TITLE 40.SOCIAL SERVICES AND ASSISTANCE

Part 1. TEXAS DEPARTMENT OF HUMAN SERVICES

Chapter 19. NURSING FACILITY REQUIREMENTS FOR LICENSURE AND MEDICAID CERTIFICATION

The Texas Department of Human Services (DHS) adopts an amendment to §19.401, and new §19.422 and §19.1207 in its Nursing Facility Requirements for Licensure and Medicaid Certification chapter with changes to the proposed text published in the February 8, 2002, issue of the Texas Register (27 TexReg 882).

Justification for the amendment and new sections is to implement Senate Bill (SB) 177 (Health and Safety Code, §§242.841-242.851), 77th Legislature, which requires nursing facilities to allow a resident, the resident's guardian, or legal representative to monitor the resident's room through the use of an electronic monitoring device. The adoption also implements SB 355 (Health and Safety Code, §242.505), 77th Legislature, which requires nursing facility residents to give informed consent before psychoactive medication is administered. The adopted amendment to the Statement of Resident Rights in §19.401 implements SB 177 and SB 355 (Health and Safety Code, §242.501), which add the right to informed consent to the administration of psychoactive medication and the right to conduct electronic monitoring to the list of Resident Rights.

The change to §19.401(b) makes a nonsubstantive grammatical change, which adds the word "to" before the colon that introduces resident rights in the Statement of Resident Rights and deletes the word "to" from the beginning of the following paragraphs. The change to §19.422 replaces "authorized electronic monitoring" with the previously introduced acronym in the "Can a resident be discharged or refused admittance for requesting AEM?" segment of the DHS Information Regarding Authorized Electronic Monitoring form.

DHS received comments from the Coalition for Nurses in Advanced Practice, the Texas Health Care Association, the Texas Association of Residential Care Communities, the Texas Association of Homes and Services for the Aging, Advocacy Inc., the Citizens Commission on Human Rights and two individuals. A summary of the comments and DHS's responses follow.

Comment: The preamble to the proposed rules indicates there is neither economic cost nor new requirements for nursing facilities as a result of enforcing or administering the new rules. The additional paperwork requirements and workload for staff add additional costs to the facility. Costs are associated with copying three different forms, one of them five pages, and the additional staff time to locate the proper individuals to sign the forms, explain the process and to implement the authorized electronic monitoring. The January 1, 2003, deadline to have all facility residents informed of this process certainly will require a large amount of staff time, in addition to the other provisions.

Response: DHS acknowledges that facilities will incur minor expenses in the implementation of these rules. DHS estimates these costs to be $1.42 per resident, which means a first-year cost of $142 for a 100-bed facility. Costs will diminish after the first year of implementation because only new admissions will be given the five-page informational form. DHS has changed the time frame to July 1, 2003, for all current residents, which gives facilities one full year to comply with the requirement to inform current residents about authorized electronic monitoring.

Comment: The proposed rule at §19.101 (27) and (36) fails to address what appear to be conflicts with the Federal Wiretap Act, 8 USC Sec. 2511. Unless everyone who goes into the room is told that their statements are under surveillance, thus removing the expectation of not being monitored, the audio surveillance portion of the proposed rules may violate federal law.

Response: The cited proposed rules are definitions based on the Health and Safety Code, §242.843 and §242.842(2). The proposed rules do require notice of possible electronic monitoring at the entrance to all facilities and notice at the doors of rooms where authorized electronic monitoring (AEM) is being conducted. DHS's position is that the proposed rules are not in conflict with the federal wiretap law.

Comment: In §19.422(c), a January 1, 2003, requirement is imposed that all residents sign the Information Regarding Authorized Electronic Monitoring notice form (the five-page document). The time required to determine which residents have capacity to understand such form or find the responsible party or guardian; explain the form to the resident, responsible party or guardian; and process the form to the residents' medical record will be costly to providers. Due to the complexity of steps needed to complete efforts to inform representatives of residents who lack capacity, we recommend the time frame be changed to June 1, 2003, for residents who lack capacity.

