PART 3. TEXAS YOUTH COMMISSION
SUBCHAPTER D. HEALTH CARE SERVICES
The Texas Youth Commission (TYC) proposes the repeal of §§91.81, 91.83, and 91.85, new §§91.75, 91.81, and 91.83, and amendments to §§91.86, 91.92, and 91.94.
New §91.75 (concerning health care definitions) will consolidate definitions used throughout the subchapter into one rule.
New §91.81 (concerning medical consent) establishes standards whereby TYC exercises its authority to consent to particular medical services for youth in TYC jurisdiction.
New §91.83 (concerning health care services for youth) consolidates information currently contained in §91.83 and §91.85. The new rule will establish criteria for providing care, the scope of available healthcare services, and standards for the delivery of healthcare services to youth.
The repeal of §§91.81, 91.83, and 91.85 will allow for the publication of new §91.81 and §91.83 in their place.
Amended §91.86 (concerning infirmary admission and discharge) provides clarification regarding the level of authorization needed to admit or discharge a youth from the infirmary for period of longer than 24 hours, and establishes that an associate psychologist may conduct the required daily evaluation for a youth admitted to the infirmary in a psychiatric emergency when a Ph.D. level psychologist is unavailable.
Amended §91.92 (concerning involuntary emergency administration of psychotropic medication) adds that commitment to a state hospital will be initiated if continued involuntary administration of psychotropic medication is necessary, and requires TYC staff to notify a youth's parent/guardian any time psychotropic medication is administered against a youth's will.
Amended §91.94 (concerning automated external defibrillators) requires each facility to designate certain first responder staff who will be required to participate in hands-on training in the use of automated external defibrillators.
Robin McKeever, Director of Administrative Services, has determined that for the first five-year period the proposal is in effect, there will be no significant fiscal impact for state or local government as a result of enforcing or administering the repeal, new sections, and amendments.
Rajendra Parikh, M.D., Medical Director, has determined that for each year of the first five years the proposal is in effect, the public benefit anticipated as a result of enforcing the repeal, new sections, and amendments will be the availability of accurate and current policy information regarding healthcare services provided by TYC.
There will be no effect on small businesses or micro-businesses. There is no anticipated economic cost to persons who are required to comply with the repeal, new sections, and amendments as proposed. No private real property rights are affected by adoption of this proposal.
Comments on the proposal may be submitted within 30 days of the publication of this notice to Steve Roman, Policy Coordinator, Texas Youth Commission, P.O. Box 4260, Austin, Texas 78765, or email to steve.roman@tyc.state.tx.us.
37 TAC §§91.75, 91.81, 91.83, 91.86, 91.92, 91.94
The new and amended sections are proposed under the Human Resources Code, §61.076, which provides the commission with the authority to provide any necessary medical or psychiatric treatment to youth committed to its care, as well as Family Code §32.001, which provides the commission with the authority to consent to the medical, dental, psychological, and surgical treatment of a child committed to it when the person having the right to consent has been contacted and that person has not given actual notice to the contrary.
The proposed new and amended sections implement the Human Resources Code, §61.034.
§91.75.Health Care Definitions.
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
(1) Automated External Defibrillator (AED)--a United States Food and Drug Administration approved electronic device which is programmed to analyze the heart's rhythm for any abnormalities and, if necessary, directs the rescuer to deliver an electrical shock (defibrillation) to assist the heart in reestablishing a normal rhythm.
(2) Health Care Professional--an individual who is licensed by a professional board to practice in the State of Texas in a field of health including nursing, medicine, psychiatry or dentistry.
(3) Health Services Administrator--an individual who is a licensed registered nurse who manages and coordinates, at the facility, the delivery of on and off-site health care services for youth.
(4) Medical Provider--a physician or mid-level practitioner who provides health care services to Texas Youth Commission (TYC) youth under a contractual agreement with TYC.
(5) Life-Threatening Medical Emergency--a situation that is either imminently life-threatening or that requires immediate health care to prevent the development of a life-threatening condition. Examples of an imminently life threatening situation would include a youth being unresponsive, being unconscious, not breathing or experiencing severe respiratory distress, or severe bleeding in streams or spurts.
