003

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


Chapter 221. MEAT SAFETY ASSURANCE

Subchapter B. MEAT AND POULTRY INSPECTION

25 TAC §221.12

The Texas Department of Health (department) adopts an amendment to §221.12, concerning meat and poultry inspection. Section 221.12 is being adopted without changes to the proposed text as published in the December 6, 2002, issue of the Texas Register (27 TexReg 11406) and, therefore, the section will not be republished. The amendment to §221.12 increases the fee per hour for overtime inspection and special services.

The Texas Meat and Poultry Inspection Act allows the department to collect fees for overtime and special services provided to establishments and for services required to be performed under this act relating to the inspection of animals, birds, or products that are not regulated under the Federal Meat Inspection Act or the Federal Poultry Products Inspection Act. The department does not collect a fee for inspection services required under the Texas Meat and Poultry Inspection Act, but not required under the federal acts. However, the department does collect a fee for overtime and special services provided to establishments. The current fee of $23 per hour is not sufficient to recover the cost of providing the services, so the department is increasing the fee to $29.50 per hour. The new fee is expected to cover the cost of providing overtime inspection and special services to industry.

There were no comments received on the proposal during the 30-day comment period.

The amendment is adopted under the Health and Safety Code, Chapter 433, which provides the department with the authority to adopt necessary regulations pursuant to the enforcement of Chapter 433; 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.

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 4, 2003.

TRD-200302212

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Chapter 227. MINIMUM GUIDELINES FOR HUMAN DONOR MILK BANKS

25 TAC §227.1

The Texas Department of Health (department) adopts new §227.1, concerning minimum guidelines for human donor milk banks without changes to the proposed text as published in the December 6, 2002, issue of the Texas Register (27 TexReg 11406), and the section will not be republished.

House Bill 391, 77th Legislative Session, 2001, added new §161.071 to the Health and Safety Code, which requires the department to establish minimum guidelines for the procurement, processing, distribution, or use of human milk by donor milk banks. Specifically, the new section adopts by reference the "Guidelines for the Establishment and Operation of a Donor Human Milk Bank" written by the Human Milk Banking Association of North America.

There were no comments received regarding the proposed new section during the comment period.

The new section is adopted under the Health and Safety Code, §161.071, which provides the department with the authority to adopt necessary minimum guidelines for the procurement, processing, distribution, or use of human milk by donor milk banks; 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.

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 4, 2003.

TRD-200302219

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Chapter 229. FOOD AND DRUG

The Texas Department of Health (department) adopts the repeal of §229.261, and new §229.261, concerning the assessment of an administrative penalty against food and drug operations. The repeal and new section are adopted without changes to the proposed text as published in the December 6, 2002, issue of the Texas Register (27 TexReg 11411) and, therefore, the section will not be republished.

The new rule applies to the following programs within the Bureau of Food and Drug Safety: food wholesaler and manufacturer, wholesale drug manufacturer and distributor, device manufacturer and distributor, narcotic treatment program, retail food establishment, tanning facility, tattoo studio, body piercing studio, salvage establishment, and salvage broker.

The title of the subchapter, new rule, and the language have been changed to more accurately reflect the fact that administrative penalties are assessed by the department, but civil penalties are not. The definitions of the severity levels have been clarified. In addition, examples of violations categorized by severity level have been removed from the rule. Examples of violations will be provided to the regulated community in a guidance document available from the Bureau. Persons and entities that will be impacted by this rule include the department staff, and licensed persons who are not in compliance with the applicable regulations.

Health and Safety Code, Chapter 145, §145.0122, Chapter 146, §146.019, Chapter 431, §431.054, Chapter 432, §432.021, Chapter 437, §437.018, and Chapter 466, §466.043, authorize the department to assess an administrative penalty against a person who violates these statutes. With these changes, the new rule will be consistent with these chapters.

Government Code §2001.039, requires each state agency to review and consider for adoption each rule adopted by that agency pursuant to Government Code, Chapter 2001 (Administrative Procedure Act). The current rule has been reviewed and the department has determined that reasons for adopting the section continue to exist. However, because substantial changes have been made to simplify this section, the current rule is being repealed and a new rule adopted.

The department published a Notice of Intention to Review for §229.261 in the Texas Register on February 25, 2000 (25 TexReg 1731). No comments were received as a result of the publication of the notice.

There were no comments received regarding the proposed repeal and new section during the comment period.

Subchapter P. ADMINISTRATIVE OR CIVIL PENALTIES

25 TAC §229.261

The repeal is adopted under the Health and Safety Code, Chapter 145, §145.011, Chapter 146, §146.015, Chapter 431, §431.241, Chapter 432, §432.011, Chapter 437, §437.0056, and Chapter 466, §466.004, which all require the department to adopt rules for the implementation and efficient enforcement of Chapters 145, 146, 431, 432, 437, and 466; and the Health and Safety Code, §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; and implements Government Code, §2001.039.

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 4, 2003.

TRD-200302213

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Subchapter P. ASSESSMENT OF ADMINISTRATIVE PENALTIES

25 TAC §229.261

The new section is adopted under the Health and Safety Code, Chapter 145, §145.011, Chapter 146, §146.015, Chapter 431, §431.241, Chapter 432, §432.011, Chapter 437, §437.0056, and Chapter 466, §466.004, which all require the department to adopt rules for the implementation and efficient enforcement of Chapters 145, 146, 431, 432, 437, and 466; and the Health and Safety Code, §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; and implements Government Code, §2001.039.

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 4, 2003.

TRD-200302214

Susan K. Steeg

General Counsel

Texas Department of Health

Effective date: April 24, 2003

Proposal publication date: December 6, 2002

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


Part 2. TEXAS DEPARTMENT OF MENTAL HEALTH AND MENTAL RETARDATION

Chapter 404. PROTECTION OF CLIENTS AND STAFF

Subchapter G. UNUSUAL INCIDENTS INVOLVING PERSONS SERVED BY TXMHMR FACILITIES

25 TAC §§404.241 - 404.249

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts the repeals of §§404.241 - 404.249 of Chapter 404, Subchapter G, concerning unusual incidents involving persons served in TXMHMR facilities, without changes to the proposal as published in the November 29, 2002, issue of the Texas Register (27 TexReg 11043).

The reporting procedures contained in the subchapter have been incorporated into internal policy and the reasons for initially adopting the rules no longer exist.

The repeal of this subchapter fulfills the requirements of the Texas Government Code, §2001.039, concerning the periodic review of agency rules.

No comments on the proposed repeals were received.

The repeals are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority.

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, 2003.

TRD-200302192

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2003

Proposal publication date: November 29, 2002

For further information, please call: (512) 206-4516


Chapter 407. INTERNAL FACILITIES MANAGEMENT

Subchapter A. FINANCIAL SERVICES

25 TAC §§407.1 - 407.6, 407.22 - 407.24

The Texas Department of Mental Health and Mental Retardation (department) adopts the repeal of existing §§407.1 - 407.6 and §§407.22 - 407.24 of Chapter 407, concerning financial services without changes to the proposal in the December 13, 2002, issue of the Texas Register (27 TexReg 11708). New Chapter 417, Subchapter A, concerning substantially the same matters is contemporaneously adopted in this issue of the Texas Register .

Sections 407.1 - 407.6 and §§407.22 - 407.24 of Chapter 407 primarily describe the department's procedures for managing department and benefit funds as well as the consumer trust fund. The adoption of the repeal of the existing sections and the new sections is made according to the department's rule review as required by the Texas Government Code, §2001.039.

Comments were not received from the public.

The repeal is adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority.

The repeal affects the Texas Health and Safety Code, §551.001 and §§551.003 - 551.005.

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 7, 2003.

TRD-200302263

Rudy Arrendondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 13, 2002

For further information, please call: (512) 206-4516


Subchapter C. LEASE OF TDMHMR SURPLUS PROPERTY

25 TAC §407.120

The Texas Department of Mental Health and Mental Retardation (department) adopts the repeal of existing §407.120 of Chapter 407, Subchapter C, concerning lease of TDMHMR surplus property, without changes to the proposAL in the December 13, 2002, issue of the Texas Register (27 TexReg 11709). New Chapter 417, Subchapter A, concerning substantially the same matter is contemporaneously adopted in the this issue of the Texas Register .

Section 407.120 described the requirements associated with the long-term lease of TDMHMR surplus property. The adoption of the repeal of the existing section and new sections are made according to the department's rule review plan that is required by Texas Government Code, §2001.039.

Comments from the public were not received.

The repeal is adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority and Texas Government Code, §2001.039, which requires the department to review its rules.

The repeal affects no statute, article, or code.

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 7, 2003.

TRD-200302264

Rudy Arrendondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 13, 2002

For further information, please call: (512) 206-4516


Chapter 410. VOLUNTEER SERVICES AND PUBLIC INFORMATION

Subchapter C. CAPITAL IMPROVEMENTS BY CITIZEN GROUPS

25 TAC §§410.101 - 410.122

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts the repeal of existing Chapter 410, Subchapter C, §§410.101 - 410.122, concerning capital improvements by citizens groups without changes to the proposal as published in the December 6, 2002, issue of the Texas Register (27 TexReg 11448). The repealed sections are replaced by new Chapter 417, Subchapter D, §§417.151 - 417.160, which contain substantially the same matters, are contemporaneously adopted in this issue of the Texas Register .

The repealed §§410.101 - 410.122 provided policies and procedures for citizens and community groups to donate a capital improvement to a facility.

The adoption of the repeals and new rule fulfill the requirements of Texas Government Code, §2001.039, concerning the periodic review of department rules.

Comments were not received from the public.

The repeals are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority and Texas Government Code §2001.039, which requires the department to review its rules.

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 7, 2003.

TRD-200302268

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 6, 2002

For further information, please call: (512) 206-4516


Chapter 414. PROTECTION OF CONSUMERS AND CONSUMER RIGHTS

Subchapter A. CLIENT-IDENTIFYING INFORMATION

25 TAC §§414.1 - 414.17

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts the repeals of §§414.1 - 414.17 of Chapter 414, Subchapter A, concerning client-identifying information, without changes to the proposal as published in the February 7, 2003, issue of the Texas Register (28 TexReg 1039). New §§414.1 - 414.8 of Chapter 414, Subchapter A, concerning protected health information, which replace the repealed sections, are contemporaneously adopted in this issue of the Texas Register .

The repeals allow for the adoption of new sections governing the same matters.

No comments on the proposed repeals were received.

The repeals are adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Mental Health and Mental Retardation Board (board) with broad rulemaking authority, and §533.009, which requires the board to adopt rules governing the exchange of patient and client records without the patient's or client's consent among department facilities, local mental health or mental retardation authorities, community centers, other designated providers, and subcontractees of mental health and mental retardation services.

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, 2003.

TRD-200302194

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2003

Proposal publication date: February 7, 2003

For further information, please call: (512) 206-4516


Subchapter A. PROTECTED HEALTH INFORMATION

25 TAC §§414.1 - 414.8

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts new §§414.1 - 414.8 of Chapter 414, Subchapter A, concerning protected health information. Sections 414.4 - 414.7 are adopted with changes to the proposed text as published in the February 7, 2003, issue of the Texas Register (28 TexReg 1040). Sections 414.1 - 414.3, and §414.8 are adopted without changes. The repeals of existing §§414.1 - 414.17 of Chapter 414, Subchapter A, concerning client-identifying information, which the new sections replace, are contemporaneously adopted in this issue of the Texas Register .

The new rules require facilities, local authorities, community centers, and their respective contract providers to comply with all applicable federal and state statutes, rules, and regulations governing privacy of protected health information. The new rules list applicable federal and state statutes, rules, and regulations. The new rules also require the Notice of Privacy Practice of each facility, local authority, and community center to include information regarding permitted disclosures under Texas Health and Safety Code, §533.009. Additionally, the new rules require each facility, local authority, and community center to include in its Notice of Privacy Practice a statement that identifies it as a part of the TDMHMR service delivery system and a statement that individuals may file a complaint with TDMHMR Consumer Services and Rights Protection/Ombudsman Office by calling 1-800-252-8154 or writing to P.O. Box 12668, Austin, Texas 78711.

The new rules also reference TDMHMR's "Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the TDMHMR Service Delivery System," which is an interpretation of the applicable federal and state statutes, rules, and regulations listed in the new rules. The new rules require TDMHMR Central Office and all facilities to comply with the interpretive guidance. Although the new rules do not require local authorities and community centers to comply with the interpretive guidance, TDMHMR notes that the document is the result of its analysis of the interaction of the numerous state and federal laws that govern the privacy of health information, including preemption of conflicting state laws. TDMHMR will be guided by the document in assessing the compliance with applicable privacy laws by local authorities and community centers.

Upon adoption, the title of Exhibit A that is referenced in §414.4(a)(2) and §414.6 has been changed to "Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the TDMHMR Service Delivery System." Two state statutes have been added to §414.5 and §414.7. In §414.6, a toll free number has been added as a more expedient manner of requesting a copy of Exhibit A as well as a web address for accessing the exhibit via the Internet.

Changes made to Exhibit A between the subchapter's proposal and adoption include adding the term "community center" to the definitions of "component" and "contract provider" in §2 and throughout the document, as appropriate. Language has been added to the definition of "MHMR services" to specifically exclude any services for alcohol or drug abuse, substance abuse, or chemical dependency. The requirement for components to document their designated record sets has been moved from §15(e)(1) to a new subsection (b) in §4. Language related to limiting incidental uses and disclosures has been revised in §4 to be consistent with the federal privacy rule. Language has been modified in §5(g) to clarify that §5(f) describes how a revised notice is to be made available. Language has been added to §6(a)(2) to ensure that determinations are individualized. Language has been modified in §8(a) to clarify that facilities are not responsible for designating a privacy official and that facilities' privacy coordinators will work with the TDMHMR Central Office Privacy Official. Language has also been added clarifying that the privacy official may be a current member of the component's workforce who performs other types of duties.

Clarifying language has been added to §9(b)(3). The term "advising" has been changed to "informing" in §9(e) and (f) and §10(d). Language has been modified in §10(b) to be consistent with federal regulations. Clarifying language has been added to §11(c)(9). The subsection related to conditioning the provision of alcohol or drug abuse treatment on the individual signing an authorization has been deleted in §11. Minor grammatical changes have been made in §12(b)(2)(B)(i) and §13(b)(2)(A). Language has been added to §15(a)(1) clarifying that an individual's LAR who is acting on the individual's behalf has a right of access to PHI about the individual. Language has been added to §15(d)(1) stating that an LAR is not entitled to access the individual's PHI that relates to alcohol or drug abuse treatment unless the individual is incompetent (as defined). The provision in proposed §15(d)(3)(ii) has been deleted. Clarifying language has been added to §19(d). The sections relating to attachments and references have been combined under §21 and references to the Texas Health and Safety Code, §614.017, and Texas Government Code, §531.042, have been added.

Minor clarifications have been made to Attachments AA, BB, CC, and DD. Additionally, language has been added to Attachments BB and CC stating that federal rules restrict any use of information about alcohol or drug abuse treatment to criminally investigate or prosecute any alcohol or drug abuse patient.

A public hearing was held on February 21, 2003. No oral or written testimony was presented at the hearing. Written comments on the proposal were received from Hilgers & Watkins, P.C., Austin; Heart of Texas Region MHMR Center, Waco; Advocacy, Inc., Austin; MHMR Authority of Harris County, Houston; and the Texas Council for Developmental Disabilities, Austin.