Response: DHS changed the time frame to July 1, 2003, for all current residents, giving facilities one full year to comply with the new requirement.

Comment: The proposed rules at §19.422(d) and (e) refer to the form as a DHS Request for AEM and DHS Consent to AEM. For clarification, these rules should specify that a state- issued form is required. There is critical information from the legislation that is included in the Information Regarding Authorized Electronic Monitoring form that currently is not in the rules. We are concerned that the rules do not clarify that this is a state-issued form. Without this being added to the rules, there is no prohibition that the facility or the state may make changes to the form at any time. Therefore, we recommend that information in this document also be included in rules. For example, information listed under "What is required for the use of a tape or recording by an agency or court?" such as date and time stamp should also be included in rules.

Response: The terms "DHS Request for AEM" and "DHS Consent to AEM" make it clear that these are DHS forms. There is no need for further clarification. The "Information Regarding Electronic Monitoring" form has been published as part of the proposed rules, so there can be no misunderstanding that this is a required state form and that facilities are not at liberty to make changes to it. This document does contain information that is not in the nursing facility rules themselves. Some of the information in the law is pertinent to consumers, but does not require anything of the nursing facility. Such information was included in the form, but not in the rules. The information about what is required for the use of a tape by an agency or court is pertinent to consumers who conduct electronic monitoring, but not to nursing facilities. It is DHS's philosophy to include as little extraneous information as possible in rules.

Comment: In §19.422(e)(2), change "condition" to "conditionally."

Response: DHS retains the language as proposed. "Condition" is the term used in the statute.

Comment: In §19.422(e)(4), add the following: "Therefore, the facility may terminate the electronic monitoring until consent or conditional consent is obtained from the other resident or the resident's guardian or legal representative."

Response: DHS retains the language as proposed. The suggested language is redundant. The rule clearly states, "the monitoring must cease until the new resident, or the resident's guardian or legal representative, consents."

Comment: In §19.422(f)(2), modify this provision to read as follows: "The resident, or the resident's guardian or legal representative, must pay for all costs associated with conducting AEM including installation in compliance with life safety and electrical codes, maintenance, removal of the equipment, posting and removal of the notice, or repair following removal of the equipment and notice, other than the cost of electricity."

Response: DHS added the suggested language to §19.422(f)(2) and to the corresponding portion of the DHS Information Regarding Authorized Electronic Monitoring form.

Comment: Modify §19.422(f)(4)(B) to read as follows: "reasonable access to power sources, to the extent such sources are available in the resident's room, for the video surveillance camera or other electronic monitoring device."

Response: DHS will retain the language as proposed. In §19.422(f)(2), the resident is required to absorb all costs associated with electronic monitoring. If a power source is not readily available in a resident's room, the facility can make the changes necessary to provide the power source, provided the resident is willing to pay for such changes. The statute and the proposed rules provide the facility protection from wholesale structural changes by requiring the facility to make reasonable accommodation for AEM.

Comment: Regarding §19.422(i), these rules repeatedly deal with the matter of notice, consent and privacy, yet when covert monitoring is discovered, the rules allow it to continue without interruption. Add a new (1) and (2) as follows and renumber the other subsections: (1) Inform the resident, or the resident's guardian or legal representative in person or by telephone, followed by a letter or facsimile, that covert electronic monitoring is not allowed by statute or rules and that the monitoring must cease. (2) Notify the DHS regional office by telephone, followed by a letter or facsimile, that covert monitoring has been discovered and that the resident or their responsible party has been notified that monitoring must cease.

Response: DHS disagrees with the suggestion and did not make the changes. The statute requires the facility to allow electronic monitoring. It is a resident right that does not distinguish between open and covert monitoring. The statute further provides that a person who conducts covert monitoring or the person who acquiesces to covert monitoring has waived any privacy right the person may have in connection with the images or sounds acquired by the monitoring device. The facility cannot be held civilly liable in connection with the covert monitoring. A facility cannot discharge a person for conducting covert monitoring.

