TITLE 40.SOCIAL SERVICES AND ASSISTANCE

Part 1. TEXAS DEPARTMENT OF HUMAN SERVICES

Chapter 18. NURSING FACILITY ADMINISTRATORS

The Texas Department of Human Services (DHS) adopts the repeals of §§18.1-18.20; and adopts new §§18.1-18.4, 18.11-18.16, 18.31-18.41, and 18.51-18.57 in its Nursing Facility Administrators chapter. New §18.13 is adopted with changes to the proposed text published in the January 9, 2004, issue of the Texas Register (29 TexReg 322). The repeals of §§18.1-18.20; and new §§18.1-18.4, §18.11, §18.12, §§18.14- 18.16, §§18.31-18.41, and §§18.51-18.57 are adopted without changes to the proposed text.

DHS is adopting the repeals and new sections as part of an agency-wide initiative to reorganize and rewrite its rules in plain English to make them easier for the public to navigate and understand. During the course of rewriting the rules, DHS, with input from the Nursing Facility Administrators Advisory Committee (NFAAC), determined that the alternate education and training requirements needed to be updated to make the rules more consistent with statutory requirements specified in Texas Health and Safety Code, §242.306(d). Therefore, the requirements in new §18.13 allow DHS to accept alternate standards of demonstrated education, training, and experience for applicants who do not meet the academic and/or internship requirements for licensure in §18.11 and §18.12. New §18.35 is being adopted to assist licensees in obtaining quality continuing education. It allows administrators to receive continuing education credit for a DHS-sponsored event or upper-division course taken at an accredited post-secondary institution of higher education that meets DHS's continuing education requirements.

DHS received written comments from two staff members of the Department of Health Services Research at Texas State University. A summary of the comments and DHS's responses follow.

Comment: The new policies in §18.13 will not help ensure that nursing facility administrators licensed in the state of Texas have the necessary licensure qualifications and expertise to provide greater protection for the health and safety of residents of nursing facilities that DHS regulates. It appears that the proposed relaxation of requirements for alternative education for licensure is not equivalent to the minimal requirements stated in §18.11 (Academic Requirements) and §18.12 (Internship Requirements). The generic knowledge base of health administration, health services administration or nursing, unless supported by specific nursing facility based information, is in no way equivalent to the knowledge bases required of nursing facility administrators. Alternative education should exceed the minimal requirements of an academic program. The best benchmark to guide the determination of equivalency in preparation in this nation is to use the guidelines of the National Association of Boards of Examiners of Long Term Care Administrators, Inc. (NAB) Domains of Practice. What curriculums in the listed disciplines have been reviewed? What courses within these curriculums have been reviewed to identify content comparable in scope and depth to the NAB Domains of Practice?

Response: DHS agrees with this comment and changed the proposed rule. Because of the concerns that have been raised, the proposed language for §18.13 has been modified to stipulate that a masters or baccalaureate degree in health administration, health services administration, health care administration, or nursing must encompass the five domains of the NAB.

Before developing the current proposed alternative educational requirements for licensure specified in §18.13, DHS reviewed the academic requirements for licensure of other states across the nation. The minimum academic requirements for the majority of states reviewed specifically require a licensure applicant to have a baccalaureate or masters degree in health care or health care services administration.

According to the United States (U.S.) Department of Labor, Bureau of Labor Statistics, Occupational Outlook Handbook, 2002-03 Edition , all states and the District of Columbia require nursing home administrators to have a baccalaureate degree and to complete a state-approved training program. A baccalaureate degree is the standard credential for employment as an administrator or department head in nursing homes or small hospitals, whereas a masters degree is generally required for employment with larger hospitals or as a regional VP with multi-facility nursing home corporations.

The federal regulation, as specified at 42 United States Code §1396g, states: (c) It shall be the function and duty of such agency or board to- (1) develop, impose, and enforce standards which must be met by individuals in order to receive a license as a nursing home administrator, which standards shall be designed to insure that nursing home administrators will be individuals who are of good character and are otherwise suitable, and who, by training or experience in the field of institutional administration, are qualified to serve as nursing home administrators. DHS's proposed alternative education requirements comply with specifications established within federal law.