One commenter stated, "The most important and informative set of information is in 'Exhibit A.' It cannot be assumed that the public has access to or understanding of the information which is contained in Exhibit A, but that information is vital if the public is to understand their rights and exercise them within the Department's processes. As stated in previous conversations we believe it is in the best interest of the public if Exhibit A is adopted by reference." TDMHMR declines to adopt Exhibit A by reference because it would not provide the public with greater access to the information. (Documents that are adopted by reference are not published in the Texas Register .) TDMHMR notes that §414.6 provides information on how to obtain a copy of the exhibit. Additionally, a toll free phone number has been added to §414.6 as well as a statement that the exhibit is accessible via the Internet at www.mhmr.state.tx.us/hipaa.html.

Regarding the definitions of "component" and "contract provider" in §2 of Exhibit A, one commenter asked whether community centers should be included. TDMHMR responds by adding the term "community center" throughout Exhibit A, as appropriate.

Regarding limiting incidental uses and disclosures of PHI in proposed §4(c)(1)(B) of Exhibit A, one commenter recommended modifying the language to state that a component must make a diligent effort to prevent incidental uses or disclosures. TDMHMR responds that the provision originates in 45 CFR §164.530(c)(2)(ii). Language related to limiting incidental uses and disclosures has been revised in §4 to be consistent with the federal privacy rule.

Regarding mitigating harmful effects which are the result of a violation of medical privacy laws in proposed §4(c)(3) of Exhibit A, one commenter asked what process would facilities use to accomplish this requirement. TDMHMR responds that any action taken by a facility would depend upon the circumstances of the particular situation. TDMHMR notes that in the Federal Register (65 Fed. Reg. 82,748 (2000)), the United States Department of Health and Human Services (HHS) responded to a similar comment by stating, "The covered entity is expected to take reasonable steps based on knowledge of where the information has been disclosed, how it might be used to cause harm to the patient or another individual, and what steps can actually have a mitigating effect in that specific situation."

Regarding consent to carry out treatment, payment, or health care operations in adopted §4(f) of Exhibit A, one commenter asked "why permit the use or disclosures when not necessary." The commenter stated that it would potentially confuse an individual or LAR and place him/her in a situation in which due process is not offered. TDMHMR responds that §4(f) is permissive; obtaining consent to carry out treatment, payment, or health care operations is at the discretion of each component. If a component determines that obtaining consent would confuse individuals and LAR, then the component may choose to not obtain consent. TDMHMR notes that the provision originates in 45 CFR §164.506(b).

Regarding making available to individuals a revised notice of privacy practices in §5(g) of Exhibit A, one commenter stated that the subsection does not articulate how a component should make the revised notice available to consumers. TDMHMR responds that §5(f) describes how the notice is to be made available. Clarifying language has been added in §5(g) to reflect this.

Regarding the requirement to document an individual's receipt of the Notice of Privacy Practices in §5(h) of Exhibit A, one commenter asked if her component should add a signature line to Attachment CC. TDMHMR responds that the commenter's component is responsible for deciding how to comply with the documentation requirement. TDMHMR notes that state mental health facilities have developed a separate form for documenting receipt of various information, including the Notice of Privacy Practices. State mental retardation facilities will use a separate form for acknowledgement of receipt of the notice.

Regarding use, disclosure, or request for an entire medical record in §6(a)(2) of Exhibit A, one commenter expressed concern that the intent of the language, which is to ensure individualized determinations are made, could be lost and the process manipulated into a blanket policy to routinely request an entire record in an effort to expedite requests for information. The commenter suggested revised language to address the concern. TDMHMR responds by using the commenter's suggested language.

Regarding complaints in §7 of Exhibit A, one commenter expressed concern that the term "complaint" does not convey the serious nature of the charges that an individual may be making with regard to misuse of his or her records. The commenter suggested that the term "complaint" be replaced with "charges of improper disclosure of PHI" in §7(a). The commenter also suggested that the phrase "a process for individuals to make complaints concerning" be replaced with "a process for individuals to file official complaints concerning." The commenter also expressed concern that §7 provides no information relating to penalties or remedies for having committed a violation of privacy laws and recommended adding a description of the penalties and remedies to ensure that both providers of services and individuals are aware of the serious nature of these laws. TDMHMR responds that the term "complaint" originates in the federal privacy rule, specifically, 45 CFR Part 160, Subpart C, §164.520(b)(1)(vi), and §164.530(d). To be consistent with federal regulations, TDMHMR declines to replace the term "complaint" as suggested by the commenter. TDMHMR notes that penalties for violating the federal privacy regulations, which are described in federal law (42 USC §1320d-6, 42 USC §290ee-3(f), and 42 USC §290dd-3(f)), would be imposed by HHS and not TDMHMR or a component.

Regarding complaints in §7 of Exhibit A, one commenter asked if the Office of Consumer Services and Rights Protection will maintain complaint information, such as number and type, and make it available to the public as it does for other risk indicators. TDMHMR responds that it will.

Regarding designation of a privacy official in §8(a) of Exhibit A, one commenter suggested that the sentence state, "Each component must designate a staff who will function in the capacity of the privacy official ..." TDMHMR declines to use the commenter's suggested language because a component's privacy official does not have to be a staff of the component. Language has been added clarifying that the privacy official may be a current member of the component's workforce who performs other types of duties.

Regarding disclosure of PHI without authorization to provide treatment and ensure continuity of care in §9(a)(2)(A) of Exhibit A, one commenter asked if such continuity of care applied to special needs offenders. The commenter also asked if chemical dependency treatment information is protected under the section. TDMHMR responds that the continuity of care referenced in §9(a)(2)(A) applies to all individuals served by components. As it relates to special needs offenders, the provision does not allow components to disclose a special needs offender's PHI to any entity or person other than a component. TDMHMR notes protection of PHI that relates to alcohol and drug abuse treatment is addressed in §10.

One commenter asked if TDMHMR takes the position that substance abuse information can be released to coroners and medical examiners. The commenter referenced §9(d)(6) of Exhibit A. TDMHMR responds that it does not take the position that substance abuse information can be released to coroners and medical examiners. Section 9(d)(6) referenced by the commenter governs psychotherapy notes under MHMR services. Section 10 governs when authorization is not required to disclose PHI that relates to alcohol or drug abuse treatment.

Regarding §9(f) of Exhibit A, one commenter expressed grave concerns that a professional could disclose PHI about an individual receiving mental retardation services without authorization when informing the individual's parent, guardian, relative, or friend of the individual's current physical condition. The commenter stated that the provision seems contrary to the intent of privacy laws and suggested that more restrictive parameters be delineated for releasing information regarding current physical and mental conditions to unauthorized individuals. TDMHMR responds that both state law (Texas Health and Safety Code, §595.010) and federal law (45 CFR §164.510(b)) authorizes such disclosures.

Regarding §11(c)(9) of Exhibit A, one commenter stated that the wording was confusing and incomprehensible. TDMHMR responds by adding clarifying language.

Regarding conditioning alcohol or drug abuse treatment on an individual's signing an authorization in §11(i) of Exhibit A, one commenter asked why the provision exists since MHMR services are not conditioned upon signing an authorization. The commenter stated that it is the position of Advocacy, Inc., that no treatment should be conditioned upon signing an authorization for disclosure and that such a provision is, at best, questionable clinical practice. TDMHMR responds by deleting §11(i). TDMHMR notes that for minors 16 and 17 years of age, 42 CFR §2.14(b) allows conditioning alcohol or drug abuse treatment on the minor individual's signing an authorization for disclosure of PHI that is necessary for the provider to obtain payment for the alcohol or drug abuse treatment.

Regarding a component administrator authorizing disclosure of PHI related to alcohol or drug abuse treatment in §13(a)(2) of Exhibit A, one commenter recommended adding a statement that directs component administrators to exercise reasonable efforts to obtain authorization for disclosure of PHI from individuals who experience episodic times during which they are unable to authorize disclosure. TDMHMR declines to add the commenter's suggested requirement because it is unnecessary considering the very limited situation being described (i.e., the adult suffers from a medical condition , the authorization is for the sole purpose of obtaining payment for alcohol or drug abuse treatment from a third-party payor). TDMHMR notes that the provision originates in 42 CFR §2.15(a)(2).

Regarding who may authorize the use or disclosure of PHI of a minor 15 years of age or younger who is receiving inpatient alcohol or drug abuse treatment in §13(b)(2)(A) of Exhibit A, one commenter expressed surprise that both the minor and the minor's LAR must authorize a use or disclosure of PHI and asked if the provision was written accurately. The commenter asked if there was a minimum age or whether the provision applied to a minor who is five years old. Two commenters asked what would happen if the minor and the minor's LAR disagreed. One of the commenters asked if either would be offered due process if such a disagreement occurs. TDMHMR responds that the provision is written accurately. Pursuant to 42 CFR §2.14, the determination of who may authorize use or disclosure is based on whether or not state law requires parental consent to the minor's treatment for inpatient alcohol or drug abuse treatment. Texas law (Health and Safety Code, §462.022(a)(3)(A)) requires the consent of a parent, managing conservator, or guardian of a minor who is 15 years of age or younger. Section 2.14(c)(1) of 42 CFR states, "Where State law requires consent of a parent, guardian, or other person for a minor to obtain alcohol or drug abuse treatment, any written consent for disclosure authorized under subpart C of these regulations must be given by both the minor and his or her parent, guardian, or other person authorized under State law to act in the minor's behalf." TDMHMR notes that no minimum age is prescribed by state or federal law. Regarding disagreement between the minor and the LAR, TDMHMR's interpretation is that both the minor and the LAR must agree or the disclosure cannot be made. Regarding the offer of due process if a disagreement occurs, TDMHMR responds that the disagreement is between the minor and LAR and does not involve the component; therefore, there is no basis for due process.

Regarding §15(c)(4) and §17(b)(3) of Exhibit A, one commenter noted that facilities were given specific maximum charge amounts for providing copies and accountings and asked if the maximum charges were appropriate for community centers as well. TDMHMR responds that each component, including facilities, is responsible for determining whether it will impose a fee. If a component decides to impose a fee, then the component (except a facility) is also responsible for determining the fee amount, which must be reasonable and cost-based. If a facility decides to impose a fee, then the facility's fee may not exceed the charges described in the boxes under §16(c)(4) and §17(b)(3) in Exhibit A. TDMHMR notes that the maximum per page charges for facilities described in Exhibit A are those established by the Texas Department of Health (see www.tdh.state.tx.us/hfc/feeinfo.htm). TDMHMR also notes the federal privacy rule (specifically, 45 CFR §164.524(c)(4)) identifies the elements that are permitted to be included in a fee for copies.

Regarding facilities' maximum charges for copies and accountings in §15(c)(4) and §17(b)(3) of Exhibit A, one commenter stated that the charges are unreasonable because many individuals accessing the services through components are living at or close to the poverty level. TDMHMR responds that the maximum per page charges for facilities described in Exhibit A are those promulgated by the Texas Department of Health at www.tdh.state.tx.us/hfc/feeinfo.htm, which states "In accordance with §241.154(e) of the Health and Safety Code, the fee for providing a patient's health care information has been adjusted 1.3% to reflect the most recent changes to the consumer price index as published by the Bureau of Labor Statistics (BLS) of the United States Department of Labor. The BLS measures the average changes in prices of goods and services purchased by urban wage earners and clerical workers." TDMHMR notes that facilities are not required to impose a fee, nor are they required to impose the maximum fee.

Regarding denying a request for amendment in §16(b)(3) of Exhibit A, one commenter expressed concern that components would be able to make a sole determination as to the accuracy and completeness of the PHI. The commenter stated that since the amendment of PHI as offered by the individual does not supplant the original information, the individual should be given the right to add his or her comment to the record. TDMHMR declines to revise the provision because it originates in 45 CFR §164.526(a)(2)(iv). TDMHMR notes that under 45 CFR §164.526(d)(2) and §16(e)(2) of Exhibit A, the individual is permitted to submit a statement of disagreement regarding the denial of an amendment, which will be kept in the individual's record.

Regarding §16(c)(2)(A) and (B) and §17(b)(2) of Exhibit A, one commenter stated that the 60-day and 30-day time frames are unreasonably lengthy. The commenter noted that "in most cases, a component should be able be able to respond to requests within 30 days, allowing for 60 days on rare occasions." TDMHMR responds that the time frames originate in 45 CFR §164.526(b)(2) and §164.528(c)(1) and represent the maximum time allowed. TDMHMR agrees with the commenter that, in most cases, a component should be able be able to respond to requests within 30 days.

Regarding confidential communications in §19(d) of Exhibit A, one commenter suggested the language be changed to state, "A component shall not require an explanation from the individual as to the basis for the request as a condition of providing confidential communications." The commenter also suggested adding a new subsection (e) to state, "An individual shall not be required to explain why a request for confidential communications of PHI is being made." TDMHMR has revised the language to address the commenter's concern.

Regarding a business associate agreement being unnecessary if disclosure of an individual's PHI by the component to a business associate concerns the treatment of the individual in §20(a)(1) of Exhibit A, one commenter stated that business associates do not provide treatment. TDMHMR responds that the definition of "business associate" in 45 CFR §160.103 and §3(4)(A) of Exhibit A includes a person, other than a member of the component's workforce, who, on behalf of the component, performs or assists in the performance of "any other function or activity regulated by the Federal Privacy Rule." Therefore, a treatment provider who is not component employee or a member of its workforce could be a business associate.

Regarding business associate agreements in §20(c) of Exhibit A, one commenter stated that a conscious violation, a pattern or practice of violations of misuse of PHI, is a serious matter and should call for an immediate report to the Secretary of the United States Department of Heath and Human Services. The commenter recommended strengthening the provision in (c) by including the penalties that may be applied when the privacy laws are violated. TDMHMR declines to add penalties as recommended by the commenter because the only action a component may take against a business associate who violates the terms of the agreement are those described in §20(c)(1) and (2) and any others as described in the agreement itself. TDMHMR notes that penalties for violating the federal privacy regulations, which are described in federal law (42 USC §1320d-6, 42 USC §290ee-3(f), and 42 USC §290dd-3(f)), would be imposed by HHS and not TDMHMR or a component.

Regarding the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter questioned why the component did not have to send out copies of the notice each time the component changed the notice's content. The commenter stated that some individuals may not have access to the Internet or be present at the facilities at which the new notice is posted. The commenter suggested that individuals be sent the revised notice. TDMHMR responds that the provision originates in 45 CFR §164.520(c)(2)(iv). TDMHMR declines to add the requirement as suggested by the commenter because it would be unreasonably burdensome and is not required by state or federal law. Further, only a small percentage of individuals would not have access to the Internet or would not go to a component's premises where they could obtain a revised notice or view a posted revised notice.

Regarding the fourth bullet on the first page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter suggested that individuals be given a point of contact to report any suspected violations of the privacy laws. TDMHMR responds that the fourth page of the attachments lists several points of contact with whom individuals may file a complaint or get further information.

Regarding the first bullet in the section titled "Your Privacy Rights at ..." on the second page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter suggested that some explanation of reasons be given regarding the statement "There are some reasons why we will not let you see or get a copy of your health information..." TDMHMR responds that the reasons for denying an individual assess to his or her health information are described in §15(d)(1) and (d)(2) of Exhibit A. TDMHMR notes that the notice states "if we deny your request [for access] we will tell you why." Additionally, on the last page of the notice, individuals are invited to contact the TDMHMR Privacy Officer for more information regarding the notice.

Regarding the third bullet in the section titled "Your Privacy Rights at ..." on the second page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter stated that it would be helpful to know what would be included on the list instead of what would not be included. TDMHMR responds that the first part of the sentence states what will be included in the list (i.e., the disclosures of your health information that the component made to other people in the last six years). The list will include all disclosures except those described in the second sentence of the bullet.