Comment: In §19.422(i), the rules aren't clear in the instance when covert monitoring is discovered, thereby making it no longer covert. In those instances, the monitoring, in essence, becomes overt and all the rules of authorized electronic monitoring should be enforced, including authorization from other resident(s) in the room.

Response: DHS rewrote §19.422(i) and the corresponding portion of the DHS Information Regarding Authorized Electronic Monitoring form as follows: (i) A facility may not discharge a resident because covert electronic monitoring is being conducted by or on behalf of a resident. If a facility discovers a covert electronic monitoring device and it is no longer covert as defined in §242.843, Health and Safety Code, the resident must meet all the requirements for AEM before monitoring is allowed to continue.

Comment: In §19.422(i), add the following and then renumber: "(1) if the room is occupied by another resident(s), terminate the electronic monitoring until consent or conditional consent is obtained from the other resident(s), or the resident's guardian or legal representative."

Response: DHS's revision to §19.422(i) (see previous comment) addresses this issue.

Comment: Regarding §19.422(i), once covert monitoring is discovered and the roommate is notified of the covert monitoring, what does the facility do if the roommate refuses to have monitoring in their room? Moving to another room is not an option, since the roommate has a right to stay in that room and has a right not to have monitoring in his/her room. This issue is not addressed in the rules.

Response: If the roommate refuses to have monitoring in the room, no authorized monitoring occurs and no further action is required of the facility.

Comment: The proposed rule fails to identify who is responsible for obtaining the roommate's consent or conditional consent. Moreover, if the resident is incapacitated, a facility generally is prohibited from disclosing who the legal representative, guardian, etc., is to others because of the resident's privacy rights. The proposed rule should provide appropriate assurances to protect a resident or resident's legal representative from undue pressure.

Response: Both the rule and the statute state the resident is required to obtain the consent of other residents in the room. The facility can either give the resident or family member the information, or can notify the roommate's guardian or legal representative of the request.

Comment: Four commenters objected to the language in §19.1207(c)(4)(A) and (B), which address how long consent to psychoactive medication is valid. One commenter stated the proposed language can be used as a loophole for a facility or practitioner to get blanket consent once for a psychoactive drug and then give that drug again at any point in the future without obtaining informed consent again. Another commenter stated the original wording of SB 355 handles the problem of blanket consent very well. The bill ensures that standard mental health codes apply in the nursing home situation, and guarantees informed consent each and every time a drug is prescribed and a course of treatment begins. A third commenter stated the stipulation that informed consent is valid until revoked will result in an effective bypass of the intent of the law for two reasons. First, the memories of the elderly often are impaired and the "standing consent" language appears to take advantage of this. Secondly, the drugs at issue have the potential for profound negative effects on cognitive functioning. The lack of opportunities to formally reconsider informed consent denies the residents (or their families) the chance to re-evaluate the risks and benefits of ongoing drug treatment. Three commenters requested the language that deviates from the bill's language be deleted. Another commenter stated the proposed language will allow a physician to get consent for a medication once, discontinue use of that medication for months or years, restart the medication and not re-inform the client of the medication's side effects. This commenter stated if a physician discontinues a medication, he or she should speak to the individual before reordering the medication, even if the interval between the prescription of the medication is only a few days. If this does not occur, the patient may not be cognizant of certain side effects or understand his or her care plan. This is especially true when a physician is dealing with an aging population whose short-term memory is often compromised.

Response: In response to comment, DHS staff met with representatives from advocacy groups and provider associations and developed compromise language. DHS did not delete the language that addresses how long consent is valid, but rewrote §19.1207(c)(4) as follows, which addresses the expressed concerns:

(4) the consent is evidenced in the resident's clinical record by a signed form prescribed by the facility, or by a statement of the person who prescribes the medication or that person's designee, that documents consent was given by the appropriate person and the circumstances under which the consent was obtained.

(A) Consent is valid until:

(i) consent is withdrawn; or

(ii) the practitioner has discontinued the medication.