Currently, there are in excess of 100 reputable undergraduate and graduate health services administration degree programs in the U.S. that are certified and accredited by the Accrediting Commission on Education for Health Services Administration (ACEHS), which is recognized by the U.S. Department of Education. Universities accredited by ACEHS include Texas (San Marcos), Indiana, New York, and California State universities, as well as Tulane, Johns Hopkins, Yale, Cornell, and Duke universities. ACEHS criteria for certification and accreditation address the five domains of the NAB, specifically resident care and quality of life, human resources, physical environment and atmosphere, finance, and leadership and management by focusing on:

(1) financial management, leadership, interpersonal and communications skills in managing human resources and health professionals in diverse organizational environments;

(2) managing information resources and collecting, analyzing and using business and health information in decision making;

(3) legal and ethical analysis applied to business and clinical decision-making;

(4) organizational and governmental health policy formulation, implementation, and effect;

(5) assessment and understanding of the health status of populations, determinants of health and illness, and managing health risks and behaviors in diverse populations;

(6) the development, organization, financing, performance, and change of health systems in diverse communities drawing broadly on the social and behavioral sciences; and

(7) business and health outcomes measurement, process/outcome relationships, and methods for process improvement in health organizations.

In developing the proposed alternative education requirements at §18.13, DHS researched other states' alternate licensure requirements and numerous university curricula by reviewing the states' licensure statutes and rules, educational curriculum from higher education institutions, occupational information and statistics from the U.S. Department of Labor, and accreditation and certification information from ACEHS. DHS also gleaned information from other long term care and nursing educational, employment, and professional associations and organizations such as the NAB.

Comment: How does management experience qualify an individual to manage a nursing home?

Response: In §18.13 (Alternate Education, Training, and Experience), DHS defined management experience as full-time employment as a department head or licensed professional supervising two or more employees in a nursing home or skilled hospital unit. An individual who has a masters degree in health administration, health services administration, health care administration, or nursing with one year of management experience as defined above, would still have to complete a 500-hour AIT internship. An individual with a baccalaureate degree in health administration, health services administration, health care administration, or nursing with three years of management experience would also still be required to complete a 500-hour AIT internship before being able to sit for the licensure examinations. DHS believes that combination of training and experience will qualify an individual to manage a nursing home.

Comment: Reducing the internship requirement from the traditional 1,000-hour requirement to a cursory 500-hour substitute is a travesty of the requirement of equality in training. The entire proposal of alternative training and experience appears to serve a vested interest proposed by individuals who want to let their buddies sneak through the doors of alternate education and become legitimate nursing facility administrators.

Response: DHS disagrees with this comment and did not change the proposed rule at §18.13. DHS's proposed Chapter 18 rules provide alternate education and training requirements for licensure pursuant to federal and state law for the licensing of nursing facility administrators. Further, many states allow credit towards the AIT internship based on an individual's academic preparation and past work experience or history. In addition, Texas Health and Safety Code, Chapter 242, specifies at §242.306(d) that an applicant who has not completed the course of instruction and training described by subsection (c) must present evidence satisfactory to the department of having completed sufficient education, training, and experience in the fields described in subsection (c) to enable the applicant to engage in the practice of nursing facility administration. For example, DHS determined that in many states, because of a registered nurse's (RN's) typical role of supervising nursing services and staff in a nursing facility, hospital, or other healthcare facility, a baccalaureate or masters degree in nursing with completion of a 500-hour AIT internship is acceptable training preparation. By still requiring completion of a 500-hour AIT internship, an RN will be able to concentrate on the laws governing the operation of nursing facilities and elements of nursing facility administration. In addition, emphasis during the 500-hour AIT internship can be focused on the domains of the NAB other than resident care/quality of life and human resources, which include finance, physical environment and atmosphere, and leadership and management. The alternate training and experience proposal offers an alternate route for qualified individuals with demonstrated academic training and experience to gain entry into the profession.

Comment: The language in the TDHS document states the flexibility provided in new §18.13 and §18.35 may help increase the availability of licensed nursing facility administrators in the state of Texas by allowing recognition of experience, training and qualifications of persons wanting to practice in Texas but who cannot meet the current educational requirements. What does "cannot meet" really mean?

Response: "Cannot meet" means that, under the present rules, individuals who currently have a masters or baccalaureate degree in health administration, health services administration, health care administration, or nursing cannot gain entry into the profession without completing an additional 15 academic credit hours in long term care administration or an equivalent that encompasses the NAB domains.

Comment: Workgroups, which often consist of stakeholders, usually play a role in rule development and are involved with the deliberations of a committee prior to the writing of rules. Why was this process not used with regard to rules pertaining to nursing facility administrators? It appears that the publication of rules in the Texas Register without soliciting input from stakeholders is a strategy to minimize discussion because relatively few individuals read the Texas Register on a daily basis.