(6) Medical Alert--a flagging or identifying process that alerts staff of a potentially dangerous or life-threatening diagnosed condition. Examples of these conditions include, but are not limited to, a history or current diagnosis of chronic/acute asthma, cardiac problems, diabetes, seizures, serious injury, anaphylactic allergic reactions, or any other condition affecting daily living activities and requiring special assistance or special attention.
(7) Psychiatric Emergency--a situation in which it may be necessary to administer psychotropic medication to prevent harmful behaviors associated with a diagnosed psychiatric condition.
(8) Sick Call--a routine time during which a health care professional addresses youth health care needs.
§91.81.Medical Consent.
(a) Purpose. The purpose of this rule is to establish a procedure by which the Texas Youth Commission (TYC) may exercise its authority to consent to particular medical services for youth in TYC jurisdiction in accordance with the Family Code, §32.001(b).
(b) Applicability.
(1) Definitions pertaining to this rule are under §91.75 of this title.
(2) TYC does not have the authority to consent to medical treatment of any nature for youth on parole status in a home placement. For purposes of this policy, the term "home placement" does not include the Independent Living Program as described in §87.23 of this title.
(c) Medical Consent.
(1) For Youth under Age 18.
(A) TYC has the authority to consent to the medical treatment of its youth under the age of 18 only when the person having the right to consent (youth's parent or guardian) has been notified and actual objection has not been received by TYC. Though TYC has the authority to consent to treatment other than that specified in §91.83 of this title, TYC will defer to and attempt to contact the person having authority to consent when such medical treatment may be necessary.
(B) When a medical or dental provider determines a youth needs a diagnostic or treatment procedure or treatment for a serious injury or illness that requires parental/guardian consent, the parent/guardian will be contacted to provide written or verbal consent directly to the medical provider. If this is not possible, the facility administrator has the authority to give his/her consent for treatment of the youth under certain conditions pursuant to §32.001, Family Code.
(C) If a parent or guardian notifies TYC that he/she objects to TYC having medical consent authority, the parent or guardian will be asked to provide written consent for routine physical, dental, mental health and chemical dependency examinations and/or evaluations, and certain immunizations required by law.
(D) When a youth is temporarily admitted to a facility of the Texas Department of State Health Services, the TYC medical director may consent to the specific care outlined in §91.83 of this title if the parent or guardian cannot be contacted directly for consent.
(2) For Youth Age 18 or Older. When a youth reaches age 18, he/she has the right to legally consent to medical treatment. The youth's consent with respect to treatment for non-life threatening conditions will prevail if there is a conflict between the youth and the parent/guardian and/or TYC.
(d) Notification. Notification regarding the provision of routine health care services and TYC's authority to consent to treatment will occur during the initial admission and recommitment to TYC and will be by certified mail to the last known address of the person having the right to consent.
§91.83.Health Care Services for Youth.
(a) Purpose. The purpose of this rule is to establish basic criteria, standards, and guidelines for delivery of health care services to youth who are assigned to Texas Youth Commission (TYC) operated residential facilities and certain identified contract care programs.
(b) Applicability.
(1) Definitions pertaining to this rule are under §91.75 of this title.
(2) For consent to treatment, see §91.81 of this title.
(c) Criteria for Medical Care.
(1) As established by the TYC medical director, primary medical care will be provided by medical providers according to the following criteria:
(A) life saving treatment;
(B) limb saving treatment;
(C) reasonable care to relieve pain; and
(D) reasonable care for a degenerative condition.
(2) Procedures outside these criteria for medical care must be approved by the TYC medical director in consultation with TYC's executive commissioner.
(d) Criteria for Dental Care.
(1) The dentist will assure equitable access to basic preventive services and essential treatment procedures based upon the occurrence of disease, significant malfunction or injury. Priority of treatment categories are:
(A) Emergency/urgent--treatment for conditions which will worsen or become life-threatening or acute without immediate intervention.
(B) Interceptive--intermediate treatment for asymptomatic advanced hard or soft tissue disease or loss of masticatory function.
(C) Rehabilitative--definitive treatment for chronic hard or soft tissue disease or loss of masticatory function.