(B) For purposes of this rule, a medication will be considered to be discontinued if therapy has been suspended for more than 70 days. If the suspended therapy is resumed within the 70- day period, an oral explanation of side effects should be documented in the clinical record.

Comment: In §19.1207(c)(4)(B)(ii), after "the" and before "has," substitute "physician" with "practitioner." Any practitioner legally authorized to prescribe a medication is also authorized to discontinue that medication. It is important to recognize all appropriate providers.

Response: The cited section has been changed in response to a previous comment. The term "practitioner" is used, rather than physician.

Comment: It appears that the proposed rules at §19.1207(c)(4) require a person to consent to a class of medications instead of a specific medication. The regulations should indicate that "informed medication consent will not be obtained by the class of the medication, but by each individual medication."

Response: DHS followed the language of the statute in §19.1207(c)(4), except for the additions that address the length of time consent is valid. DHS does not intend residents to consent to classes of medications and does not see that the rules can be construed that way. Consequently, no change is necessary.

Subchapter E. RESIDENT RIGHTS

40 TAC §19.401, §19.422

The amendment and new section are adopted under the Health and Safety Code, Chapter 242, which authorizes the department to license and regulate convalescent and nursing homes and related institutions.

The amendment and new section implement the Health and Safety Code, §242.501 and §§242.841-242.851.

§19.401.Introduction.

(a) The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident.

(b) The Texas Department of Human Services (DHS) has developed the following statement of the rights of a resident.

Figure: 40 TAC §19.401(b)

(c) The facility must give a copy of the Statement of Resident Rights to each resident, next of kin or guardian, and facility staff member. The facility must maintain a copy of the statement, signed by the resident or the resident's next of kin or guardian, in the facility records.

(d) The Statement of Resident Rights must be posted in accordance with §19.1921 of this title (relating to General Requirements for a Nursing Facility).

§19.422.Authorized Electronic Monitoring (AEM).

(a) A facility must permit a resident or the resident's guardian or legal representative to monitor the resident's room through the use of electronic monitoring devices.

(b) A facility may not refuse to admit an individual and may not discharge a resident because of a request to conduct authorized video monitoring.

(c) The Texas Department of Human Services (DHS) Information Regarding Authorized Electronic Monitoring form must be signed by or on behalf of all new residents upon admission. The form must be completed and signed by or on behalf of all current residents by July 1, 2003. A copy of the form must be maintained in the active portion of the resident's clinical record.

Figure: 40 TAC §19.422(c)

(d) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM must request AEM by giving a completed, signed, and dated DHS Request for Authorized Electronic Monitoring form to the administrator or designee. A copy of the form must be maintained in the active portion of the resident's clinical record.

(1) If a resident has capacity to request AEM and has not been judicially declared to lack the required capacity, only the resident may request AEM, notwithstanding the terms of any durable power of attorney or similar instrument.

(2) If a resident has been judicially declared to lack the capacity required to request AEM, only the guardian of the resident may request AEM.

(3) If a resident does not have capacity to request AEM and has not been judicially declared to lack the required capacity, only the legal representative of the resident may request AEM.

(A) A resident's physician makes the determination regarding the capacity to request AEM. Documentation of the determination must be made in the resident's clinical record.

(B) When a resident's physician determines the resident lacks capacity to request AEM, a person from the following list, in order of priority, may act as the resident's legal representative for the limited purpose of requesting AEM:

(i) a person named in the resident's medical power of attorney or other advance directive;

(ii) the resident's spouse;

(iii) an adult child of the resident who has the waiver and consent of all other qualified adult children of the resident to act as the sole decision-maker;

(iv) a majority of the resident's reasonably available adult children;

(v) the resident's parents; or

(vi) the individual clearly identified to act for the resident by the resident before the resident became incapacitated or the resident's nearest living relative.

(e) A resident, or the resident's guardian or legal representative, who wishes to conduct AEM also must obtain the consent of other residents in the room, using the DHS Consent to Authorized Electronic Monitoring form. When complete, the form must be given to the administrator or designee. A copy of the form must be maintained in the active portion of the resident's clinical record.