Regarding the fourth bullet in the section titled "Your Privacy Rights at ..." on the second page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter suggested adding language to state that the component will make a good faith effort to abide by an individual's request to restrict the way health information is used to the extent allowed by law. TDMHMR declines to add language as suggested by the commenter because it is possible that a component would not be able to "make a good faith effort to abide by" every request for restriction.

Regarding the introductory sentence on the third page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, one commenter suggested that an assurance be given to individuals that, although their permission is not required, they will receive notification of the disclosure of health information. TDMHMR declines to add requirements for such assurance and notification as suggested by the commenter because it would be unreasonably burdensome and is not required by state or federal law. TDMHMR notes that individuals may request an accounting of disclosures if they so desire.

Regarding the fourteenth bullet on the third page of the Notice of Privacy Practices in Attachments BB and CC of Exhibit A, a commenter again expressed concern that PHI about an individual receiving mental retardation services could be disclosed without authorization when informing the individual's parent, guardian, relative, or friend of the individual's current physical condition. The commenter stated that the provision seems contrary to the intent of privacy laws and suggested that more restrictive parameters be delineated for releasing information regarding current physical and mental conditions to unauthorized individuals. TDMHMR responds that both state law (Texas Health and Safety Code, §595.010) and federal law (45 CFR §164.510(b)) authorizes such disclosures. TDMHMR notes that federal law (45 CFR §164.514(h)) and §4(e)(1) of Exhibit A requires a component to verify the identity of a person requesting health information.

Regarding the bolded sentence under "Payment" in the section titled "Treatment, Payment, and Health Care Operations" on the second page of the Notice of Privacy Practices in Attachment CC of Exhibit A, one commenter stated that the term "matching programs" should be defined, in order to make the statement clear to the average individual. TDMHMR responds that this sentence is included pursuant to 5 USC §552a(o)(1)(D), which requires an entity administering federal benefit programs to provide individualized notice to applicants and recipients of financial assistance under such programs that any information provided by them may be subject to verification through matching programs. TDMHMR declines to add a definition of "matching program" because the definition, which is contained in 5 USC §552a(a)(8), is extremely lengthy and complex and would not provide clarification. TDMHMR notes that on the last page of the notice, individuals are invited to contact the TDMHMR Privacy Officer for more information regarding the notice.

Regarding the notation on Attachment DD of Exhibit A relating to the form's appropriateness as the consent required by 42 CFR §2.31, one commenter asked "under 42 CFR, Part 2 is it not stated, 'This information has been ... and cannot be used to prosecute ...'?" The commenter stated that "it would seem appropriate to continue the use of that phrase on" Attachment DD of Exhibit A. The commenter also stated that "the federal law prohibits the use of a 'general release' for chemical dependency treatment." TDMHMR responds that, instead of including the information in Attachment DD, it has added language to the Notice of Privacy Practices in Attachments BB and CC stating that federal rules restrict any use of information about alcohol or drug abuse treatment to criminally investigate or prosecute any alcohol or drug abuse patient. TDMHMR notes that 42 CFR §2.32 and §14 of Exhibit A require a notice to accompany all disclosures of PHI that relate to alcohol or drug abuse treatment, and the notice states that 42 CFR Part 2 restricts any use of the disclosed PHI to criminally investigate or prosecute any alcohol or drug abuse patient. Additionally, Attachment DD should not be considered a "general release" because it requires a description of the specific types of information, including time period covered, to be disclosed, used, or received.

Regarding the "Note" portion of Attachment DD of Exhibit A, a commenter expressed concern about the clarity of the language, especially the term "re-disclosure." The commenter suggested replacing the phrase "the information disclosed pursuant to this authorization may not be protected by medical privacy laws and may be subject to re-disclosure by the recipient" be changed to state, "by signing this form your medical information may not be protected by medical privacy laws. The organization or facility that you are authorizing to receive your medical information may disclose that information to other entities." TDMHMR responds by adding clarifying language to address the commenter's issue.

One commenter asked whether the 42 CFR Part 2 protections apply to an individual with chemical dependency issues documented in his or her records if the individual is not receiving, and has never received, treatment for the dependency and the component does not provide chemical dependency services. TDMHMR responds that the situation referenced by the commenter is not addressed in federal or state law and suggests the commenter consult legal counsel for advice regarding compliance with applicable laws, rules, and regulations.

One commenter asked how the proposed rules impact the Texas Council for Offenders with Mental Impairments (TCOMI). TDMHMR responds that the rules do not apply to TCOMI and should have no impact on it except to the extent that a component's compliance with these rules affects how TCOMI receives, uses, or discloses PHI. TDMHMR notes that facilities, local authorities, and community centers currently may exchange PHI and other information relating to a special needs offender as permitted by §614.017 of the Texas Health and Safety Code, which is part of TCOMI's enabling legislation. However, the federal privacy rule preempts this state statute; therefore, the practice must cease on April 14, 2003, when the federal privacy rule becomes effective. TDMHMR also notes that a bill (Senate Bill 519) has been introduced in the 78th Texas Legislative Session which would require the exchange of certain information among the entities and persons described in §614.017(c)(1) of the Texas Health and Safety Code, rather than permit the exchange, which would allow components to continue to exchange information under §614.017. If Senate Bill 519 is passed, TDMHMR will amend Exhibit A to include the exchange of information for special needs offenders.

One commenter asked if it is a violation of privacy to use envelopes with the component's return address when mailing notices and reminders to individuals. The commenter noted that no one would know from the envelope that the individual was receiving MHMR services, unless the envelope identified the addressee as a "consumer." TDMHMR responds that the situation referenced by the commenter is not specifically addressed in federal or state law and suggests the commenter consult legal counsel for advice regarding compliance with applicable laws, rules, and regulations.

The new sections are adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Mental Health and Mental Retardation Board (board) with broad rulemaking authority, and §533.009, which requires the board to adopt rules governing the exchange of patient and client records without the patient's or client's consent among department facilities, local mental health or mental retardation authorities, community centers, other designated providers, and subcontractees of mental health and mental retardation services.

§414.4.Requirements.

(a) TDMHMR Central Office and each facility, local authority, and community center shall comply with all applicable federal and state statutes, rules and regulations pertaining to privacy of protected health information (PHI) including, but not limited to, the federal and state statutes, rules and regulations described in §414.5 of this title (relating to Regulations and Statutes Governing Confidentiality of Protected Health Information).

(1) As set forth in 45 CFR Part 160 Subpart B, where a provision of 45 CFR Part 160 or 164 is contrary to a provision of state law, the federal regulation preempts the state law unless the provision of state law:

(A) is more stringent (as defined) than the provision of the federal regulation;

(B) provides for the reporting of disease or injury, child abuse, birth, or death, or for the conduct of public health surveillance, investigation, or intervention; or

(C) requires a health plan to report, or to provide access to, information for the purpose of management audits, financial audits, program monitoring and evaluation, or the licensure or certification of providers or persons.

(2) TDMHMR's "Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the TDMHMR Service Delivery System," referenced as Exhibit A in §414.6 of this title (relating to Exhibits), provides an interpretation of the applicable federal and state statutes, rules and regulations described in §414.5 of this title, applying the preemption provisions described in paragraph (1) of this subsection. TDMHMR Central Office and all facilities must comply with the "Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the TDMHMR Service Delivery System."

(b) Information to be included in Notice of Privacy Practice.

(1) Each facility, local authority, and community center shall include in its Notice of Privacy Practice a statement that disclosures may be made between facilities, local authorities, community centers, their respective contract providers, and TDMHMR Central Office for the purpose of treatment, payment, or health care operations without the individual's consent as permitted by Texas Health and Safety Code, §533.009.

(2) TDMHMR Central Office and each facility, local authority, and community center shall include in its Notice of Privacy Practice a statement:

(A) that identifies it as a part of the TDMHMR service delivery system; and

(B) that individuals may file a complaint with TDMHMR Consumer Services and Rights Protection/Ombudsman Office by calling 1-800-252-8154 or writing to P.O. Box 12668, Austin, TX 78711.

(c) Each facility, local authority, and community center is responsible for ensuring that contracts with its contract providers require compliance with subsection (a) of this section.

§414.5.Regulations and Statutes Governing Confidentiality of Protected Health Information.

(a) Federal regulations. The following federal regulations pertain to privacy of protected health information (PHI):

(1) Code of Federal Regulations, Title 45, Parts 160 and 164, Federal Standards for Privacy of Individually Identifiable Health Information (i.e., Federal Privacy Rule), promulgated by the Secretary of the United States Department of Health and Human Services;

(2) Code of Federal Regulations, Title 42, Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, promulgated by the Secretary of the United States Department of Health and Human Services;

(3) Code of Federal Regulations, Title 34, Part 99, governing the disclosure of educational records of school-age children, promulgated by the Secretary of the United States Department of Education; and

(4) Code of Federal Regulations, Title 42, Part 51, Subpart D, and Code of Federal Regulations, Title 45, §1386.22, governing access to PHI by advocates for individuals with mental illness and mental retardation, promulgated by the Secretary of the United States Department of Health and Human Services.

(b) Federal statutes.

(1) The Health Insurance Portability and Accountability Act (HIPAA), 42 USC §1320d et seq. , provides the statutory authority for the United States Department of Health and Human Services to promulgate the Federal Privacy Rule.

(2) 42 USC §10805(a)(4) (Protection and Advocacy for Mentally Ill Individuals) and 42 USC §15043(a)(2)(I) (Protection and Advocacy of Individual Rights) provide the authority for access of PHI by Advocacy, Inc.

(3) 42 USC §290dd-2 provides the statutory authority to promulgate the federal regulations on confidentiality of alcohol and drug abuse patient records, referenced in subsection (a)(2) of this section.

(c) State statutes.

(1) Texas Health and Safety Code, Chapter 181, governing uses and disclosures of PHI in the State of Texas, applies portions of 45 CFR Parts 160 and 164 (Federal Privacy Rule) to most entities and persons not covered by HIPAA.

(2) Texas Open Records Act, Texas Government Code, Chapter 552, provides that all information collected, assembled, or maintained in any form by governmental bodies, and agencies operating in part or whole with state funds, in connection with the transaction of official business is public information; however, the act does set out certain exceptions. One such exception is information deemed confidential by law, such as PHI.

(3) Texas Health and Safety Code, §576.005 and Chapter 611, govern the confidentiality of PHI that relates to MHMR services.

(4) Texas Health and Safety Code, Chapter 81, Subchapter F, governs the confidentiality of information related to HIV/AIDS test results.

(5) The provisions for disclosure of PHI that relates to 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 Texas Health and Safety Code should be interpreted together in reaching a determination regarding the use or disclosure of PHI that relates to mental retardation services.

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

(7) Texas Medical Practice Act, Texas Occupations Code, Chapter 159, governs physician-patient communication.

(8) Texas Health and Safety Code, §533.009, governs the exchange of PHI between facilities, local authorities, community centers, and their respective contract providers.

(9) Texas Health and Safety Code, §595.005(c), governs the disclosure of educational records of individuals receiving mental retardation services.

(10) Texas Government Code, Chapter 559, provides that persons have a right to be informed about information that a state governmental body collects about them, and to have incorrect information that is possessed about them by a state governmental body corrected.

(11) Texas Family Code, Chapter 32, governs consent to treatment of a child by a non-parent or the child.

(12) Texas Health and Safety Code, Chapter 241, Subchapter G, governs the disclosure of PHI in hospitals licensed under the chapter.

(13) Texas Health and Safety Code, §614.017, governs the exchange of information relating to a special needs offender.

(14) Texas Government Code, §531.042, requires information regarding care and support options be given to at least one family member of a patient or client, if possible.

§414.6.Exhibit.

This subchapter references Exhibit A--"Interpretive Guidance on Laws Pertaining to Privacy of Mental Health and Mental Retardation Records for the TDMHMR Service Delivery System," copies of which are available by contacting TDMHMR, Policy Development, P.O. Box 12668, Austin, TX 78711-2668, or by calling toll free at 1-888-404-1511, extension 4516. The exhibit is also accessible via the Internet at www.mhmr.state.tx.us/hipaa.html.

§414.7.References.

Reference is made to the following state and federal statutes, rules, and regulations:

(1) 45 CFR Parts 160 and 164, and §1386.22;

(2) 42 CFR Part 2 and Part 51, Subpart D;

(3) 34 CFR Part 99;

(4) 42 USC §290dd-2, §1320d et seq. , §10805(a)(4), and §15043(a)(2)(I);

(5) Texas Health and Safety Code:

(A) Chapter 81, Subchapter F;

(B) Chapter 241, Subchapter G;

(C) Chapter 534, Subchapter A;

(D) Chapters 181; 595; and 611; and

(E) §§533.009, 533.035(a), 576.005, 595.005(c), and 614.017;

(6) Texas Government Code, Chapters 552 and 559, and §531.042;

(7) Texas Human Resources Code, Chapter 48;

(8) Texas Occupations Code, Chapter 159; and

(9) Texas Family Code, Chapter 32.

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, 2003.

TRD-200302195

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2003

Proposal publication date: February 7, 2003

For further information, please call: (512) 206-4516


Chapter 417. AGENCY AND FACILITY RESPONSIBILITIES

Subchapter A. STANDARD OPERATING PROCEDURES

25 TAC §§417.2, 417.4, 417.49

The Texas Department of Mental Health and Mental Retardation (department) adopts the repeals of existing §§417.2, 417.4, and 417.49 of Chapter 417, Subchapter A, concerning standard operating procedures are adopted without changes to the proposal in the December 13, 2002, issue of the Texas Register (27 TexReg 11709). New Chapter 417, Subchapter A, concerning substantially the same matters is contemporaneously adopted in this issue of the Texas Register .

Sections 417.2, 417.4, and 417.49, describe the subchapter's application, definitions and references, to which minor revisions were necessary when the new sections regarding department procedures for reporting unauthorized departure, managing department and benefit funds, and the protecting the personal property of consumers and staff. The adoption of the repeal of the existing sections and adoption of the new sections are made according to the department's rule review plan as required by the Texas Government Code, §2001.039.

Comments were not received from the public.

The repeal is adopted under the Texas Health and Safety Code, §532.015, which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority.

The repeal affect Texas Government Code, §2001.039.

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 7, 2003.

TRD-200302265

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 13, 2002

For further information, please call: (512) 206-4516


25 TAC §§417.2, 417.4, 417.20, 417.23, 417.27 - 417.29, 417.33, 417.34, 417.38 - 417.46, 417.49

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts new §§417.2, 417.4, 417.23, 417.27 - 417.29, 417.33, 417.34, 417.38 - 417.46 of Chapter 417, Subchapter A, concerning standard operating procedures with changes to the language proposed in the December 13, 2002, issue of the Texas Register (27 TexReg 11710). Section 417.20 and §417.49 are adopted without changes and the text will not be republished. Existing §§407.1 - 407.6 and §§407.22 - 407.24 of Chapter 407, Subchapter A, concerning financial services; §407.120 of Chapter 407, Subchapter C, concerning lease of department property; and §§417.2, 417.4, and 417.49, concerning application, definitions, and references of Chapter 417, Subchapter A, which the new sections would replace, are contemporaneously repealed in this issue of the Texas Register .