(D) Elective or special needs.
(2) The attending dentist may vary from this prioritization on an individual basis if judged to be necessary for the protection of the youth's overall health.
(3) TYC will provide for necessary care of orthodontic braces to prevent injury to the mouth. Maintenance and treatment will be arranged by and paid for by the parent/guardian after notification of TYC policy. TYC staff will assist youth and parents/guardians in making appointments and providing transportation for orthodontic care.
(e) Services.
(1) TYC will administer the following services, either directly or through contractual arrangements. These services include but are not limited to the following:
(A) physical examinations and treatment;
(B) dental examinations and treatment;
(C) treatment of injuries;
(D) mental health evaluations;
(E) immunizations;
(F) laboratory and diagnostic tests;
(G) administration of prescription or non-prescription medication for an illness or condition;
(H) chemical dependency evaluations; and
(I) examination following use of physical force and/or contamination caused by use of oleoresin capsicum spray, also known as pepper spray.
(2) Each TYC-operated facility and certain identified contract care programs will have a health services administrator who is designated to act as the local health authority.
(3) The appropriate level of health care services will be provided in the infirmary at each institution through contract health care professionals for youth who are not in need of hospitalization, but who need increased observation or medical care.
(4) Nurses will provide services for routine sick call requests at least five days per week. Medical providers, dentists, and a psychiatrist will provide services on-site or via telemedicine/telepsychiatry at least once weekly.
(5) In halfway houses, nursing case management and consultation will be provided as needed. Medical providers, dentists, and psychiatrists will provide services as needed.
(6) Upon admission to TYC, all youth will receive a health screening, physical examination (if no documentation within the past 90 days), mental health screening and evaluation, a dental screening, examination, and dental cleaning as prescribed by the dentist. Youth will receive a health screening, physical examination, dental examination, and dental cleaning annually thereafter.
(7) Upon admission to TYC, all youth will receive a vision screening. If the vision screening indicates that the youth needs a new prescription, state-issued prescription eyewear will be provided. Youth whose placement is in a high restriction facility are prohibited from wearing contact lenses, except where medically necessary as a form of treatment and glasses are ineffective for correcting vision.
(8) In facilities housing females, obstetrical, gynecological, and family planning services will be available on-site or by referral.
(f) Limitation of Services.
(1) TYC is not responsible for medical costs incurred by a youth:
(A) on furlough with a parent, relative, or guardian; or
(B) on parole status, unless the youth's placement is in a TYC-operated/contract residential program; or
(C) on escape/abscond status; or
(D) in a detention center or a county facility.
(2) Pharmaceutical, cosmetic, and medical experiments are prohibited. This policy does not preclude individual treatment of a youth based on the need for a specific medical procedure which is not generally available.
(g) Health Care Requirements.
(1) Facilities housing more than 25 youth must have a central medical room with medical examination facilities.
(2) Youth present in the infirmary will be supervised by a TYC staff member at all times.
(3) The physician or dentist is the decision authority for medical/dental services at the respective facility.
(4) The medical provider will develop the youth's medical plan of care.
(5) A medical provider will be available once each week to respond to youth complaints regarding services which they did or did not receive.
(6) In each TYC-operated residential program and certain identified contract care programs, the superintendent, health services administrator, medical provider and dentist must have regularly scheduled meetings to review health care services, including any concerns or problems related to the provision of health care. If problems are identified, follow-up must occur to ensure that the recommended actions are implemented and the problem has been resolved.
(7) A youth, who by history or examination has a serious or life-threatening medical condition, may be placed on medical alert status by a medical provider. A nurse may place a youth on medical alert status if such conditions occur during movement from one facility to another until a medical provider can be notified.
(8) The medical provider or psychiatrist may authorize medical and pharmacological intervention when required in a life-threatening situation consistent with §91.81 of this title. When this intervention requires the use of psychotropic medication, the authorization must be consistent with criteria in §91.92 of this title.
(9) Each TYC-operated residential program and certain identified contract care programs will post procedures for providing health care to youth when there is not a nurse on duty, including how to contact the on-call nurse.