(1) Consent to AEM may be given only by:

(A) the other resident or residents in the room;

(B) the guardian of the other resident, if the resident has been judicially declared to lack the required capacity; or

(C) the legal representative of the other resident, determined by following the same procedure established under (d)(3) of this section.

(2) Another resident in the room may condition consent on:

(A) pointing the camera away from the consenting resident, when the proposed electronic monitoring is a video surveillance camera; and

(B) limiting or prohibiting the use of an audio electronic monitoring device.

(3) AEM must be conducted in accordance with any limitation placed on the monitoring as a condition of the consent given by or on behalf of another resident in the room. The resident's roommate, their guardian, or legal representative assumes responsibility for assuring AEM is conducted according to the designated limitations.

(4) If AEM is being conducted in a resident's room, and another resident is moved into the room who has not yet consented to AEM, the monitoring must cease until the new resident, or the resident's guardian or legal representative, consents.

(f) When the completed Request for Authorized Electronic Monitoring form and the Consent to Authorized Electronic Monitoring form, if applicable, have been given to the administrator or designee, AEM may begin.

(1) Anyone conducting AEM must post and maintain a conspicuous notice at the entrance to the resident's room. The notice must state that the room is being monitored by an electronic monitoring device.

(2) The resident, or the resident's guardian or legal representative, must pay for all costs associated with conducting AEM, including installation in compliance with life safety and electrical codes, maintenance, removal of the equipment, posting and removal of the notice, or repair following removal of the equipment and notice, other than the cost of electricity.

(3) The facility must meet residents' requests to have a video camera obstructed to protect their dignity.

(4) The facility must make reasonable physical accommodation for AEM, which includes providing:

(A) a reasonably secure place to mount the video surveillance camera or other electronic monitoring device; and

(B) access to power sources for the video surveillance camera or other electronic monitoring device.

(g) All facilities, regardless of whether AEM is being conducted, must post an 8-inch by 11-inch notice at the main facility entrance. The notice must be entitled "Electronic Monitoring" and must state, in large, easy-to-read type, "The rooms of some residents may be monitored electronically by or on behalf of the residents. Monitoring may not be open and obvious in all cases."

(h) A facility may:

(1) require an electronic monitoring device to be installed in a manner that is safe for residents, employees, or visitors who may be moving about the room, and meets all local and state regulations;

(2) require AEM to be conducted in plain view;

(3) place a resident in a different room to accommodate a request for AEM.

(i) A facility may not discharge a resident because covert electronic monitoring is being conducted by or on behalf of a resident. If a facility discovers a covert electronic monitoring device and it is no longer covert as defined in §242.843, Health and Safety Code, the resident must meet all the requirements for AEM before monitoring is allowed to continue.

(j) DHS may assess an administrative penalty of $500 against a facility for each instance in which the facility:

(1) refuses to permit a resident, or the resident's guardian or legal representative, to conduct AEM;

(2) refuses to admit an individual or discharges a resident because of a request to conduct AEM;

(3) discharges a resident because covert electronic monitoring is being conducted by or on behalf of the resident; or

(4) violates any other provision related to AEM.

(k) All instances of abuse or neglect must be reported to DHS, as required by §19.602 of this title (relating to Incidents of Abuse and Neglect Reportable to the Texas Department of Human Services (DHS) by Facilities). For purposes of the duty to report abuse or neglect and the criminal penalty for the failure to report abuse or neglect, established under the Health and Safety Code, §242.122, the following apply:

(1) A person who is conducting electronic monitoring on behalf of a resident is considered to have viewed or listened to a tape or recording made by the electronic monitoring device on or before the 14th day after the date the tape or recording is made.