The adoption of new sections and repeals of existing sections are made according to the department's rule review plan required by Texas Government Code, §2001.039, and includes new sections regarding the procedures for long-term lease of department property, ensuring the safety of individuals' personal property and funds, managing department and benefit funds, and reporting unauthorized departures. The application section clarifies that the sections regarding personal funds apply only to state mental health facilities while the remaining sections apply to all state mental health and mental retardation facilities. The definitions section has been revised to include terms that are used in the new sections concerning lease of department property, personal funds, managing department and benefit funds, and unauthorized departures.

Throughout the subchapter minor grammatical changes were made, clarifying language was added, and unnecessary language was deleted (i.e., the term "facility staff" was replaced by the term "staff."

In §417.2, Application, the section numbers are revised consistent with the section numbers that apply only to State Mental Health Facilities (i.e., §§417.39 - 417.46). Section 417.47, Audit, was deleted as Chapter 411, Subchapter F, concerning internal audit provides the department's audit staff with the authority to conduct audits and investigations at State Mental Health and Mental Retardation Facilities.

A definition for the acronym "CEO" (i.e., chief executive officer) was added. Language was added to the term "facility" to clarify that a facility can be either a SMHF or a SMRF to reduce confusion about the applicability of §§417.39 - 417.46, concerning trust funds that apply only to State Mental Health Facilities definitions for the acronyms "SMHF" (i.e., State Mental Health Facilities) and "SMRF" (i.e., State Mental Retardation Facilities) to provide further clarification about the application of the subchapter. The definitions section was renumbered as a result of the acronyms and clarifying language that were added.

In §417.28, the minimum trust fund amount that may be transferred to the Central Office investment program has been changed from multiples of $5,000 to multiples of $2,500 because at many facilities consumer's trust fund balances did exceed the minimum investment of $5,000.

In §417.29, Benefit Funds: Use and Control, titles were added to subsections (a) - (h) to make the section easier to read.

Throughout §§417.39 - 417.46 the terms "facility" and "CEO" were replaced with the term "SMHF" to clarify that the sections apply only to SMHFs. However, in §417.44(2)(A) - (B) the term facility was retained as an individual may be transferred to a SMRF rather than another SMHF.

A new subsection (a) was added in §417.39 to reference the rules concerning the management of trust funds for persons who are receiving services from ICF/MR Program providers, including SMRFs. As a result of the addition, the remaining subsections were renumbered. In subsection (b) of the same section, the reference to the sections that apply only to SMHFs was revised consistent with the elimination of §417.47, Audit.

Unnecessary language was deleted from §417.41(b)(4) because it was repeated in subsection (c) of the same section.

Comments were received from the Evelyn Cherry, Garland, Texas and the Parent Association for the Retarded of Texas (PART), Austin, Texas.

The commenter indicated that fiscal note language regarding possible cost to family members and guests who may stay overnight in department facilities does not appear to apply to the subchapter. Further, the commenter requested clarification as to whether the possible cost applies only to family members or guests who stay overnight on campus while visiting a consumer.

The department responds that the language was inadvertently retained in the fiscal note language from the previous proposal. Section 417.15 sets forth the provisions for family members or guests who may stay overnight on campus while visiting a consumer. The facility CEO has the authority to waive or reduce the charges for overnight accommodations. There is a schedule of recommended charges in the TDMHMR Fiscal Manual .

The commenters expressed support for including playground equipment in the list of examples of items that can be paid for with benefit funds. The commenters noted that several years ago playground equipment was removed from campuses and further noted that adults receiving services enjoyed using playground equipment. The department appreciates the commenters' support.

The commenters expressed concern about the protection of individual's personal property specifically the language "the facility is limited in its ability to protect any personal property that an individual keeps on the unit..." and inventorying personal property "if a discrepancy arises, develop a process for documenting, investigating, and resolving the discrepancy" because the language seems to make it easier for staff to avoid responsibility when personal property disappears.

The department responds that it makes every effort to protect individual's personal property. Further, the department responds that the language "if an individual chooses to keep personal property on the unit" to serve as notice that protection of personal property kept on the unit cannot be guaranteed and that property of any value should be held by the facility. The language "if a discrepancy arises, develop a process for documenting, investigating, and resolving the discrepancy" is included to require that staff adhere to processes for documenting and resolving discrepancies concerning personal property. The department notes that similar language appears in Chapter 404, Subchapter E, concerning rights of persons receiving mental health services.

The commenters asked that the term "LAR" (i.e., legally authorized representative) be added in several places in §417.38, Individual's Personal Property. The department agrees to add the term "LAR" as the commenters suggested.

The commenters requested that a distribution section, including advocacy groups, be added to the subchapter. The department responds that the §417.50, Distribution, was adopted at the September 2002 Board meeting. Although, advocacy groups were inadvertently omitted from the list the new subchapter will be distributed to such groups in hard copy and electronically, as appropriate. The department further responds that the distribution section will be amended section with the next revision to the subchapter.

The new sections are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority, and Texas Government Code, §2001.039, which requires the department to review it rules.

The new sections affect Texas Health and Safety Code, §532.015; Texas Human Resources Code, §32.021; Texas Government Code, §531.021, and Texas Government Code, §2001.039;

§417.2.Application.

Except for §§417.39 - 417.46, concerning trust funds, that apply only to state hospitals, the subchapter applies to state hospitals, state schools, state centers, Central Office, and any entity that may become part of the Texas Department of Mental Health and Mental Retardation (TDMHMR).

§417.4.Definitions.

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

(1) Budgeted amount--The amount of cash that may be disbursed to an individual at regular intervals, e.g., weekly or monthly for discretionary spending without obtaining a sales receipt for the expenditure.

(2) CEO--The chief executive officer of a state mental health facility or a state mental retardation facility.

(3) Commercial lease--A lease of real property to a private enterprise.

(4) Competitive bid--A competitive process for determining the award of a lease, more particularly described in Texas Health and Safety Code, §533.084 and §533.087.

(5) Department--The Texas Department of Mental Health and Mental Retardation (TDMHMR).

(6) Facility--A state mental health facility (SMHF) or a state mental retardation facility (SMRF) operated by the TDMHMR.

(7) Individual--A person receiving services from the Texas Department of Mental Health and Mental Retardation.

(8) LAR (legally authorized representative)--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, and may include a parent, guardian, or managing conservator of a minor individual, a guardian of an adult individual, or a personal representative of a deceased individual.

(9) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, senility, substance abuse or dependency, mental retardation, autism or pervasive developmental disorder) that:

(A) substantially impairs an individual's thought, perception of reality, emotional process, or judgment; or

(B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.

(10) Mental retardation--Subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and originating during the developmental period.

(11) Material safety data sheet--The document provided by a manufacturer that describes a material's or part's chemical properties along with guidelines for proper use, storage, and disposal.

(12) Non-commercial group--A group of people associated with an organization, e.g., civic, fraternal, religious, social, service, community, or public employee organization.

(13) Pooled account--A trust fund account containing the personal funds of more than one individual.

(14) Prevailing market rate--A reasonable estimate of the annual rent for a real property based upon its fair market value that reflects the real property's condition, location, and other salient factors.

(15) Public benefit lease--A lease of non-surplus real property between the department and a federal or state agency, a unit of local government, a not-for-profit organization, or an entity that provides services to individuals and/or employees. Such a lease is determined or defined by the board as providing a public benefit.

(16) Public employee organization--An organization that represents department staff in legislative, human resource, and related issues.

(17) Sales receipt--A written statement issued by the seller that includes:

(A) the date it was created; and

(B) the cost of the item or service.

(18) SMHF--A state mental health facility (e.g., state hospital).

(19) SMRF--A state mental retardation facility (e.g., state school or state center).

(20) Surplus property--Real property designated by the Texas Mental Health and Mental Retardation Board (board) as having minimal value to the present delivery system as described in the department's long-range plan.

(21) Trust fund account--An account at a financial institution in the facility's control that contains personal funds.

(22) Unauthorized departure that may have unusual consequences--The unauthorized departure of an individual that causes a reasonably prudent staff member who has knowledge of the person's condition to believe that harm or injury to the individual or to others may occur as a result of the unauthorized departure, e.g., the unauthorized departure of an individual who the treatment staff believes to be a danger to self or to others or the unauthorized departure of an individual who requires maintenance medication such as insulin.

(23) Unclaimed personal funds or property--Personal funds or property managed by the facility that has not been disbursed to the individual or LAR within 30 calendar days after the individual's discharge, e.g., if an individual dies and staff are unable to find the LAR or heir to the estate.

(24) Unidentified personal funds or property--Personal funds or property managed by the facility for which the facility cannot identify ownership.

§417.23.Unauthorized Departures That May Have Unusual Consequences.

The CEO or designee shall immediately if possible, but in no case more than one hour later make a missing person report to the appropriate law enforcement agency upon discovering an unauthorized departure that may have unusual consequences for an individual who:

(1) is unable to ensure his or her personal safety and/or is considered to be a danger to self or others; and

(2) is receiving court-ordered inpatient or residential services or is voluntarily receiving mental retardation residential services.

§417.27.Depositing Department Funds.

The CEO or designee is responsible for ensuring that:

(1) all funds received are deposited with the state treasurer or in an account that is insured under state or federal law.

(2) the balance of such account does not exceed the insured limit of the financial institution; and

(3) all funds that must be deposited in the State Treasury are deposited within three business days of receipt.

§417.28.Investing Department Funds.

(a) The CEO or designee must ensure that funds which are not required for current use are invested with Texas financial institutions or the Central Office investment plan. Earnings on invested funds other than trust funds shall be added to the funds from which earnings are derived. The interest rate and the availability for withdrawal in case of emergency must be considered in making investment selections.

(1) Texas financial institutions. If the Texas financial institution is insured under state or federal law, the funds may be invested in certificates of deposit or savings accounts. If the investment amount exceeds the limits of state and federal insurance the investment source must pledge additional securities equal to the investment amount.

(2) Central Office investment program. Central Office offers a short term fund, current interest rate, investment plan for the benefit of all facilities. Funds may be transferred to Central Office, Financial Services in multiples of $2,500 for immediate return upon request. Interest payments are remitted by Central Office, Financial Services at the end of each month.

(b) A register of investments, including individuals' personal funds must be maintained in the office of the CEO or designee, including:

(1) name of financial institution;

(2) a description of each investment;

(3) the amount and date of the investment;

(4) interest due dates;

(5) interest paid dates;

(6) maturity date; and

(7) reinvestment information.

(c) The CEO or designee must use the register of investments to verify collection of income and principal.

§417.29.Benefit Funds: Use and Control.

(a) Authority. As authorized by the Texas Health and Safety Code, §551.004, the CEO must be the trustee of a special fund designated as the benefit fund. The CEO may expend the money in any such fund for the education or entertainment of individuals or for the actual expense of maintaining the fund at the financial institution.

(b) Source of funds. The source of benefit funds are:

(1) private donations or gifts; and

(2) interest earned from investment of benefit funds.

(c) Use of funds. Except for specific purpose funds, benefit funds may be used only for the purposes of education or entertainment of individuals and be of general benefit to the facility's population. However, this does not mean or imply that every individual must benefit from each expenditure from the benefit fund. Benefit funds must not be spent in a manner that shows partiality or preferential treatment of an individual or selected groups of individuals. Expenditures from the benefit fund must be supported by sales receipts to show the exact purpose and, if practical, to show the name of the individuals' benefiting from the expenditure.

(d) Allowable expenditures. Expenditures from the benefit funds may include items such as:

(1) supplies for behavior therapy programs, which involve a token economy or point level system;

(2) outings for individuals, including admission fees and meals for those staff who are required to accompany the individuals;

(3) coffee for individuals;

(4) religious items;

(5) educational books and supplies;

(6) salaries of temporary teachers, including athletic instructors and recreation assistants;

(7) playground equipment, televisions, record players, and stereos, for use by individuals as a whole in the living areas; and

(8) grocery items purchased for classes in home economics.

(e) Unallowable expenditures. Expenditures that cannot be made from the benefit fund include:

(1) travel of state employees;

(2) operating supplies;

(3) supplies for volunteer center training program;

(4) nursery stock;

(5) clothing for individuals;

(6) cash issues to individuals with no personal funds.

(7) purchase of canteen coupon books for individuals with no personal funds;

(8) staff salary augmentation;

(9) transportation for individuals' home visits; and

(10) furniture and equipment normally purchased from state appropriated funds.

(f) Prohibition on use of funds. Unless prohibited by department policy or state or federal laws and regulations, funds that are donated for a specific purpose must be used for that purpose. If the purpose for the funds is prohibited, the donor is contacted and asked to specify a purpose that permits expenditure in compliance with department policy or state or federal law and regulations.

(g) Depositing funds. The CEO or designee must ensure that all benefit fund receipts are deposited in a financial institution insured by state or federal and all expenditures are made by check according to the TDMHMR Fiscal Manual .

(h) Administrative expenses. The actual expense of maintaining benefit funds may include expenditures to cover administrative errors which arise in the administration or disbursement of benefit funds and personal funds, provided the following restrictions are met:

(1) the amount of benefit funds expended to cover any single loss does not exceed $250;

(2) in each instance of loss, prior approval for the use of benefit funds to cover the administrative error must be obtained from the CEO;

(3) the circumstances surrounding each administrative error must be documented and attached in the supporting records;

(4) for auditing purposes, the expenditure, if approved and made, must be charged to cash shortage;

(5) benefit funds must not be used to cover losses that result from the gross negligence of any employee or employees;

(6) the facility in which the administrative error occurred must take the action necessary to correct the error and/or prevent its recurrence, including, but not limited to, counseling staff on the correct procedure for the administration and disbursement of benefit funds and personal funds; and

(7) employees responsible for administrative errors in the administration or disbursement of benefit funds and personal funds may be subject to disciplinary action.

§417.33.Mail for Staff Residing On Campus.

(a) Staff mail. Except as provided by subsection (b) of this section, all mail addressed to staff is delivered unopened to the addressee. Routine, indiscriminate opening of an employee's mail is prohibited. Unless living on grounds, staff must not have personal mail delivered to the facility.

(b) Authority to open mail. If the CEO determines that it is in the best interest of the facility to maintain fiscal control over monies belonging to the facility, an individual, or to control contraband, the CEO has the authority to open any mail addressed to a staff member, office, or section of the facility (except personal mail addressed to staff or their families living on the grounds or mail marked "personal" or "confidential"). Mail addressed to an employee (except that indicated in subsection (a) of this section) can be opened only in the presence of the employee.

§417.34.Commercial Solicitation on Grounds.

The CEO is responsible for developing and implementing local procedures regarding commercial solicitation on the grounds of the facility that include the requirement for staff to direct sales representatives to those staff who are responsible for ordering the types of products being offered, e.g., drug representatives are directed to the pharmacy director or the given the times, dates, and locations of the meetings of the executive formulary committee.

§417.38.Individual's Personal Property.

(a) Local procedures. The CEO or designee is responsible for developing and implementing local procedures to ensure an individual's right to reasonable protection of personal property including clothing and mail from theft or loss consistent with Chapter 404, Subchapter E, concerning Rights of Persons Receiving Mental Health Services, and Chapter 405, Subchapter Y, concerning Client Rights--Mental Retardation Services or any other department rules that concern the rights of individuals.

(b) Personal property. The CEO or designee is responsible for developing and implementing written processes that protect each individual's personal property that include:

(1) advising individuals and LARs that the facility is limited in its ability to protect any personal property that an individual keeps on the unit, however, if loss or theft of such property is reported staff must make every effort to find and return the missing property to the owner;

(2) documenting the receipt of any personal property that is to be held under the facility's control;

(3) physically inventorying personal property under the facility's control and documenting personal property received from individuals to ensure it is accounted for and if a discrepancy arises develop a process for documenting, investigating, and resolving the discrepancy;

(4) documenting and honoring an individual's request for the return of any or all of his or her personal property previously under the facility's control.