Response: DHS's Credentialing Department has involved outside work groups when drafting previous rule revisions to the Nursing Facility Administrators licensure rules. In fact, the Nursing Facility Administrators Advisory Committee (NFAAC) chair has appointed subcommittees and enlisted assistance from providers and advocates such as the Texas Health Care Association (THCA), the Texas Association for Homes and Services for the Aging (TAHSA), and other stakeholders when proposing significant changes to the licensure requirements. However, the original purpose of the current rule revisions was to convert the licensure rules to plain English. During the course of this process, DHS, with input from the NFAAC, determined that modifications should be made to the alternate education and training requirements. Because the proposed modifications were not outside the current national standards for licensure, but were reflective of the national minimum standards for licensure, the NFAAC did not appoint a subcommittee to look further into this matter. The NFAAC approved the rules for submittal as proposed rules in October 2003.

40 TAC §§18.1 - 18.20

The repeals are adopted under the Health and Safety Code, Chapter 242, Subchapter I, consisting of §§242.301 to 242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01, which authorizes DHS to license and regulate nursing facility administrators.

The repeals implement the Health and Safety Code, §§242.301-242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01.

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 16, 2004.

TRD-200402536

Carey Smith

Deputy Commissioner, Legal Services

Texas Department of Human Services

Effective date: June 1, 2004

Proposal publication date: January 9, 2004

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


Chapter 18. NURSING FACILITY ADMINISTRATORS

Subchapter A. GENERAL INFORMATION

40 TAC §§18.1 - 18.4

The new sections are adopted under the Health and Safety Code, Chapter 242, Subchapter I, consisting of §§242.301 to 242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01, which authorizes DHS to license and regulate nursing facility administrators.

The new sections implement the Health and Safety Code, §§242.301-242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01.

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 16, 2004.

TRD-200402537

Carey Smith

Deputy Commissioner, Legal Services

Texas Department of Human Services

Effective date: June 1, 2004

Proposal publication date: January 9, 2004

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


Subchapter B. REQUIREMENTS FOR LICENSURE

40 TAC §§18.11 - 18.16

The new sections are adopted under the Health and Safety Code, Chapter 242, Subchapter I, consisting of §§242.301 to 242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01, which authorizes DHS to license and regulate nursing facility administrators.

The new sections implement the Health and Safety Code, §§242.301-242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01.

§18.13.Alternate Education, Training, and Experience.

(a) Applicants not meeting the academic and/or internship requirements for licensure in §18.11 and §18.12 of this chapter (relating to Academic Requirements; and Internship Requirements), are eligible for licensure if they present evidence satisfactory to the Texas Department of Human Services of the following alternate education and experience:

(1) a master's degree in health administration, health services administration, health care administration, or nursing, which includes coursework that encompasses the five domains of the National Association of Boards of Examiners of Long Term Care Administrators, Inc. (NAB), with one year of management experience and completion of a 500-hour internship; or

(2) a baccalaureate degree in health administration, health services administration, health care administration, or nursing, which includes coursework that encompasses the five domains of the NAB, with three years of management experience and completion of a 500-hour internship.

(b) Management experience is defined as full-time employment as a department head or licensed professional supervising two or more employees in a nursing home or skilled nursing hospital unit.

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 16, 2004.

TRD-200402538

Carey Smith

Deputy Commissioner, Legal Services

Texas Department of Human Services

Effective date: June 1, 2004

Proposal publication date: January 9, 2004

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


Subchapter C. LICENSES

40 TAC §§18.31 - 18.41

The new sections are adopted under the Health and Safety Code, Chapter 242, Subchapter I, consisting of §§242.301 to 242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01, which authorizes DHS to license and regulate nursing facility administrators.

The new sections implement the Health and Safety Code, §§242.301-242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01.

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 16, 2004.

TRD-200402539

Carey Smith

Deputy Commissioner, Legal Services

Texas Department of Human Services

Effective date: June 1, 2004

Proposal publication date: January 9, 2004

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


Subchapter D. REFERRALS, COMPLAINT PROCEDURES, AND SANCTIONS

40 TAC §§18.51 - 18.57

The new sections are adopted under the Health and Safety Code, Chapter 242, Subchapter I, consisting of §§242.301 to 242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01, which authorizes DHS to license and regulate nursing facility administrators.

The new sections implement the Health and Safety Code, §§242.301-242.322, as added by Acts 1997, 75th Leg., ch. 1280, §1.01.

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 16, 2004.

TRD-200402540

Carey Smith

Deputy Commissioner, Legal Services

Texas Department of Human Services

Effective date: June 1, 2004

Proposal publication date: January 9, 2004

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