(2) If a resident, who has capacity to determine that the resident has been abused or neglected and who is conducting electronic monitoring, gives a tape or recording made by the electronic monitoring device to a person and directs the person to view or listen to the tape or recording to determine whether abuse or neglect has occurred, the person to whom the resident gives the tape or recording is considered to have viewed or listened to the tape or recording on or before the seventh day after the date the person receives the tape or recording.

(3) A person is required to report abuse based on the person's viewing of or listening to a tape or recording only if the incident of abuse is acquired on the tape or recording. A person is required to report neglect based on the person's viewing of or listening to a tape or recording only if it is clear from viewing or listening to the tape or recording that neglect has occurred.

(4) If abuse or neglect of the resident is reported to the facility and the facility requests a copy of any relevant tape or recording made by an electronic monitoring device, the person who possesses the tape or recording must provide the facility with a copy at the facility's expense. The cost of the copy must not exceed the community standard. If the contents of the tape or recording are transferred from the original technological format, a qualified professional must do the transfer.

(5) A person who sends more than one tape or recording to DHS must identify each tape or recording on which the person believes an incident of abuse or evidence of neglect may be found. Tapes or recordings should identify the place on the tape or recording that an incident of abuse or evidence of neglect may be found.

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 30, 2002.

TRD-200202669

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: July 1, 2002

Proposal publication date: February 8, 2002

For further information, please call: (512) 438-3734


Subchapter M. PHYSICIAN SERVICES

40 TAC §19.1207

The new section is adopted under the Health and Safety Code, Chapter 242, which authorizes the department to license and regulate convalescent and nursing homes and related institutions.

The new section implements the Health and Safety Code, §242.505.

§19.1207.Prescription of Psychoactive Medication.

(a) In this section, the following words and terms have the following meanings, unless the context clearly indicates otherwise:

(1) Medication-related emergency--A situation in which it is immediately necessary to administer medication to a resident to prevent:

(A) imminent probable death or substantial bodily harm (emotional or physical) to the resident; or

(B) imminent physical or emotional harm to another because of threats, attempts, or other acts the resident overtly or continually makes or commits.

(2) Psychoactive medication--A medication prescribed for the treatment of symptoms of psychosis or other severe mental or emotional disorders and used to exercise an effect on the central nervous system to influence and modify behavior, cognition, or affective state when treating the symptoms of mental illness. The term includes the following categories when used as described by this subdivision:

(A) anti-psychotics or neuroleptics;

(B) antidepressants;

(C) agents for control of mania or depression;

(D) anti-anxiety agents;

(E) sedatives, hypnotics, or other sleep-promoting drugs; and

(F) psychomotor stimulants.

(b) A person may not administer a psychoactive medication to a resident who does not consent to the prescription unless:

(1) the resident is having a medication-related emergency; or

(2) the person authorized by law to consent on behalf of the resident has consented to the prescription.

(c) Consent to the prescription of psychoactive medication given by a resident, or by a person authorized by law to consent on behalf of the resident, is valid only if:

(1) the consent is given voluntarily and without coercive or undue influence;

(2) the person who prescribes the medication, or that person's designee, provides the resident and, if applicable, the person authorized by law to consent on behalf of the resident, with the following information in a single document identified as being for the purpose of consent to treatment with psychoactive medication:

(A) the specific condition to be treated;

(B) the beneficial effects on that condition expected from the medication;

(C) the probable clinically significant side effects and risks associated with the medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and

(D) the proposed course of the medication;

(3) the resident and, if appropriate, the person authorized by law to consent on behalf of the resident, are informed in writing that consent may be revoked; and

(4) the consent is evidenced in the resident's clinical record by a signed form prescribed by the facility, or by a statement of the person who prescribes the medication or that person's designee, that documents consent was given by the appropriate person and the circumstances under which the consent was obtained.

(A) Consent is valid until:

(i) consent is withdrawn; or

(ii) the practitioner has discontinued the medication.

(B) For purposes of this rule, a medication will be considered to be discontinued if therapy has been suspended for more than 70 days. If the suspended therapy is resumed within the 70-day period, an oral explanation of side effects should be documented in the clinical record.