(c) Returning personal property. If an individual is discharged from the facility, staff must upon discharge or a soon as possible thereafter document and return to the individual or LAR all of the individual's personal property under the facility's control.

(d) Individual's personal mail. Except as described in this section and department rules concerning the rights of individuals, an individual's personal mail must be delivered unopened to the addressee. If staff have reason to believe that mail addressed to an individual is an invoice and the facility is responsible for its payment, then the mail must be opened by the individual and witnessed by two staff. If the mail contains such an invoice, it is forwarded to accounts payable for processing, an explanation of the situation is given to the individual, and the situation is documented in the individual's record.

§417.39.Protecting an Individual's Personal Funds.

(a) Rules concerning the personal funds of individuals receiving services from a state mental retardation facility (SMRF) are in Chapter 419, Subchapter E, concerning ICF/MR Program.

(b) The state mental health facility (SMHF) must implement §§417.39 - 417.46 of this title according to the generally accepted accounting principles of the American Institute of Certified Public Accountants.

(c) The CEO must develop and implement local procedures regarding personal funds that protect the financial interest of individuals and, at a minimum, require the SMHF to allow individuals to hold and manage their personal funds to the extent of their abilities.

§417.40.Notice Regarding Personal Funds.

At the time of admission to the SMHF, and if changes to services or charges occur, staff must provide each individual or LAR with written notification containing the following information:

(1) a written explanation of §417.41 of this title (relating to Determining Management of Personal Funds), which describes who may manage personal funds;

(2) a statement that the admitting physician determines whether the individual has the ability to manage his or her personal funds and if, an individual is unable to manage such funds, the funds are deposited in the trust fund account for no longer than seven calendar days when the treating physician reevaluates the admitting physician's determination;

(3) a statement that the individual, CEO, or LAR may request that the Social Security Administration appoint a representative payee to receive the individual's federal benefits in accordance with 20 CFR Part 416, Subpart F;

(4) a statement that, if the facility manages the individual's personal funds, staff must make available the individual's personal funds ledger upon the individual's or LAR's request but in no case longer than 30 calendar days; and

(5) a statement that at the request of the individual or LAR, or if the individual is discharged from the SMHF, the SMHF must whenever possible disburse the individual's personal funds to the individual or LAR upon discharge but in no event more than 30 calendar days after the request or discharge, if the SMHF manages the individual's personal funds.

(6) a statement that the facility is not responsible for personal funds mailed directly to individuals; and

(7) a statement that the SMHF maintains a trust fund to protect personal funds and such funds including cash and checks that are to be deposited in the trust fund must be mailed to the cashier's attention.

§417.41.Determining Management of Personal Funds.

(a) Within seven business days after an individual is admitted to the SMHF, the treating physician must determine if the individual has the ability to manage his or her personal funds.

(b) If an individual does not have an LAR and is determined by the treating physician to have the ability to decide who manages his or her personal funds or if an individual has an LAR, the facility must allow the individual or LAR to choose one of the following to manage his or her personal funds and document such choice as determined by local procedures:

(1) the individual, if the individual is determined to have the ability to manage his or her personal funds;

(2) the individual's LAR;

(3) another person identified by the individual or LAR who has agreed in writing to manage the individual's personal funds; or

(4) the facility.

(c) If an individual is determined not to have the ability to decide who manages his or her personal funds and the individual has no LAR, the SMHF must manage the individual's personal funds in accordance with this subchapter.

(d) The treating physician must reassess an individual's understanding of financial management at the individual's or LAR's request.

§417.42.SMHF--Managed Personal Funds.

(a) Accounting for personal funds. If the facility manages an individual's personal funds, the SMHF must comply with this section and ensure that:

(1) a complete accounting of personal funds entrusted to the SMHF is maintained;

(2) personal funds are not commingled with facility funds or the funds of any person other than another individual for whom the SMHF manages personal funds; and

(3) an individual's personal funds are only expended for that individual's use and benefit.

(b) Account requirements. The SMHF must manage personal funds in a pooled trust fund account.

(1) The trust fund account must be insured under federal or state law.

(2) The SMHF must retain all bank statements from financial institutions regarding trust fund accounts.

(3) Within 30 calendar days after receiving the bank statement, the facility must reconcile the bank statement with the general ledger as described in subsection (c) of this section and personal funds ledger as described in subsection (h)(5) of this section.

(4) Each business day, staff must reconcile:

(A) each individual's transactions with the trust fund control ledger; and

(B) the personal funds ledger with the trust fund control ledger.

(c) General ledger. The SMHF must maintain a general ledger that separately identifies each financial transaction, including:

(1) the name of the individual for whom the transaction was made;

(2) the date and amount of the transaction, including interest;

(3) the balance after the transaction; and

(4) identify the SMHF name in the account title and the type of account, e.g., Austin State Hospital, Trust Fund Account.

(d) Investment. Unless an exception is granted by the director, State Mental Health Facilities and written documentation of such is maintained at the facility, the SMHF must invest at least 75% of the average monthly balance of the total held in trust for the previous six months in an insured Texas financial institution.

(e) Interest. If personal funds accrue interest, the SMHF must prorate and distribute the interest earned to each participating individual at the end of the month.

(f) Depositing personal funds. The SMHF must deposit in the trust fund account all funds that it receives on behalf of an individual.

(g) Access to personal funds. The treating physician must determine the individual's ability to manage his or her personal funds and:

(1) if there is a need for a budgeted amount, set the amount, and document the amount in the individual's medical record; and

(2) if there is a need to restrict the individual's use of personal funds the treating physician must document the need for the restriction in the individual's medical record.

(h) Personal funds documentation. Staff must maintain a personal funds documentation for each individual that includes:

(1) the name of the individual;

(2) the name of the individual's LAR and representative payee, as applicable;

(3) the date of the individual's admission to the SMHF;

(4) the individual's budgeted amount;

(5) a personal funds ledger that includes the date and amount of each transaction and the balance after each transaction; and

(6) any contribution acknowledgment as described in §417.46 of this title (relating to Contributions).

(i) Documenting expenditures and deposits.

(1) Expenditures.

(A) Staff must retain a sales receipt for each expenditure made on behalf of an individual.

(i) If a sales receipt documents an expenditure for more than one individual, the SMHF must indicate on the sales receipt the amount allocated to each individual.

(ii) If a sales receipt does not include the specific item or service purchased or the name of the seller, staff must attach such documentation.

(B) Staff must explain each expenditure to the individual and request that the individual sign the receipt. If staff determine that the individual does not understand the explanation, the individual does not sign the receipt, or the individual's signature is illegible, a witness to the expenditure must sign the receipt. The witness cannot be responsible for managing personal funds or responsible for supervising persons performing such duties.

(2) Deposits. Except for deposits made electronically, staff must retain a deposit slip issued by the financial institution for each deposit.

§417.43.Requests for Personal Funds from Trust Fund Accounts.

If staff receive a request, from an individual or other person except staff to expend an individual's personal funds without written evidence supporting the disbursement, a written request specifying the amount and purpose of the expenditure is signed by the requestor, the facility may release such funds to the requestor if the funds recipient acknowledges receiving the funds in writing.

§417.44.Returning Individual's Personal Funds on Discharge.

If an individual is discharged from the facility, staff must upon discharge or in no case more than 30 calendar days after the discharge:

(1) reconcile the personal funds ledger to the trust fund control ledger and the trust fund control ledger to the general ledger;

(2) transfer all personal funds managed by the facility:

(A) to the facility receiving the individual, if the individual is discharged to another facility; or

(B) to the individual or LAR, if the individual is not discharged to another SMHF;

(C) the copy of a check serves as documentation for the distribution of personal funds.

(3) provide to the admitting SMHF, individual, or LAR the individual's current personal funds documentation.

§417.45.Unclaimed Personal Funds and Property.

(a) If a person makes a request for an individual's unclaimed personal funds or property that:

(1) exceeds $500 and provides written authorization from the probate court to receive such funds or property, staff release the funds or property.

(2) is $500 or less and the CEO or designee is reasonably certain that the person is the lawful heir and that there is no concern for a future dispute over the disbursed funds or property, facility staff release the funds or property.

(b) If no request for the unclaimed funds or property is received, staff must make a good faith effort to locate the individual to whom the funds or property belong or the LAR. If the individual or LAR:

(1) is located or a request for the personal funds or property is received, staff must transfer the funds or property to the individual or LAR; or

(2) is not located, staff must maintain the personal funds in a bank account as described in §417.42(b) of this title (relating to SMHF--Managed Personal Funds) or maintain the property in a secure location.

(A) The SMHF must hold the unclaimed personal funds or property for three years.

(B) At the end of three years if no request for the funds or property is received, the SMHF must transfer to State Comptroller's Office the unclaimed funds or property according to the Holder Information Report instructions published by the State Comptroller's Office.

§419.46.Contributions.

If the individual or LAR makes a contribution to the SMHF using personal funds, the SMHF and the contributor must sign and date an acknowledgement that the SMHF's services are not predicated on a contribution and the contribution is voluntary. The acknowledgement must be made a part of the individual's personal funds documentation. There are additional requirements for accepting contributions in Chapter 417, Subchapter G, concerning community relations.

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 7, 2003.

TRD-200302262

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 13, 2002

For further information, please call: (512) 206-4516


Subchapter D. PERMANENT IMPROVEMENTS DONATED BY INDIVIDUALS OR COMMUNITY GROUPS

25 TAC §§417.151 - 417.160

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts new Chapter 417, Subchapter D, §§417.151, 417.152, 417.155 - 417.160, concerning permanent improvements donated by individuals or community groups without changes to the proposed text published in the December 6, 2002, issue of the Texas Register (27 TexReg 11449). Section 417.153 and §417.154 are adopted with changes to the proposed text. The new sections replace Chapter 410, Subchapter C, §§410.101 - 410.122, which contained substantially the same issues, are contemporaneously repealed in this issue of the Texas Register .

The adoption of new §§417.151 - 417.160 and the contemporaneous repeals of §§410.101 - 410.122 are made to describe the procedures and approval process for individuals and community groups to donate a permanent improvement to a facility.

The adoption of the new rules and repeals fulfill the requirements of Texas Government Code, §2001.039, concerning the periodic review of department rules.

In §417.153, the definition of the term "construction" an error in capitalization was corrected.

In §417.154(a), the abbreviation of permanent improvement, i.e., (PI improvement) that should have read (improvement) was corrected.

Comments were not received from the public.

The new sections are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority and Texas Government Code, §2001.039, concerning the periodic review of department rules.

§417.153.Definitions.

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

(1) Asset Management--The Central Office division whose staff are responsible for overseeing TDMHMR's real property.

(2) Board--The Texas Board of Mental Health and Mental Retardation.

(3) Business entity--A sole proprietorship (including a person), partnership, firm, corporation, holding company, joint-stock company, receivership, trust, or any other entity recognized by law.

(4) Community group--A volunteer services council that is affiliated with TDMHMR or a group of people associated with an organization (e.g. civic, fraternal, corporate, religious, social, service, community, or educational).

(5) Construction--The implementation of a physical improvement (e.g., erecting, remodeling, renovating, or altering a building or addition thereto, gazebo, pavilion, road, sidewalk, fountain, or pond) and/or installing or extending a building system (e.g., roofing, mechanical, plumbing, or electrical system) that is integral to the durability and habitability of a building (e.g., air conditioning units, water or wastewater distribution lines, electrical wiring located in walls or underground, and subflooring or foundation work).

(6) Construction documents--Construction drawings, specifications, and all addenda issued prior to, and all modifications issued after execution of the contract.

(7) Dedicated construction account--A unique, restricted interest-bearing account insured by an agency of the federal government that is established for the sole purpose of ensuring that sufficient funds are in place prior to initiating construction of a permanent improvement.

(8) Donor--A person, community group, or business entity who wants to donate a permanent improvement.

(9) Director, facility community relations--The staff person who is responsible for coordinating the community relations functions, volunteer programs, and fundraising at a facility.

(10) Endowment fund--A permanent, restricted fund established and maintained by the volunteer services council to fund, by generating interest income from the principal fund, the ongoing operating expenses for a specific permanent improvement.

(11) Facility--A state school, state hospital, state center, or other real property, except Central Office, that is operated by the Texas Department of Mental Health and Mental Retardation (TDMHMR).

(12) Facility chief executive officer (CEO)--The chief administrator of a facility.

(13) Landscaping--An improvement involving the systematic installation of plant materials (e.g., trees, shrubs, grass, blooming plants, irrigation systems, and/or grading, clearing, or other alteration of the existing topography and composition of the land).

(14) Local project manager--A facility staff person designated by the permanent improvement committee who acts on behalf of the permanent improvement committee in dealing with the design professional and contractor for the duration of the improvement's construction.

(15) Permanent improvement (improvement)--A facility improvement that requires construction or an improvement consisting of landscaping.

(16) Permanent improvement committee (PI committee)--The committee that is appointed by the executive committee of the facility's volunteer services council for the purpose of overseeing and/or donating a permanent improvement.

(17) SMHMRFs--State Mental Health and Mental Retardation Facilities.

(18) TDMHMR--The Texas Department of Mental Health and Mental Retardation.

(19) Volunteer services council (VSC)--A facility's 501(c)(3) organization that is formed for generating resources on behalf of the facility and to appoint a permanent improvement committee to implement permanent improvements.

(20) Volunteer services council (VSC) board--The board of directors of the facility's volunteer services council.

(21) Volunteer services council (VSC) chair--The primary officer of the board of directors of the facility volunteer services council, elected according to the VSC bylaws.

§417.154.Permanent Improvement Process.

(a) The facility CEO, with assistance from the director, facility community relations, and the VSC chair, must submit a written description of the proposed permanent improvement (improvement) by completing and submitting the Permanent Improvement Concept form referred to in §417.159 of this title.

(b) If the concept is approved by the commissioner or designee as described in §417.155 of this title (relating to Permanent Improvement Approval), the facility CEO with assistance from the director, facility community relations, and the VSC chair, submit a completed Permanent Improvement Proposal form, which is referred to in §417.159 of this title (relating to References).

(c) The director, facility community relations, or VSC chair may consult with the donor throughout all phases of the review and approval process, including:

(1) the proposal review process;

(2) the design, fundraising, and construction review process; and

(3) the acceptance process.

(d) If requested by the facility CEO, the donor must establish an endowment fund for ongoing maintenance and support for the improvement.

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 7, 2003.

TRD-200302267

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 27, 2003

Proposal publication date: December 6, 2002

For further information, please call: (512) 206-4516


Subchapter K. ABUSE, NEGLECT, AND EXPLOITATION IN TDMHMR FACILITIES

25 TAC §§417.501 - 417.518

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts the repeals of §§417.501 - 417.518 of Chapter 417, Subchapter K, concerning abuse, neglect, and exploitation in TDMHMR facilities, without changes to the proposal as published in the November 29, 2002, issue of the Texas Register (27 TexReg 11044). New §§417.501 - 417.505 and §§417.507 - 417.518 of Chapter 417, Subchapter K, concerning the same, which replace the repealed sections, are contemporaneously adopted in this issue of the Texas Register .

The repeals allow for the adoption of new sections governing the same matters.

No comments on the proposed repeals were received.

