Proposed Rules Title 25

TITLE 25. HEALTH SERVICES

PART 1. DEPARTMENT OF STATE HEALTH SERVICES

CHAPTER 412. LOCAL MENTAL HEALTH AUTHORITY RESPONSIBILITIES

SUBCHAPTER G. MENTAL HEALTH COMMUNITY SERVICES STANDARDS

The Executive Commissioner of the Health and Human Services Commission on behalf of the Department of State Health Services (department) proposes the repeal of §§412.301 - 412.322, and new §§412.301, 412.303, 412.304, 412.311 - 412.318, and 412.321 - 412.327, concerning mental health community services standards.

BACKGROUND AND PURPOSE

The purpose of this subchapter is to describe requirements for ensuring the adequate provision and appropriate delivery of mental health community services. Repeal of the existing rules is necessary due to substantial changes being made to the rules to align them with existing service delivery requirements. Beginning with fiscal year 2005, the department began incorporating principles of Resiliency and Disease Management (RDM) into its overall approach to regulating the delivery of community mental health services. The core services affected by RDM include mental health rehabilitative and mental health case management services. However, key components of RDM are reflected throughout the proposed new rules.

Although the rules proposed for repeal applied to all Medicaid managed care organizations, the new proposed rules will only apply to local mental health authorities, managed care organizations, and other providers that contract directly with the department. Under the Texas Health and Safety Code, §533.047, Managed Care Organizations: Medicaid Program, the former Texas Department of Mental Health and Mental Retardation was charged with developing performance and quality of care standards for the provision of mental health and mental retardation services to Medicaid clients by managed care organizations involved in the Medicaid Program. As a result of the passage of House Bill 2292 (78th Texas Legislature, Regular Session, 2003), effective September 1, 2004, the responsibility to implement the Texas Health and Safety Code, §533.047, was transferred to Health and Human Services Commission. Therefore, the department is only responsible for developing standards for community mental health services by those providers with which the department contracts directly.

Additionally, Texas Government Code, §2001.039, requires that each state agency review and consider for re-adoption each rule adopted by that agency pursuant to the Government Code, Chapter 2001 (Administrative Procedure Act). Sections 412.301 - 412.322 have been reviewed and the department has determined that reasons for adopting some of the sections continue to exist because rules on this subject are needed.

SECTION-BY-SECTION SUMMARY

Throughout the entire subchapter, replacement of the terms, "consumer" with "individual," and "MMCO or Medicaid managed care organization" with "MCO or managed care organization," is proposed, to reflect current usage of terminology within the mental health care delivery system. Other changes made include various grammatical, punctuation, and formatting changes. In addition to these overall changes, more specific proposed changes are described as follows.

Division 1. General Provisions.

Proposed §412.301 states the purpose of the subchapter and its application to providers with which the department contracts.

Proposed §412.303 sets forth a number of definitions of terms used throughout the subchapter, including the following not previously included in the rules being proposed for repeal: "Advanced practice nurse," "Advocacy," "Appeal," "Assessment," "COPSD or co-occurring psychiatric and substance use disorders," "CSSP or community services specialist," "Department," "Department-approved algorithm," "Face-to-face," "Family partner," "HIPPA," "Indicator," "Individual," "LCDC or licensed chemical dependency counselor," "LCSW or licensed clinical social worker," "LMFT or licensed marriage and family therapist," "LOC or level of care," "LPC or licensed professional counselor," "LPHA or licensed practitioner of the healing arts," "LVN or licensed vocational nurse," "MCO or managed care organization," "Peer provider," "Physician," "Physician assistant," "Psychologist," "Recovery," "RN or registered nurse," "Restraint," "Seclusion," "Staff member," "Support services," "Telemedicine," "Uniform assessment," "Utilization management exception," "Utilization management guidelines" and "Volunteer."

Proposed §412.304 specifically identifies which of the divisions in the subchapter apply to which types of providers, and sets forth the responsibilities of local mental health authorities (LMHAs), and managed care organizations (MCOs) to obligate and monitor other providers for compliance with the subchapter.

Division 2. Organizational Standards.

Proposed §412.311 sets forth primary leadership responsibilities of the LMHA and MCO, including, requiring encouragement and support of advocacy for individuals, policies and procedures to avoid conflict of interest, and collaboration with other health care agencies and community resources.

Proposed §412.312 sets forth requirements to ensure a proper environment of care and safety at service delivery sites, including clarification on the use of restraint and seclusion.