(10) Pharmaceutical procedures will comply with federal and state laws and accepted industry practices pertaining to the acquisition, storage, administration, and documentation of prescription drugs.
(h) Medical Concerns Reported by Youth.
(1) Any youth may request a sick call for the evaluation of health care concerns.
(2) Any youth may file a complaint related to his/her health care service through the youth grievance procedure in accordance with §93.31 of this title.
(i) Emergency Room Referrals. Emergency room referrals may only be authorized by a medical provider, health services administrator or designee or the medical or nursing director.
(j) Notification. Parents or guardians will immediately be notified of a youth's serious illness, injury, or recommended need for surgery.
§91.86.Infirmary Admission and Discharge .
(a) Purpose. The purpose of this rule is to establish conditions and procedures for use of infirmaries in Texas Youth Commission (TYC) facilities.
(b) General Provisions.
(1) [(b)] Nursing care will be
provided in the infirmary at each institution through contract health
care staff for youth who are not in need of hospitalization, but who
need increased observation or medical care. Infirmary admissions
include [includes
] youth who are acutely ill, injured, or
are recovering from surgery or illness; or youth who need increased
observation as result of a psychiatric crisis (identified by a Ph.D.
level psychologist or psychiatrist).
(2) [(c)] Juvenile Corrections
Officers (JCO's) shall [at all times,] supervise youth
admitted to the infirmary at all times. [for a psychiatric
crisis. JCO's shall provide supervision as needed for youth admitted
to the infirmary for medical conditions.]
(3) [(d)] Physician [Physician's
] orders shall be received only by nursing staff
directly from the physician.
(c) [(e)] Infirmary Admission for Medical Diagnosis.
(1) The medical provider or health services administrator
or designee determines if a youth requires [Admission to
the infirmary for youth in need of] observation or treatment
for a medical diagnosis or condition [is determined by facility
health care staff].
(2) The health services administrator may admit a youth for a medical diagnosis or condition to the infirmary for up to 24 hours. Admission to the infirmary for 24 hours or longer may only be authorized by the medical provider.
(3) [(2)] Discharge from the
infirmary may be ordered only by a physician if the
youth was admitted for 24 hours or longer. A physician or nurse may
discharge youth admitted for less than 24 hours. [or initiated
by nursing staff when the youth is well enough to participate in daily
program activities.]
(d) [(f)] Infirmary Admission
for Psychiatric Crisis.
(1) Admission to the infirmary for youth needing close
observation for a psychiatric crisis may be authorized by a psychiatrist
, if available. The director of clinical services [
psychology] may authorize the admission when a psychiatrist
is not on-site, and will immediately notify the psychiatrist,
or a physician if a psychiatrist is not available, and document
the notification. Psychiatrist or physician [Physician's]
orders shall be obtained for youth admitted to the infirmary within
two hours of admission.
(2) In obtaining psychiatrist or physician [physician's
] orders for youth experiencing a psychiatric crisis, [
mental health disorders,] nursing staff
should provide to the psychiatrist relevant medical information
such as current medications, [any medical data, observations,
information from the medical file as relevant, and any other objective
data, such as] vital signs, subjective or objective data
(e.g., laboratory values), observations, and assessment. The
psychiatrist or physician [psychiatrist's
] order should include
instructions regarding any observations that nursing staff must make
about the youth's mental status, as well as instructions for any other
type of monitoring or medications that are to be administered.
(3) A Ph.D. level psychologist or psychologist associate (if a Ph.D. level psychologist is not available) will evaluate the youth at least once a day.
(4) Disposition (discharge or referral) will be made by the psychiatrist.
§91.92. Involuntary Emergency Administration of Psychotropic Medication [Medication-Related Emergencies ].
(a) Purpose. The purpose of this rule is to establish
criteria and procedure for administering [a] psychotropic
medication to youth in TYC-operated high restriction residential facilities
in a psychiatric [drug in a medication-related] emergency
when the [a] youth cannot or will not give consent
for the administration.
(b) References.
(1) For definitions pertaining to this rule, see §91.75 of this title.
(2) See §97.23 of this title for use of force procedures and approved techniques.