The repeals 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 Human Resources Code, Chapter 48, which requires the reporting and investigations of abuse, neglect, and exploitation of elderly and disabled persons; §48.255, which requires TDMHMR and the Texas Department of Protective and Regulatory Services (TDPRS) to develop joint rules to facilitate investigations in facilities operated by TDMHMR; the Texas Family Code, Chapter 261, which requires the reporting and investigations of abuse or neglect of a child; §261.404, which requires TDMHMR and TDPRS to develop joint rules to facilitate investigations of a child receiving services in a facility operated by TDMHMR; and the Texas Civil Practice and Remedies Code, §81.006, which requires the reporting of alleged sexual exploitation by a mental health services provider to the county prosecuting attorney.

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, 2003.

TRD-200302193

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2003

Proposal publication date: November 29, 2002

For further information, please call: (512) 206-4516


25 TAC §§417.501 - 417.505, 417.507 - 417.518

The Texas Department of Mental Health and Mental Retardation (TDMHMR) adopts new §§417.501 - 417.505 and §§417.507 - 417.518 of Chapter 417, Subchapter K, concerning abuse, neglect, and exploitation in TDMHMR facilities. Sections 417.503 - 417.505, 417.507 - 417.510, 417.512, and 417.515 - 417.517 are adopted with changes to the proposed text as published in the November 29, 2002, issue of the Texas Register (27 TexReg 11045). Sections 417.501, 417.502, 417.511. 417.513, 417.514, and 417.518 are adopted without changes. The repeals of existing §§417.501 - 417.518 of Chapter 417, Subchapter K, concerning the same, which the new sections replace, are contemporaneously adopted in this issue of the Texas Register .

The new rules prescribe the procedures for reporting allegations of abuse, neglect, and exploitation of persons served in TDMHMR facilities to the Texas Department of Protective and Regulatory Services (TDPRS); for facilitating TDPRS investigations of allegations; and for ensuring the safety and protection of persons served involved in allegations. Additionally, the new rules prescribe the disciplinary action to be taken when an employee or agent is found to have committed abuse, neglect, or exploitation.

Certain definitions and procedures have been revised to either reference TDPRS rules governing investigations in TDMHMR facilities or to be consistent with TDPRS rules. The definition of "facility" has been modified to include any entity providing mental health or mental retardation services that is operated by TDMHMR. The definition of "non-serious physical injury" has been revised to provide the criteria for a non-serious physical injury (i.e., an injury requiring minor first aid) and to permit a registered nurse or advanced practice nurse, as well as a physician, to apply the criteria to determine whether an injury is non-serious. The definition of "serious physical injury" has been revised to provide the criteria for a serious physical injury (i.e., any injury requiring medical intervention or hospitalization) and to provide an alternate criteria (i.e., any injury determined by a physician or advanced practice nurse to be serious). Either criteria is sufficient to determine an injury as serious. The purpose of the alternate criteria is to allow a physician or advanced practice nurse to categorize a lesser injury as serious if the physician or advanced practice nurse determines that it is appropriate to do so. For example, a bruise generally requires minor first aid, but a physician or advanced practice nurse may determine a bruise on the face to be serious. A new definition of "medical intervention" has been added.

Reference to the Client Injury/Incident Report form has been changed to client injury assessment because the term is inclusive of an electronic reporting system, which some facilities began using on September 1, 2002. The new rules do not include data collection requirements as specified in the repealed rules.

Upon adoption, a definition of "advanced practice nurse" has been added in §417.503. The definition of "department" has been deleted and replaced with "TDMHMR." A definition of "primary contact" has been added, which uses the descriptive language in proposed §417.508(b)(5)(C). Additionally the term has been added in §§417.505(a)(4), 417.507(a), 417.508(b)(5), 417.509(f), 417.510(l), and 417.512(f), where guardians and parents are mentioned. The definition of "sexually transmitted disease" has been deleted because the term is self-evident to the physicians who diagnosis such diseases. The definition of "sexual exploitation" has been deleted in §417.503, but a reference to the definition of "sexual exploitation" in the Texas Civil Practice and Remedies Code has been added in §417.504(b)(1)(B)(viii) and §417.508(d), where the term is used.

Language has been added to §417.507(a) that prohibits retaliatory action against a family member of a person served, the guardian of a person served, or the primary contact of a person served who in good faith reports an allegation. In §417.508(b)(1), reference to a registered nurse, advanced practice nurse, or physician completing the "Seriousness of Physical Injury" portion of the Client Abuse and Neglect Report (AN-1-A) form has been deleted because completion of that portion of the form is not necessary if the same information is recorded on the client injury assessment by a registered nurse, advanced practice nurse, or physician, as appropriate. In §417.508(b)(2), reference to the "Guidelines for Separation of Alleged Victim and Alleged Perpetrator During Abuse/Neglect Investigations" has been deleted. New language has been added requiring any action taken to ensure the protection of the alleged victim to be appropriate within the context of the allegation. Additionally, the Human Resources Operating Instruction is referenced as it relates to reassigning the employee and granting emergency leave as possible actions. Language has been modified in §417.508(b)(5) and §417.510(k) to ensure consistent notifications are made to appropriate persons (e.g., alleged victim and/or guardian or parent if the alleged victim is a child, primary contact). Clarifying language has been added in §417.508(e). Language regarding a written reprimand resulting from confirmed abuse or neglect has been deleted in §417.512(d) and (f)(2) because a non-probationary employee may file a grievance in response to any of the disciplinary actions. Section 417.516 has been reorganized to reflect the re-lettering of exhibits.

Written comments on the proposal were received from the Parent Association for the Retarded of Texas (PART), Austin; American Habilitation Services, Inc., Houston; and the parent of a state school resident, Garland.

One commenter asked if local mental retardation authorities (MRAs) are considered TDMHMR facilities under §417.502(a) and, if so, would the rules apply to a private provider that contracts with an MRA to provide services to people with developmental disabilities within the MRA's specified service area. The commenter also asked that, if the rules apply to the private provider because it contracts with a particular MRA, then would the rules apply to the private provider at locations in other areas of the state at which the private provider delivered the same or similar services (e.g., MRLA, CLASS, HCS, HCS-O or ICF/MR services). TDMHMR responds that MRAs are not considered TDMHMR facilities. Facilities are owned and operated by TDMHMR.

Two commenters suggested adding to the definition of "serious physical injury" the example used in the preamble proposal to illustrate how the alternate criteria for determining serious physical injury could be used. The commenters wrote, "This must be stated somewhere in this document so they will know it matters if it is a bruise on the head instead of the arm. We have already experienced this situation so don't say the medical personnel will already know this. It must be spelled out clearly." TDMHMR responds that the example merely illustrates how the criteria could be applied in a particular situation, if a physician or advanced practice nurse determines it is appropriate to do so. Stating that any facial bruise is a serious physical injury does not allow medical staff to freely exercise medical judgment; therefore, TDMHMR declines to add the example as suggested.

Regarding the purpose section in §417.501, two commenters objected to the deletion of language stating that one of the subchapter's purposes is to define and prohibit abuse, neglect, and exploitation in TDMRMR facilities. The commenters observed that the statement was still valid and wrote, "this document should define and prohibit all of this. Too much of the definitions of abuse, neglect, and exploitation are being removed from this document!" TDMHMR responds that the language was deleted because it is not a true statement. State law prohibits abuse, neglect, and exploitation of disabled persons and state law authorizes TDPRS to define "abuse," "neglect," and "exploitation." TDMHMR notes that the rules still prohibit the abuse, neglect, and exploitation of persons served (see §417.504(a)) and still contain definitions for "abuse," "neglect," and "exploitation" (see §417.504(b)), which originate in TDPRS's rules (Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs)).

Regarding the exceptions to what is not considered abuse, neglect, and exploitation in §417.504(c)(3), two commenters suggested adding the phrase "or restriction of a person's movement for staff convenience" after the proposed language that states "such actions do not include acts of unnecessary force or the inappropriate use of restraints or seclusion, including PMAB." The commenters noted that, although the additional phrase would be redundant, they recommended including it "so staff and facility administration don't think this is 'vague' or 'confusing.'" TDMHMR responds that it declines to add the phrase as suggested because the action it describes (i.e., restriction of a person's movement for staff convenience) is an inappropriate use of restraints, which is already stated.

Regarding general complaints in §417.504(c)(4), two commenters stated, "This is very clear that 'general complaints' do not include 'a specific incident or allegation involving a specific person served' that is to be 'investigated administratively by the head of the facility.' Some facility administrations do not know this and MIGHT APPEAL SOMETHING THEY SHOULD NOT APPEAL." TDMHMR responds that the commenters' issue is unclear and notes that these rules do not address appealing the outcome of a complaint that is investigated administratively by the facility.

Two commenters supported the provision regarding disciplinary action for making a false statement of fact during an investigation in §417.505(d). TDMHMR responds that it appreciates the support and notes that the provision has been in place many years.

Regarding prohibition against retaliatory action for reporting an allegation in §417.507(a), two commenters stated that recent legislation added protection from retaliation for family members and guardians and requested that language be added to the subsection to reflect such. TDMHMR responds by adding language in §417.507(a) prohibiting retaliatory action against a family member of a person served or the guardian of a person served who in good faith reports an allegation.

Regarding the requirement to report to the prosecuting attorney any alleged sexual exploitation committed by a mental health services provider in §417.508(d), two commenters suggested the requirement be extended for any staff who is alleged to have committed sexual exploitation. TDMHMR responds that §417.508(d) highlights a state statute that mandates certain actions be taken by a specific person in response to a specific allegation being committed by a specific type of employee. Any employee or agent alleged to have committed sexual exploitation will be reported to law enforcement by TDPRS. TDPRS rules state that the investigator notifies law enforcement of any allegation involving serious physical injury, sexual abuse , or death of an adult person served and of any allegation involving a child. (See §711.401 of Title 40 (relating to Who and when does the investigator notify of an allegation and when is the reporter revealed?).)

Regarding the investigative report containing an analysis of the evidence that includes how the evidence was weighted and what testimony was considered credible in §417.510(a)(3), two commenters stated that the "head of the facility should also weigh the 'credibility' of testimony before appealing, contesting or asking for a review and be sure their actions are based on the truth, not how it could affect an employee's career." TDMHMR responds that it agrees with the commenters.

Regarding prompt notification in §417.510(k), two commenters stated that "a week or more to notify the guardian is not 'promptly'" and requested that "promptly" be defined as within 24 hours. TDMHMR responds that notification in §417.510(k) is to the victim or guardian, or parent if the (alleged) victim is a child, regarding the final finding, the method to appeal the finding, and of the right to receive a copy of the investigative report. This detailed information is written and notification to the guardian or parent is by mail. Therefore, depending upon mail service, "promptly" may be a week. Although the rules provide the parameters for which notification is made, guardians and parents may request immediate notification of the final finding by phone.

Regarding reference to Chapter 711, Subchapter M of Title 40 (concerning Requesting an Appeal if You Are the Reporter, Alleged Victim, Legal Guardian, or With Advocacy, Incorporated) in §417.510(k)(2), two commenters stated, "Yes, people forget Advocacy, Inc. can be called in by the LAR to help in this kind of situation." TDMHMR responds that the commenters' point is unclear.

Regarding staff training that includes practices and attitudes that support the prevention of abuse, neglect, and exploitation in §417.515(a)(1)(G), two commenters stated that "this would be a good thing if it is done by facility administration. If employees are shown that they can get away with abuse, neglect, or exploitation with little or no disciplinary actions then it reinforces this bad behavior." TDMHMR responds that the training curriculum is developed by TDMHMR System Human Resources and each facility is responsible for using the curriculum to conduct training for its employees and agents. Regarding employees getting away with abuse, neglect, or exploitation, §417.512(c) requires the head of the facility to take prompt and proper disciplinary action (in accordance with the rules) when an allegation involving an employee/agent is confirmed.

The new sections are adopted under the Texas Health and Safety Code, §532.015(a), which provides the Texas Mental Health and Mental Retardation Board with broad rulemaking authority; the Texas Human Resources Code, Chapter 48, which requires the reporting and investigations of abuse, neglect, and exploitation of elderly and disabled persons; §48.255, which requires TDMHMR and TDPRS to develop joint rules to facilitate investigations in facilities operated by TDMHMR; the Texas Family Code, Chapter 261, which requires the reporting and investigations of abuse or neglect of a child; §261.404, which requires TDMHMR and TDPRS to develop joint rules to facilitate investigations of a child receiving services in a facility operated by TDMHMR; and the Texas Civil Practice and Remedies Code, §81.006, which requires the reporting of alleged sexual exploitation by a mental health services provider to the county prosecuting attorney.

§417.503.Definitions.

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

(1) Adult Protective Services (APS) investigator--An employee of the Texas Department of Protective and Regulatory Services (TDPRS) with expertise and demonstrated competence in conducting investigations.

(2) Advanced practice nurse (APN)--A registered nurse approved by the Board of Nurse Examiners for the State of Texas to practice as an advanced practice nurse on the basis of completion of an advanced educational program. The term includes a nurse practitioner, nurse midwife, nurse anesthetist, and clinical nurse specialist. The term is synonymous with advanced nurse practitioner.

(3) Agent--Any individual not employed by the facility but working under the auspices of the facility, (e.g., a volunteer, a student).

(4) Allegation--A report by an individual suspecting or having knowledge that a person served has been or is in a state of abuse, neglect, or exploitation as defined in this subchapter.

(5) Child--A person served under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed pursuant to the Texas Family Code, Chapter 31.

(6) Clinical practice--Relates to the demonstration of professional competence in nursing, dental, pharmacy, or medical practice as described, respectively, in the Nursing Practice Act, Vocational Nurse Act, Dental Practice Act, Pharmacy Practice Act, or Medical Practice Act.

(7) Confirmed--Term used to describe an allegation which is determined to be supported by the preponderance of evidence.

(8) Contractor--Any organization, entity, or individual who contracts with a facility to provide mental health and mental retardation services. The term includes a local independent school district with which a facility has a memorandum of understanding (MOU) for educational services.

(9) Designee--A staff member immediately available who is temporarily or permanently appointed to assume designated responsibilities of the head of the facility.

(10) Facility--A state hospital, state school, state center, or other entity providing mental retardation or mental health services that is operated by the Texas Department of Mental Health and Mental Retardation.

(11) Guardian--An individual appointed and qualified as a guardian of the person under the Probate Code, Chapter 13.

(12) Head of the facility--The superintendent or executive director of a facility, or designee. (If the superintendent or executive director is the alleged perpetrator, then the designee assumes all responsibilities of the head of the facility described in this subchapter.)

(13) Incitement--To spur to action or instigate into activity; implies responsibility for initiating another's actions.

(14) Inconclusive--Term used to describe an allegation leading to no conclusion or definite result due to lack of witnesses or other relevant evidence.

(15) Medical intervention--Treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant, or advanced practice nurse (APN). For the purposes of this subchapter, the term does not include first aid, an examination, diagnostics (e.g., x-ray, blood test), or the prescribing of oral or topical medication.

(16) Non-serious physical injury--Any injury requiring minor first aid and determined not to be serious by a registered nurse, advanced practice nurse (APN), or physician.

(17) Office of Consumer Services and Rights Protection - Ombudsman--The office located at the Texas Department of Mental Health and Mental Retardation's Central Office.

(18) Peer review--A review of clinical and/or medical practice(s) by peer physicians; a review of clinical and/or dental practice(s) by peer dentists; a review of clinical and/or pharmacy practice(s) by peer pharmacists; or a review of clinical and/or nursing practice(s) by peer nurses.

(19) Perpetrator--A person who has committed an act of abuse, neglect, or exploitation.