(d) The Health and Safety Code, Chapter 313, Consent to Medical Treatment, provides guidance on treatment decisions when a resident is comatose, incapacitated, or otherwise mentally or physically incapable of communication. An ethics committee also may prove helpful in such situations.

(e) A resident's refusal to consent to receive psychoactive medication must be documented in the resident's clinical record.

(f) If a person prescribes psychoactive medication to a resident without the resident's consent because the resident is having a medication-related emergency:

(1) the person must document the necessity of the order in the resident's clinical record in specific medical or behavioral terms; and

(2) treatment of the resident with the psychoactive medication must be provided in the manner, consistent with clinically appropriate medical care, least restrictive of the resident's personal liberty.

(g) A physician, or a person designated by the physician, is not liable for civil damages or an administrative penalty and is not subject to disciplinary action for a breach of confidentiality of medical information for a disclosure of the information provided under subsection (c)(2) made by the resident, or the person authorized by law to consent on behalf of the resident, that occurs while the information is in the possession or control of the resident or the person authorized by law to consent on behalf of the resident.

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 30, 2002.

TRD-200202670

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: July 1, 2002

Proposal publication date: February 8, 2002

For further information, please call: (512) 438-3734


Subchapter V. ENFORCEMENT

2. LICENSING REMEDIES

40 TAC §19.2115

The Texas Department of Human Services (DHS) adopts an amendment to §19.2115 in its Nursing Facility Requirements for Licensure and Medicaid Certification chapter. The amendment is adopted without changes to the proposed text published in the November 23, 2001, issue of the Texas Register (26 TexReg 9535).

Justification for the amendment is to comply with Senate Bill 1839, 77th Legislature, which amended the law regarding amelioration of violations that are subject to administrative penalties in nursing facilities and intermediate care facilities for persons with mental retardation. The adopted amendment outlines the conditions under which DHS must allow violators to use all or part of the administrative penalty to correct violations. The amendment stipulates the minimum elements that must be contained in a plan for amelioration.

DHS received no comments regarding adoption of the amendment.

The amendment is adopted under the Health and Safety Code, Chapter 242, which authorizes the department to license and regulate convalescent and nursing homes and related institutions.

The amendment implements the Health and Safety Code, §242.071.

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 May 3, 2002.

TRD-200202763

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: June 1, 2002

Proposal publication date: November 23, 2001

For further information, please call: (512) 438-3734


Chapter 90. INTERMEDIATE CARE FACILITIES FOR PERSONS WITH MENTAL RETARDATION OR RELATED CONDITIONS

The Texas Department of Human Services (DHS) adopts amendments to §90.19 and §90.236 in its Intermediate Care Facilities for Persons with Mental Retardation or Related Conditions chapter. The amendments are adopted without changes to the proposed text published in the November 23, 2001, issue of the Texas Register (26 TexReg 9536).

Justification for the amendments is to incorporate the quality assurance fee as a license for intermediate care facilities for persons with mental retardation or related conditions (ICF/MR) as directed by the Health and Safety Code, §§252.202-252.208.

DHS received one written comment from the Private Provider Association of Texas. A summary of the comment and DHS's response follows.

Comment: The administrative penalty applied for failure to pay the quality assurance fee should not be included in the administrative penalty schedule.

Response: The fine is an administrative penalty stated in the Health and Safety Code, §252.205, and must be included on the schedule.

Subchapter B. APPLICATION PROCEDURES

40 TAC §90.19

The amendment is adopted under the Health and Safety Code, Chapter 252, which authorizes the department to license and regulate intermediate care facilities for persons with mental retardation or related conditions.

The amendment implements the Health and Safety Code, §§252.202-252.208.

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 May 3, 2002.

TRD-200202764

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: June 1, 2002

Proposal publication date: November 23, 2001

For further information, please call: (512) 438-3734


Subchapter H. ENFORCEMENT

40 TAC §90.236

The amendment is adopted under the Health and Safety Code, Chapter 252, which authorizes the department to license and regulate intermediate care facilities for persons with mental retardation or related conditions.