Proposed §412.313 sets forth the rights and protections that must be afforded by providers to all individuals who are seeking or receiving mental health services, and requires a non-coercive policy and specific factors that cannot affect eligibility for services.

Proposed §412.314 sets forth requirements relating to the provision of adequate access to mental health community services, including requirements for telephone access, crisis services and hotline telephone calls, emergency care services, urgent care services, routine care services, and referrals for physical health services.

Proposed §412.315 sets forth the requirements relating to maintenance of medical records and requires a written disaster recovery plan to ensure service continuity.

Proposed §412.316 sets forth requirements for certain competencies of staff members, which expands credentialing and documentation requirements for staff members beyond that required in the rules proposed for repeal.

Proposed §412.317 requires that community mental health services be provided under a detailed quality management plan and expands the requirements beyond what was previously required under the rules proposed for repeal.

Proposed §412.318 requires providers to develop and implement a utilization management program, timely prior authorization system, and appeal and fair hearing procedures, including special requirements for Medicaid-eligible individuals.

Division 3. Standards of Care.

Proposed §412.321 identifies specific requirements relating to the provision of crisis services, including documentation and communication of crisis contacts.

Proposed §412.322 identifies various aspects of providers' responsibilities relating to service authorization; assessment, diagnosis and provision of services and related documentation; implementation and use of the department's utilization management guidelines and uniform assessment tools; and integrated treatment planning.

Proposed §412.323 sets forth requirements concerning medication services, including delegation of services, handling of medications, supervision of self-administration of medication, and medication errors.

Proposed §412.324 sets forth additional standards of care relating to the administration of the uniform assessment and the provision of mental health community services to children and adolescents, including an expansion of previous requirements for transition planning for adolescents who will continue to need mental health community services as adults.

Proposed §412.325 sets forth requirements for the provision of telemedicine and/or telepsychiatry, including implementation of procedures and clinical oversight.

Proposed §412.326 sets forth specific documentation requirements relating to service provision, including a requirement that such documentation be made within two business days after each service encounter occurs. The two-day requirement would not apply to crisis services, which is addressed in §412.321; day programs for acute needs, addressed in Chapter 419, Subchapter L; and case management services, which is addressed in Chapter 412, Subchapter I.

Proposed §412.327 sets forth requirements for supervision of various staff members, and for implementation of a peer review process for licensed staff members.

FISCAL NOTE

Mike Maples, Assistant Commissioner for Mental Health and Substance Abuse Services, has determined that for each year of the first five-year period that the sections will be in effect, there will be no fiscal implications to state or local governments as a result of enforcing and administering the sections as proposed.

SMALL AND MICRO-BUSINESS IMPACT ANALYSIS

Mr. Maples has also determined that the proposed rules will have no direct adverse economic impact on small businesses. The rules have direct application only to those entities with which the department contracts to provide community mental health services, none of which meet the definition of small business under the Texas Government Code, §2006.001. The economic cost to those entities required to comply with the rules is anticipated to be minimal or none at all, because the rules are primarily being updated to incorporate principles of RDM that are already required by contract; and any costs associated with changes related to implementation of crisis services redesign are likely to be offset by additional funding to be appropriated and provided under contract. To the extent that the rules may have any indirect effect on small businesses with which the department's contractors may contract to provide services, maintaining the standards applicable to the department's contractors under these rules is essential to protecting the health and welfare of the state. Therefore, an economic impact statement and regulatory flexibility analysis for small businesses are not required. There is no anticipated impact on local employment.

PUBLIC BENEFIT

In addition, Mr. Maples has also determined that for each year of the first five years the sections are in effect, the public will benefit from adoption of the sections. The public benefit anticipated as a result of enforcing or administering the rules is to ensure adequate and appropriate provision of mental health community services throughout the state.

REGULATORY ANALYSIS

The department has determined that this proposal is not a "major environmental rule" as defined by Government Code, §2001.0225. "Major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risk to human health from environmental exposure and that may adversely affect, in a material way, the economy, a sector of the economy, productivity, competition, jobs, the environment or the public health and safety of a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure.

TAKINGS IMPACT ASSESSMENT

The department has determined that the proposed repeals and new rules do not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, do not constitute a taking under Government Code, §2007.043.

PUBLIC COMMENT

Comments on the proposal may be submitted to Janet Fletcher, Program Services Section, Program Design Unit, Department of State Health Services, Mail Code 2018, 909 West 49th Street, Austin, Texas 78751, (512) 419-2673 or by email to janet.fletcher@dshs.state.ts.us. Comments will be accepted for 30 days following publication of the proposal in the Texas Register.