(20) Perpetrator unknown--Term used to describe instances in which abuse, neglect, or exploitation is evident but positive identification of the responsible person(s) cannot be made, and in which self-injury has been eliminated as the cause.

(21) Person served--Any person registered or assigned in the Client Assignment and Registration (CARE) system who is receiving services from a facility or contractor.

(22) Preponderance of evidence--The greater weight of evidence, or evidence which is more credible and convincing to the mind.

(23) PMAB or Prevention and Management of Aggressive Behavior--TDMHMR's proprietary risk management program that uses the least intrusive, most effective options to reduce the risk of injury for persons served and for staff from acts or potential acts of aggression.

(24) Primary contact--In cases in which the alleged victim is an adult with mental retardation who is unable to authorize the disclosure of protected health information and who does not have a guardian, the individual designated as the alleged victim's correspondent who receives all other information about the alleged victim (e.g., spouse, parent).

(25) Reporter--The individual who reports an allegation of abuse, neglect, or exploitation.

(26) Retaliatory action--Any action intended to inflict emotional or physical harm or inconvenience on a person that is taken because the person has reported abuse, neglect, or exploitation. This includes, but is not limited to, harassment, disciplinary measures, discrimination, reprimand, threat, and criticism.

(27) Review authority--An individual or panel of individuals who, at the discretion and request of the head of the facility, reviews selected cases of abuse, neglect, or exploitation, including those that are confirmed, unconfirmed, unfounded, or inconclusive. The review authority may include a member of the facility's public responsibility committee.

(28) Serious physical injury--Any injury requiring medical intervention or hospitalization or any injury determined to be serious by a physician or advanced practice nurse (APN).

(29) TDMHMR--The Texas Department of Mental Health and Mental Retardation.

(30) TDPRS--The Texas Department of Protective and Regulatory Services.

(31) Unconfirmed--Term used to describe an allegation in which a preponderance of evidence exists to prove that abuse, neglect, or exploitation did not occur.

(32) Unfounded--Term used to describe an allegation that is spurious or patently without factual basis.

§417.504.Prohibition and Definitions of Abuse, Neglect, and Exploitation.

(a) Abuse, neglect, and exploitation of any person served is prohibited.

(b) Consistent with Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs), the terms "abuse," "neglect," and "exploitation" are defined as follows when the alleged perpetrator is an employee, agent, contractor, or is unknown.

(1) Abuse is:

(A) physical abuse, which is:

(i) an act or failure to act performed knowingly, recklessly, or intentionally, including incitement to act, which caused or may have caused physical injury or death to a person served;

(ii) an act of inappropriate or excessive force or corporal punishment, regardless of whether the act results in a physical injury to a person served; or

(iii) the use of chemical or bodily restraints on a person served not in compliance with federal and state laws and regulations, including:

(I) Chapter 405, Subchapter F of this title (concerning Voluntary and Involuntary Behavioral Interventions in Mental Health Programs); and

(II) Chapter 405, Subchapter H of this title (concerning Behavior Management - Facilities Serving Persons with Mental Retardation);

(B) sexual abuse, which is any sexual activity involving an employee, agent, or contractor and a person served, including but not limited to:

(i) kissing a person served with sexual intent;

(ii) hugging a person served with sexual intent;

(iii) stroking a person served with sexual intent;

(iv) fondling a person served with sexual intent;

(v) engaging in with a person served:

(I) sexual conduct as defined in the Texas Penal Code, §43.01; or

(II) any activity that is obscene as defined in the Texas Penal Code, §43.21;

(vi) requesting, soliciting, or compelling a person served to engage in:

(I) sexual conduct as defined in the Texas Penal Code, §43.01; or

(II) any activity that is obscene as defined in the Texas Penal Code, §43.21;

(vii) in the presence of a person served:

(I) engaging in or displaying any activity that is obscene, as defined in the Texas Penal Code §43.21; or

(II) requesting, soliciting, or compelling another person to engage in any activity that is obscene, as defined in the Texas Penal Code §43.21;

(viii) committing sexual exploitation, as defined in the Texas Civil Practice and Remedies Code, §81.001, against a person served. A copy of the Texas Civil Practice and Remedies Code, §81.001, is referenced as Exhibit A in §417.516 of this title (relating to Exhibits);

(ix) committing sexual assault as defined in the Texas Penal Code §22.011, against a person served;

(x) committing aggravated sexual assault as defined in the Texas Penal Code, §22.021, against a person served; and

(xi) causing, permitting, encouraging, engaging in, or allowing the photographing, filming, videotaping, or depicting of a person served if the employee, agent, or contractor knew or should have known that the resulting photograph, film, videotape, or depiction of the person served is obscene as defined in the Texas Penal Code, §43.21, or is pornographic; and

(C) verbal/emotional abuse, which is any act or use of verbal or other communication, including gestures, to:

(i) curse, vilify, or degrade a person served; or

(ii) threaten a person served with physical or emotional harm.

(2) Neglect is a negligent act or omission by any individual responsible for providing services to a person served, which caused or may have caused physical or emotional injury or death to a person served or which placed a person served at risk of physical or emotional injury or death. Neglect includes, but is not limited to, the failure to:

(A) establish or carry out an appropriate individual program plan or treatment plan for a person served;

(B) provide adequate nutrition, clothing, or health care to a specific person served; or

(C) provide a safe environment for a specific person served, including the failure to maintain adequate numbers of appropriately trained staff.

(3) Exploitation is the illegal or improper act or process of using a person served or the resources of a person served for monetary or personal benefit, profit, or gain.

(c) Abuse, neglect, or exploitation does not include:

(1) the proper use of restraints and seclusion, including PMAB, and the approved application of behavior modification techniques as described in:

(A) Chapter 405, Subchapter F of this title, relating to Voluntary and Involuntary Behavioral Interventions in Mental Health Programs;

(B) Chapter 404, Subchapter E of this title, relating to Rights of Persons Receiving Mental Health Services; and

(C) Chapter 405, Subchapter H of this title, relating to Behavior Management--Facilities Serving Persons With Mental Retardation;

(2) other actions taken in accordance with TDMHMR rules;

(3) such actions as an employee/agent/contractor may reasonably believe to be immediately necessary to avoid imminent harm to self, persons served, or other individuals if such actions are limited only to those actions reasonably believed to be necessary under the existing circumstances. Such actions do not include acts of unnecessary force or the inappropriate use of restraints or seclusion, including PMAB; or

(4) general complaints (e.g., regarding rights violations; theft of property; the daily administrative operations of a facility; the failure to carry out individual program/treatment plans or the failure to maintain adequate numbers of appropriately trained staff) that do not relate to a specific incident or allegation involving a specific person served. (Within 24 hours of receipt of such a complaint, the APS investigator refers the complaint to the head of the facility using the Adult Protective Services Referral Form, who ensures the complaint is investigated administratively by the head of the facility, the facility rights officer, or other appropriate parties.)

§417.505.Reporting Responsibilities of All TDMHMR Employees, Agents, and Contractors: Reports to Texas Department of Protective and Regulatory Services (TDPRS).

(a) Reporting suspected abuse, neglect, or exploitation.

(1) Each employee/agent/contractor who suspects or has knowledge that a person served is being abused, neglected, or exploited shall make a verbal report to TDPRS immediately, if possible, but in no case more than one hour after suspicion or after learning of the incident, by calling 1-800-647-7418.

(2) Each employee/agent/contractor who suspects or has knowledge that a person served has been abused, neglected, or exploited, including prior to admission, during an absence, or while in residence at the facility, shall make a verbal report to TDPRS immediately, if possible, but in no case more than one hour after suspicion or after learning of the incident, by calling 1-800-647-7418.

(3) If the person making the allegation is not an employee/agent/contractor (e.g., a person served, a guest), staff shall assist the person in making the report, if necessary.

(b) Any pregnancy of a person served, provided there is medical verification that there is reasonable expectation that conception could have occurred while the person was a resident of the facility or contractor, or any diagnosis of a sexually transmitted disease in a person served which could have occurred while the person was a resident of the facility or contractor, shall be reported in accordance with this subchapter as possible abuse or neglect.

(c) If an aggressive action by a person served, including non-consensual sexual activity between persons served, occurs as a result of possible neglect, then the action is reported as neglect in accordance with this subchapter.

(d) Failure to make reports as required by this section within the allotted time period without sufficient justification is considered a violation of this section and makes the employee/agent subject to disciplinary action and possible criminal prosecution. An employee/agent found to have made a false statement of fact during an investigation is also subject to disciplinary action.

(e) In addition to reporting to TDPRS, employees shall take appropriate steps to secure evidence related to an allegation, if any, consistent with "Guidelines for Securing Evidence," referenced as Exhibit B in §417.516 of this title (relating to Exhibits).

§417.507.Prohibition Against Retaliatory Action.

(a) Retaliatory action. Any employee/agent or any individual affiliated with an employee/agent is prohibited from engaging in retaliatory action against a person served, a family member of a person served, the guardian of a person served, the primary contact of a person served, or an employee/agent who in good faith reports an allegation.

(1) Any person who believes he or she is being subjected to retaliatory action upon reporting an allegation, or who believes an allegation has been ignored, should immediately contact the head of the facility. The person may also contact:

(A) the Office of Consumer Services and Rights Protection - Ombudsman at the dedicated toll-free number for facilities at 1-800-252-8154; or

(B) the Office of the Attorney General at 512/463-2185 (Consumer Protection Division) which, under the Whistleblower Act, Texas Civil Statutes, Article 6252-16a, may prosecute a supervisor who suspends or terminates a public employee for reporting a violation of law to law enforcement authorities.

(2) Retaliatory action against a person served which might be considered abuse, neglect, or exploitation is reported to TDPRS in accordance with this subchapter.

(b) Disciplinary action. Any employee/agent found to have engaged in retaliatory action is subject to disciplinary action.

§417.508.Responsibilities of the Head of the Facility.

(a) All allegations are investigated in accordance with Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs).

(b) Immediately upon notification of an allegation by the APS investigator, the head of the facility takes measures to ensure the safety of the alleged victim(s), including the following actions:

(1) As necessary, the head of the facility ensures immediate and on-going medical attention is provided to the alleged victim and any other person served involved in the incident (e.g., examination for and treatment of injuries, screening and treatment for sexually transmitted diseases). The examination and treatment of abuse/neglect-related injuries is documented on the client injury assessment, with a copy submitted to the APS investigator. All issues relating to clinical practice are referred to the medical/clinical director for consultation.

(2) The head of the facility ensures the protection of the alleged victim. Action taken to ensure the protection of the alleged victim must be appropriate within the context of the allegation and may include:

(A) reassigning the employee/agent to a non-direct care area in accordance with the Human Resources Operating Instruction 407-12;

(B) allowing the employee/agent to remain in his or her current position pending investigation;

(C) granting the employee emergency leave in accordance with the Human Resources Operating Instruction 407-12; or

(D) suspending the agent pending investigation.

(3) As necessary, the head of the facility ensures psychological attention is provided to the alleged victim and any other person served who may have witnessed or been affected by the incident. The psychological attention shall be provided in a timely manner while preserving the integrity of the investigation.

(4) If the alleged perpetrator is known but is not an employee/agent (e.g., family member, friend, guest), the head of the facility imposes a restriction on the alleged perpetrator's access to the alleged victim pending investigation. The restriction should be documented in the record of the alleged victim.

(5) Immediately, but in no case later than 24 hours after notification of an allegation, the head of the facility notifies the following individuals of the allegation:

(A) the alleged victim (if appropriate); and

(B) the alleged victim's guardian or primary contact (as defined), or parent if the alleged victim is a child.

(c) The head of the facility designates a contact staff person to coordinate with the APS investigator to ensure private interview space, private telephones, and employees/agents are available to the APS investigator. The head of the facility shall require employees/agents to cooperate with APS investigators so that the investigators are afforded immediate access to all records and evidence and provided keys as are necessary to conduct an investigation in a timely manner. The head of the facility shall assist in whatever way possible to make employees/agents who are relevant to the investigation available in an expeditious manner. Employees/agents who fail to cooperate with an investigation are subject to disciplinary action.

(d) Reports regarding alleged "sexual exploitation" committed by a "mental health services provider" (as defined in the Texas Civil Practice and Remedies Code, §81.001) are made by the head of the facility to the prosecuting attorney in the county in which the alleged sexual exploitation occurred and any state licensing board that has responsibility for the mental health services provider's licensing in accordance with the Texas Civil Practice and Remedies Code, §81.006. A copy of the Texas Civil Practice and Remedies Code, §81.001 and §81.006, is referenced as Exhibit A in §517.516 of this title (relating to Exhibits).

(e) At facilities that operate an intermediate care facility for the mentally retarded (ICF/MR), the head of the facility must report those allegations that are considered reportable incidents to the Texas Department of Human Services (TDHS), ICF/MR/RC Department in accordance with the memorandum of understanding, referenced as Exhibit C in §417.516 of this title (relating to Exhibits), between TDMHMR, TDHS, and Texas Department of Protective and Regulatory Services.

§417.509.Peer Review.

(a) If the allegation involves the actions of a physician, dentist, pharmacist, registered nurse, or licensed vocational nurse, then a determination of whether the allegation involves the clinical practice, as defined in §417.503 of this title (relating to Definitions), of the physician, dentist, pharmacist, registered nurse, or licensed vocational nurse is made by the head of the facility, the APS investigator, and the facility medical\dental\nursing\pharmacy director, as appropriate to the discipline involved.

(1) If the allegation does not involve clinical practice the APS investigator pursues an investigation.

(2) If the allegation does involve clinical practice the APS investigator refers the allegation to the head of the facility, who immediately refers the allegation to the facility medical\dental\nursing\pharmacy director, as appropriate to the discipline involved, for review for possible peer review as follows:

(A) for allegations involving physicians, pharmacists, and dentists, Investigative Medical Peer Review Operating Instruction 417-19; and

(B) for allegations involving registered nurses and licensed vocational nurses, Investigative Nursing Peer Review Operating Instruction 408-1.

(3) If the allegation involves clinical practice and non-clinical issues, then the allegation is referred to peer review in accordance with paragraph (2) of this subsection and is investigated by the APS investigator.

(4) If a determination of whether the allegation involves clinical practice cannot be made, then:

(A) the allegation is referred to peer review in accordance with paragraph (2) of this subsection and is investigated by the APS investigator; or

(B) the regional APS program administrator and the head of the facility jointly agree to use a previously mutually agreed-upon physician/dental/nursing/pharmacy consultant, as appropriate to the discipline involved, to make the final determination within 24 hours. The facility is responsible for the costs of the consultant's services.

(b) If the allegation involves the facility medical\dental\nursing\pharmacy director, the head of the facility refers the allegation to the TDMHMR medical\dental\nursing\pharmacy director, as appropriate to the discipline involved, for review for possible peer review in accordance with subsection (a)(2)(A) or (B) of this section. If the allegation involves the TDMHMR pharmacy director, then the head of the facility refers the allegation to the TDMHMR medical director for review for possible peer review in accordance with subsection (a)(2)(A) of this section.

(c) All allegations involving physicians, pharmacists, nurses (RN or LVN), and dentists, regardless of type or clinical/non-clinical practice, are reported by the head of the facility to the TDMHMR medical\nursing\dental\pharmacy director, as appropriate to the discipline, within five working days of the allegation. The report may be brief, but will include;

(1) the date of the alleged incident;

(2) name of the alleged victim and alleged perpetrator;

(3) a brief description of the incident; and

(4) a brief description of the investigation planned.