(c) [(b)] Criteria for the
Involuntary Administration of Psychotropic Medication.
(1) Psychotropic medication may be administered in
an injectable form to a youth in a psychiatric emergency [
against the will of the youth in a medication-related emergency]
when the youth cannot or will not give consent if the youth has
a diagnosed psychiatric disorder and one or both of the following criteria
[herein] are met.
[(2) A medication-related emergency
is defined as a situation in which it is immediately necessary to
administer the medication to prevent harmful behaviors associated
with a diagnosed psychiatric condition and to prevent:]
(A) imminent and substantial harm to self [the youth
] because the youth is overtly engaging in behaviors
that could result in [serious] bodily harm or death; or
(B) imminent and substantial physical harm
to another because of [attempts or
] acts the youth overtly [or continually makes or] commits.
(2) Only a facility psychiatric provider (under the direction of a psychiatrist) or physician may prescribe the involuntary emergency use of psychotropic medication.
(d) [(c)] Restrictions for
Administering Psychotropic Medication.
(1) Psychotropic drugs shall not be administered for the purposes of punishment or for program management or control. Pharmaceutical experimentation or research using TYC youth is strictly prohibited.
(2) Standing medication orders are prohibited in a psychiatric emergency.
[(2) The use of psychotropic medication
in an emergency must be ordered by the responsible physician or facility
psychiatrist. Medication for this purpose shall not be authorized
through the use of standing orders.]
[(3) Psychotropic medication may be
administered only to a youth who has a diagnosed psychiatric disorder
and who has had a physical examination prior to psychotropic medication
being prescribed.]
[(4) Psychotropic medication may be
administered in either oral or injectable form.]
(e) Emergency Commitment to a State Hospital or Admission to Corsicana Stabilization Unit.
(1) For a youth who requires continued medication against his/her will, commitment to a state hospital will be initiated. See §87.69 of this title regarding procedures for commitment to a state hospital.
(2) If the youth qualifies for admission to Corsicana Stabilization Unit (CSU), staff shall immediately initiate an admission referral to CSU. See §87.67 of this title regarding admission to CSU.
(f) Notification.
(1) The facility administrator or designee will notify the parent/guardian of involuntary administration of psychotropic medication as soon as possible following the action.
(2) Psychiatric emergencies will be reported in accordance with agency procedures for reporting serious incidents.
§91.94.Automated External Defibrillators.
(a) Purpose. The purpose of this policy is to establish
procedures and guidelines for the operation, storage, [strike>and]
maintenance, and training requirements associated with the use of
Automated External Defibrillators (AEDs). [It is Texas Youth
Commissions (TYC's) objective to provide immediate emergency response
to a sudden cardiac arrest that occurs at a TYC-operated facility,
designated TYC district offices, and Central Office/Annex.]
(b) Applicability.
[(1)] This rule applies to employees at
TYC-operated facilities, designated district offices, and Central
Office/Annex.
[(2) The use of AEDs applies to TYC
youth, staff, volunteers, visitors, and contractors.]
(c) Definitions [Explanation of Terms Used].
Definitions pertaining to this rule are under §91.75
of this title.
[(1) Automated External Defibrillator
(AED)--a United States Food and Drug Administration (FDA) approved
electronic device, about the size of a laptop computer, which is programmed
to analyze the heart's rhythm for any abnormalities and, if necessary,
directs the rescuer to deliver an electrical shock (defibrillation)
to assist the heart in reestablishing a normal rhythm.]
[(2) Cardiac Arrest--a malfunction
in the heart's electrical system (ventricular fibrillation or rapid
ventricular tachycardia) that may cause the heart to stop suddenly.]
[(3) Myocardial Infarction--death
of heart muscle tissue caused by lack of blood supply to the heart
due to plaque or blood clot.]
(d) General Provisions.
(1) [(d)] The TYC medical director [
Medical Director] authorizes the acquisition of AEDs
for placement at all TYC-operated facilities,
designated district [District] offices, and
the Central Office/Annex.
(2) [(e)] Upon acquiring an AED,
the chief local administrator or designee shall notify the local
emergency medical service (EMS) [EMS
] provider of the existence, location, and type of AED.