The amendment implements the Health and Safety Code, §252.205.

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 May 3, 2002.

TRD-200202765

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: June 1, 2002

Proposal publication date: November 23, 2001

For further information, please call: (512) 438-3734


Subchapter H. ENFORCEMENT

40 TAC §90.241

The Texas Department of Human Services (DHS) adopts an amendment to §90.241 in its Intermediate Care Facilities for Persons with Mental Retardation or Related Conditions chapter with changes to the proposed text published in the November 23, 2001, issue of the Texas Register (26 TexReg 9537).

Justification for the amendment is to comply with Senate Bill 1839, passed during the 77th Legislature, which amended the law regarding amelioration of violations that are subject to administrative penalties in nursing facilities and intermediate care facilities for persons with mental retardation.

DHS received one written comment from the Private Provider Association of Texas regarding adoption of the amendment. A summary of the comment and DHS's response follows.

Comment: SB 1839 allows DHS to accept amelioration plans for violations the facility has a right to correct under Chapter 252 of the Health and Safety Code, which is the licensing authority for the Intermediate Care Facilities for Persons with Mental Retardation or Related Conditions (ICF/MR) program. Chapter 252 is different from the nursing facility program, licensed under Chapter 242 of the Health and Safety Code, which prohibits the same action.

Response: The proposed rules did not provide that a facility could be given both the right to correct and the right to submit a plan of amelioration. The commenter is correct that DHS is not prohibited under Chapter 252 from offering amelioration to a person for a charged violation that the person has a right to correct. The rule is revised to delete the right to correct violation as one of the violations for which the department will not offer amelioration.

The amendment is adopted under the Health and Safety Code, Chapter 252, which authorizes the department to license and regulate intermediate care facilities for persons with mental retardation or related conditions.

The amendment implements the Health and Safety Code, §252.071.

§90.241.Amelioration of Violation.

(a) In lieu of demanding payment of an administrative penalty, the commissioner may allow the person to use, under the supervision of the Texas Department of Human Services (DHS), a portion of the penalty to ameliorate the violation or to improve services, other than administrative services, in the facility.

(b) DHS will offer amelioration to a person for a violation if DHS determines that the violation does not constitute immediate jeopardy to the health and safety of a resident. In this section, "immediate jeopardy to health and safety" means a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

(c) DHS will not offer amelioration to a person if DHS determines that the violation constitutes immediate jeopardy to the health and safety of a resident.

(d) DHS will offer amelioration to a person not later than the 10th day after the date the person receives from DHS a final notification of assessment of administrative penalty that is sent to the person after an informal dispute resolution process but before an administrative hearing.

(e) A person to whom amelioration has been offered must file a plan for amelioration not later than the 45th day after the date the person receives the offer of amelioration from DHS. In submitting the plan, the person must agree to waive the person's right to an administrative hearing if DHS approves the plan.

(f) At a minimum, a plan for amelioration must:

(1) propose changes to the management or operation of the facility that will improve services to or quality of care of residents,

(2) identify, through measurable outcomes, the ways in which and the extent to which the proposed changes will improve services to or quality of care of residents,

(3) establish clear goals to be achieved through the proposed changes,

(4) establish a timeline for implementing the proposed changes, and

(5) identify specific actions necessary to implement the proposed changes.

(g) DHS may require that an amelioration plan propose changes that would result in conditions that exceed the minimum requirements for facility licensure.

(h) DHS will approve or deny an amelioration plan not later than the 45th day after the date DHS receives the plan. On approval of a person's plan, DHS will deny a pending request for a hearing submitted by the person.

(i) DHS will not offer amelioration to a person:

(1) more than three times in a two-year period; or

(2) more than one time in a two-year period for the same or similar violation.

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 May 3, 2002.

TRD-200202766

Paul Leche

General Counsel, Legal Services

Texas Department of Human Services

Effective date: June 1, 2002

Proposal publication date: November 23, 2001

For further information, please call: (512) 438-3734