(d) The TDMHMR medical\dental\nursing\pharmacy director, as appropriate to the discipline involved, ensures that reports of allegations of abuse and neglect are made, if required by law, to the licensing authority for the discipline under review, i.e., the Texas Board of Medical Examiners for physicians, the State Board of Dental Examiners for dentists, the Texas State Board of Pharmacy, the Board of Nurse Examiners for the State of Texas for registered nurses, or the Board of Vocational Nurse Examiners for licensed vocational nurses.

(e) Upon receipt of an allegation involving physician misconduct or malpractice, the TDMHMR medical director reports the allegation to the Texas Board of Medical Examiners in accordance with §533.006 of the Texas Health and Safety Code and the memorandum of understanding, referenced as Exhibit D in §417.516 of this title (relating to Exhibits), between TDMHMR, TDPRS, and the Texas Board of Medical Examiners.

(f) When an allegation is determined to involve the clinical practice of a physician, nurse (RN or LVN), pharmacist, or dentist, then the head of the facility ensures that the alleged victim, guardian, or primary contact, or parent (if the alleged victim is a child) are informed that the allegation has been referred for peer review.

§417.510.Completion of the Investigation.

(a) The APS investigator sends a copy of the investigative report to the head of the facility in accordance with Chapter 711, Subchapter G of Title 40 (concerning Release of Report and Findings). The investigative report includes:

(1) a statement of the allegation(s);

(2) a summary of the investigation;

(3) an analysis of the evidence, including:

(A) factual information related to what occurred;

(B) how the evidence was weighed; and

(C) what testimony was considered credible;

(4) a finding that the allegation is confirmed, unconfirmed, inconclusive, or unfounded;

(5) recommendations resulting from the investigation;

(6) the name of the perpetrator or alleged perpetrator or the designation of "perpetrator unknown";

(7) a recommended classification for each allegation as described in §417.512(a) of this title (relating to Classifications and Disciplinary Actions);

(8) the exam and treatment of abuse/neglect-related injuries documented on the client injury assessment;

(9) photographs relevant to the investigation, including photographs showing the existence of injuries or the non-existence of injuries, when appropriate;

(10) all witness statements and supporting documents; and

(11) a signed and dated Client Abuse and Neglect Report (AN-1-A) form, referenced as Exhibit E in §417.516 of this title (relating to Exhibits), reflecting the information contained in paragraphs (4), (6), and (7) of this section.

(b) Upon receiving the investigative report from the APS investigator, the head of the facility may submit the report and concerns articulated by the APS investigator to a review authority for review.

(1) The review authority may interview witnesses in the course of its review.

(2) If the review authority is reviewing a case determined by the APS investigator to be unfounded, it may consult with the APS investigator if appropriate. If the review authority determines that there is good cause to reopen the investigation (e.g., new evidence or information that was not previously available during the investigation), the head of the facility may contact the local APS supervisor to request that the case be re-opened.

(3) The review authority submits a report of its review to the head of the facility.

(c) The head of the facility:

(1) reviews the APS investigator's report;

(2) reviews the review authority's report, if applicable; and

(3) interviews witnesses, if necessary.

(d) The rights of employees who appear before the review authority or the head of the facility are outlined in "Procedures in Facility Abuse, Neglect, and Exploitation Investigations and Thurston Rebuttal Proceedings," referenced as Exhibit F in §417.516 of this title (relating to Exhibits).

(e) The head of the facility may not change a confirmed finding. However, if the head of the facility disagrees with the APS investigator's finding of unconfirmed, inconclusive, or unfounded, the head of the facility may elect to change the finding to confirmed. If the head of the facility elects to change the finding to confirmed, then the confirmed finding cannot be appealed to TDPRS.

(f) If the head of the facility believes that the methodology used in conducting the investigation was flawed (e.g., failure to collect or consider evidence, such as witnesses' statement, progress notes, test results), the head of the facility may request a review in accordance with Chapter 711, Subchapter K of Title 40 (concerning Requesting a Review of Finding if You Are the Administrator or Contractor CEO).

(g) If the head the facility disagrees with:

(1) the APS investigator's finding, the head of the facility may contest the finding by requesting a review in accordance with Chapter 711, Subchapter K of Title 40 (concerning Requesting a Review of Finding if You Are the Administrator or Contractor CEO).

(2) the APS review as described in §711.1007 of Title 40 (relating to How is the Review of a Finding Conducted?), the head of the facility may contest the review by apprising the TDMHMR director of state mental health facilities or state mental retardation facilities, as appropriate. If the TDMHMR director also disagrees with the APS review, the TDMHMR director may request a decision by the TDMHMR commissioner and the TDPRS executive director. The decision of the TDMHMR commissioner and the TDPRS executive director may not be contested.

(h) The final finding is the last uncontested finding, which may be:

(1) the APS investigator's finding in accordance with subsection (a)(4) of this section;

(2) the head of the facility's confirmed finding in accordance with subsection (e) of this section;

(3) the APS finding in accordance with subsection (g)(1) of this section; or

(4) the TDMHMR commissioner and the TDPRS executive director's decision in accordance with subsection (g)(2) of this section.

(i) Within 30 calendar days of receipt of the investigative report or the final finding, the head of the facility is responsible for completing the Client Abuse and Neglect Report (AN-1-A) form, referenced as Exhibit E in §417.516 of this title (relating to Exhibits), and ensuring the information is entered into the Client Abuse and Neglect Reporting System (CANRS).

(j) The APS investigator notifies the reporter in accordance with §711.609 of Title 40 (relating to How and When is the Reporter Notified of the Finding?).

(k) The head of the facility ensures that the (alleged) victim or guardian or parent if the (alleged) victim is a child is promptly notified of:

(1) the final finding and if any previous findings were contested;

(2) the method of appealing the final finding as described in Chapter 711, Subchapter M of Title 40 (concerning Requesting an Appeal if You Are the Reporter, Alleged Victim, Legal Guardian, or With Advocacy, Incorporated), if the final finding was not made by the head of the facility as provided by subsection (e) of this section; and

(3) the right to receive a copy of the investigative report in accordance with §417.511(b) of this title (relating to Confidentiality of Investigative Process and Report) upon request.

(l) The head of the facility ensures that the primary contact is promptly notified of the final finding.

(m) The head of the facility informs the perpetrator or alleged perpetrator of the final finding.

(n) If the (alleged) perpetrator and (alleged) victim will again be in close proximity following an investigation, the head of the facility is responsible for ensuring appropriate reconciliation efforts are considered, offered, and provided in accordance with "Therapeutic Reconciliation," referenced as Exhibit G in §417.516 of this title (relating to Exhibits).

(o) The head of the facility shall establish a mechanism for evaluating any recommendations concerning problematic patterns or trends identified during the investigation by the APS investigator and the review authority, if applicable.

§417.512.Classifications and Disciplinary Actions.

(a) The APS investigator recommends a classification for each allegation as follows:

(1) Class I Abuse, if the allegation involves:

(A) physical abuse which caused or may have caused serious physical injury; or

(B) sexual abuse.

(2) Class II Abuse, if the allegation involves:

(A) physical abuse which caused or may have caused non-serious physical injury; or

(B) exploitation.

(3) Class III Abuse, if the allegation involves verbal/emotional abuse.

(4) Neglect, if the allegation involves neglect.

(b) Under no circumstances may the head of the facility change a recommended classification to a lower classification (e.g., Class I to Class II). However, the head of the facility may change a recommended classification to a higher classification (e.g., Class II to Class I) in accordance with the evidence and subsection (a) of this section.

(c) The head of the facility is responsible for taking prompt and proper disciplinary action when an allegation involving an employee/agent is confirmed.

(1) Disciplinary action against an employee is based on criteria including, but not limited to:

(A) the seriousness of the abuse, neglect, and/or exploitation;

(B) the circumstances surrounding the incident;

(C) the employee's work record; and

(D) repeat violations and the length of time between violations.

(2) When an allegation has been confirmed the head of the facility takes the following disciplinary action.

(A) Class I Abuse. The employee/agent is dismissed.

(B) Class II Abuse.

(i) The employee is placed on suspension for up to 10 days, demoted, or dismissed. If the employee is exempt under the provisions of the Fair Labor Standards Act (FLSA), the suspension shall be in compliance with relevant provisions of the FLSA and current TDMHMR personnel policies.

(ii) The agent is dismissed.

(C) Class III Abuse or Neglect.

(i) The employee receives a written reprimand which becomes a part of the employee's personnel file, or the employee is placed on suspension for up to 10 days, demoted, or dismissed. If the employee is exempt under the provisions of the FLSA the suspension shall be in compliance with relevant provisions of the FLSA and current TDMHMR personnel policies.

(ii) The agent is dismissed.

(d) When disciplinary action is taken against an employee based on confirmed abuse or neglect, the head of a facility notifies the employee in writing of the disciplinary action taken and any right to a grievance hearing the employee may have under TDMHMR's internal policies and procedures relating to employee grievances. If the employee files a grievance in response to disciplinary action resulting from confirmed abuse or neglect, the head of the facility, upon the employee's written request, provides the employee with a copy of or access to the investigative report. Before receiving or inspecting the report, the employee is required to complete a document acknowledging that the report's content must be kept confidential. Additional documentary evidence, if any, may be accessed by the employee in accordance with procedures outlined in the Human Resources Operating Instruction 407-12, §18 (relating to Employee Grievances).

(e) When disciplinary action is taken against an agent as a result of confirmed abuse or neglect, the head of a facility notifies the agent in writing of the disciplinary action taken.

(f) The head of the facility ensures the victim, guardian, or primary contact, or parent if the victim is a child is promptly notified of:

(1) the disciplinary action taken against the employee/agent;

(2) the employee's right to request a grievance hearing to dispute the disciplinary action; and

(3) an offer to inform the victim, guardian, primary contact, or parent if the employee files a grievance if such information is requested.

(g) If Advocacy, Inc. informs the head of the facility that it represents the victim of confirmed Class I abuse, the head of the facility will notify Advocacy, Inc. if the dismissed employee requests a grievance hearing.

(h) If requested by the head of the facility, the APS investigator who conducted the investigation shall provide consultation and testimony at the grievance hearing.

(i) The head of the facility provides the APS director with a copy of hearings officers' decisions of employee grievances that involve TDPRS investigations.

§417.515.Staff Training in Identifying, Reporting, and Preventing Abuse, Neglect, and Exploitation.

(a) This subchapter shall be thoroughly and periodically explained to all employees/agents of each facility as follows:

(1) All new employees/agents who will provide direct services to persons served and all new employees/agents who will routinely perform job duties in proximity to persons served shall receive training on the contents of this subchapter prior to performing their duties and annually thereafter. The training will include:

(A) an explanation and examples of the acts and signs of possible abuse, neglect, and exploitation;

(B) the effects of abuse, neglect, and exploitation;

(C) an explanation that abuse, neglect, and exploitation of persons served is prohibited;

(D) the disciplinary consequences for:

(i) committing abuse, neglect, and exploitation; and

(ii) failure to cooperate with an investigation;

(E) the procedures for reporting allegations of abuse, neglect, and exploitation;

(F) a definition of retaliatory action, an explanation that retaliatory action is prohibited, and an explanation of the consequences of retaliatory action;

(G) practices and attitudes that support the prevention of abuse, neglect, and exploitation; and

(H) PMAB.

(2) All new employees/agents who will not provide direct services to persons served and who will not routinely perform any job duty in proximity to persons served shall receive training on the contents of this subchapter within two months of employment or placement and every two years thereafter. The training will include:

(A) an explanation and examples of the acts and signs of possible abuse, neglect, and exploitation;

(B) the effects of abuse, neglect, and exploitation;

(C) an explanation that abuse, neglect, and exploitation of persons served is prohibited;

(D) the disciplinary consequences for:

(i) committing abuse, neglect, and exploitation; and

(ii) failure to cooperate with an investigation;

(E) the procedures for reporting allegations of abuse, neglect, and exploitation; and

(F) a definition of retaliatory action, an explanation that retaliatory action is prohibited, and an explanation of the consequences of retaliatory action.

(3) Physicians shall receive additional training on how to identify signs and symptoms of abuse, neglect, and exploitation.

(4) All new employees who will provide direct services to persons served shall receive training on the procedures for securing evidence in accordance with "Guidelines for Securing Evidence," referenced as Exhibit B in §417.516 of this title (relating to Exhibits) prior to performing their duties and annually thereafter.

(5) Within 90 days after the effective date of this subchapter, the head of the facility shall inform all current employees/agents/contractors of changes to policies and procedures as a result of this subchapter.

(b) All supervisory personnel have a continuing responsibility to keep employees/agents informed of current rules and policies governing abuse, neglect, and exploitation and to ensure that employees/agents receive training in accordance with this section.

(c) Instructional materials, audiovisual, and/or other training aids concerning this subchapter are developed and available through the TDMHMR System Human Resource Development, Central Office.

(d) Records of all training content and activities related to course titles shall be kept by each facility. Records shall also be kept on each employee/agent receiving training in compliance with this section, which include:

(1) the employee/agent's name and signature;

(2) the course title;

(3) the result of any assessment;

(4) the date of the training; and

(5) the name of the person facilitating, monitoring, or conducting the training.

§417.516.Exhibits.

The following exhibits referenced in this subchapter are available from the Texas Department of Mental Health and Mental Retardation, Office of Policy Development, P.O. Box 12668, Austin, TX 78711-2668.

(1) Exhibit A--Texas Civil Practice and Remedies Code, §81.001 and §81.006;

(2) Exhibit B--"Guidelines for Securing Evidence";

(3) Exhibit C--Memorandum of Understanding between TDMHMR, TDHS, and TDPRS concerning Reportable Incidents in State Schools, State Centers, State Operated Community-based MHMR Services, and Community MHMR Centers with Intermediate Care Facilities for the Mentally Retarded (ICF/MR);

(4) Exhibit D--Memorandum of Understanding between TDPRS, Texas Board of Medical Examiners, and TDMHMR concerning Mandatory Reporting of Physician Misconduct or Malpractice;

(5) Exhibit E--Client Abuse and Neglect Report (AN-1-A) form;

(6) Exhibit F--"Procedures in Facility Abuse, Neglect, and Exploitation Investigations and Thurston Rebuttal Proceedings"; and

(7) Exhibit G--"Therapeutic Reconciliation."

§417.517.References.

Reference is made to the following statutes, rules, and TDMHMR operating instructions:

(1) Texas Health and Safety Code, Chapters 242, 481, and 577;

(2) Probate Code, Chapter 13;

(3) Whistleblower Act, Texas Civil Statutes, Article 6252-16a;

(4) Texas Penal Code, §§22.011, 22.021, 43.01, and 43.21;

(5) Texas Family Code, Chapter 31;

(6) Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(7) Chapter 405, Subchapter F of this title (relating to Voluntary and Involuntary Behavioral Interventions in Mental Health Programs;

(8) Chapter 405, Subchapter H of this title (relating to Behavior Management--Facilities Serving Persons With Mental Retardation);

(9) Chapter 711 of Title 40 (concerning Investigations in TDMHMR Facilities and Related Programs).

(10) Human Resources Operating Instruction 407-12;

(11) Investigative Medical Peer Review Operating Instruction, 417-19;

(12) Investigative Nursing Peer Review Operating Instruction, 408-1;

(13) Texas Civil Practice and Remedies Code, §81.006; and

(14) 42 USC §10805(a)(4) and §15043(a)(2)(I).

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, 2003.

TRD-200302196

Rudy Arredondo

Chairman, Texas MHMR Board

Texas Department of Mental Health and Mental Retardation

Effective date: April 23, 2003

Proposal publication date: February 7, 2003

For further information, please call: (512) 206-4516