(e) [(f)] Cardiac Chain of Survival.
Cardiac chain of survival is the current treatment for sudden cardiac
arrest that includes the following four steps:
(1) Call 911 or facility gatehouse/control center and include notification that an AED will be used;
(2) begin Cardiopulmonary Resuscitation (CPR);
(3) provide early defibrillation; and
(4) provide Advanced Cardiac Life Support (to
be preformed by EMS). [facilitate access to advanced medical
care.]
(f) [(g)] Restrictions for Use.
(1) The AED is to be used only if the person is unresponsive and has no pulse.
(2) The AED is to be used only on persons over the
age of eight [(8)] years old.
(3) The AED will provide voice prompts giving further instructions if it cannot read the cardiac rhythm due to improper electrode placement, motion of the person, low battery, or electromagnetic interference, etc.
(4) The AED voice prompt will not instruct the user to shock the person if the person's cardiac rhythm does not warrant a shock or if the person's cardiac rhythm suddenly changes and shock is no longer indicated.
(5) The AED voice prompts will not advise the user to shock the person if the person is experiencing a myocardial infarction.
(g) [(h)] AED Training.
(1) A qualified CPR/First Aid/AED TYC trainer
or a qualified contracted trainer will provide American Red Cross
CPR/First Aid training and instruction in the use of an AED to all
TYC sole supervision staff annually. The facility administrator will
designate staff to receive additional hands-on training on the use
of AED. [AED training is incorporated into the American
Red Cross CPR/First Aid training required for all TYC direct care
staff. All TYC direct care staff are required to be trained annually
by a qualified CPR/First Aid/AED TYC trainer or a qualified contracted
trainer.]
(2) All TYC [non-direct care] staff [working
in TYC facilities that house youth, designated district offices, and
Central Office/Annex] are required to watch the AED training
video [at least once] annually. Training will include
the location of the AED[,] and [the training
will] be documented and maintained by the local training officer.
(3) The AED training program is approved by the TYC medical
director [Medical Director] and the
Texas Department of State Health Services [
Texas Department of Health] in accordance with the Health
and [&] Safety Code, Chapter 779.
(h) [(i)] General Requirements.
(1) The AED shall be readily accessible to staff,
but at [At] no time shall an AED be accessible
to [a] TYC youth [
be accessible to the AED].
(2) Each TYC-operated facility that houses youth, designated
TYC district offices, and the Central Office/Annex will
have an AED on-site. [Al Price State Juvenile Correctional Facility,
Ron Jackson State Juvenile Correctional Complex, and McLennan County
State Juvenile Correctional Facility will have two AEDs on-site (one
for each unit and one for the medical dorm).]
(3) The AED should be stored in a protective case at all times. The storage area is free from water, dirt, extreme cold (less than 32 degrees F), and extreme heat (over 100 degrees F).
(4) The following equipment should be stored with each AED:
(A) carrying case;
(B) trauma shears or blunt-tipped (safety) scissors;
(C) defibrillation pads (2 sets; each facility/district office will keep on hand an additional set of AED replacement pads);
(D) razor;
(E) towel;
(F) CPR breathing barrier or resuscitation mask; and
(G) latex disposable gloves.
This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State on May 6, 2009.
TRD-200901729
Cheryln K. Townsend
Executive Commissioner
Texas Youth Commission
Earliest possible date of adoption: June 21, 2009
For further information, please call: (512) 424-6014
(Editor's note: The text of the following sections proposed for repeal will not be published. The sections may be examined in the offices of the Texas Youth Commission or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)
The repeals are proposed under the Human Resources Code, §61.034, which provides the commission with the authority to adopt rules appropriate to the proper accomplishment of its functions.
The proposed repeals implement the Human Resources Code, §61.034.
§91.81.Medical Consent.
§91.83.Criteria for Healthcare.
§91.85.Medical Care.
This agency hereby certifies that the proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of the Secretary of State on May 6, 2009.
TRD-200901728
Cheryln K. Townsend
Executive Commissioner
Texas Youth Commission
Earliest possible date of adoption: June 21, 2009
For further information, please call: (512) 424-6014