LEGAL CERTIFICATION

The Department of State Health Services General Counsel, Lisa Hernandez, certifies that the proposed rules have been reviewed by legal counsel and found to be within the state agencies' authority to adopt.

DIVISION 1. GENERAL PROVISIONS

25 TAC §§412.301 - 412.306

(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 Department of State Health Services or in the Texas Register office, Room 245, James Earl Rudder Building, 1019 Brazos Street, Austin.)

STATUTORY AUTHORITY

The proposed repeals are authorized by Texas Health and Safety Code, §534.053, which requires the department to ensure that certain community-based services are available in each service area; Texas Health and Safety Code, §534.058, which requires the department to develop standards of care for the services provided by local mental health authorities and their subcontractors; and Texas Government Code, §531.0055, and Texas Health and Safety Code, §1001.075, which authorize the Executive Commissioner of the Health and Human Services Commission to adopt rules and policies necessary for the operation and provision of health and human services by the department and for the administration of Texas Health and Safety Code, Chapter 1001.

The proposed repeals affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.301.Purpose.

§412.302.Application.

§412.303.Definitions.

§412.304.Responsibility for Compliance.

§412.305.TDMHMR Responsibilities.

§412.306.Outcomes for Mental Health Community Services.

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 January 22, 2009.

TRD-200900277

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 2. ORGANIZATIONAL STANDARDS

25 TAC §§412.307 - 412.313

STATUTORY AUTHORITY

The proposed repeals affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.307.Leadership.

§412.308.Environment of Care and Safety.

§412.309.Rights and Protection.

§412.310.Access to Mental Health Community Services.

§412.311.Medical Records System.

§412.312.Competency and Credentialing.

§412.313.Quality Management.

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 January 22, 2009.

TRD-200900279

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 3. STANDARD OF CARE

25 TAC §§412.314 - 412.316

STATUTORY AUTHORITY

The proposed repeals affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.314.Crisis Services.

§412.315.Assessment and Treatment Planning.

§412.316.Additional Standards of Care Specific to Mental Health Community Services for Children and Adolescents.

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 January 22, 2009.

TRD-200900281

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 4. SERVICE STANDARDS

25 TAC §§412.317 - 412.320

STATUTORY AUTHORITY

The proposed repeals affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.317.Rehabilitative Services.

§412.318.Supported Employment.

§412.319.Supported Housing.

§412.320.Assertive Community Treatment (ACT).

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 January 22, 2009.

TRD-200900283

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 5. REFERENCES AND DISTRIBUTION

25 TAC §412.321, §412.322

STATUTORY AUTHORITY

The proposed repeals affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.321.References.

§412.322.Distribution.

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 January 22, 2009.

TRD-200900284

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 1. GENERAL PROVISIONS

25 TAC §§412.301, 412.303, 412.304

STATUTORY AUTHORITY

The proposed new rules are authorized by Texas Health and Safety Code, §534.053, which requires the department to ensure that certain community-based services are available in each service area; Texas Health and Safety Code, §534.058, which requires the department to develop standards of care for the services provided by local mental health authorities and their subcontractors; and Texas Government Code, §531.0055, and Texas Health and Safety Code, §1001.075, which authorize the Executive Commissioner of the Health and Human Services Commission to adopt rules and policies necessary for the operation and provision of health and human services by the department and for the administration of Texas Health and Safety Code, Chapter 1001.

The proposed new rules affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.301.Purpose and Application.

(a) The purpose of this subchapter is to establish performance requirements and standards for the provision of mental health community services, as authorized by the Texas Health and Safety Code, §534.052.

(b) This subchapter applies to persons and entities with which the department contracts, including local mental health authorities (LMHA), managed care organizations (MCO), providers of mental health rehabilitative services, as defined in §419.453 of this title (relating to Definitions), and providers of mental health case management services, as defined in §412.403 of this title (relating to Definitions), and requires that they ensure the performance requirements and standards in this subchapter are met in the provision of mental health community services.

§412.303.Definitions.

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

(1) Access--The ability to obtain mental health community services based upon components such as availability and acceptability of services to the individual, or the individual's Legally Authorized Representative (LAR) on the individual's behalf, transportation, distance, hours of operation, language, and the cultural competency of staff members. Barriers to access may be structural, financial, or specific to the individual.

(2) Adolescent--An individual who is at least 13 years of age, but younger than 18 years of age.

(3) Adult--An individual who is 18 years of age or older.

(4) Advanced practice nurse--A staff member who is a registered nurse approved by the Texas Board of Nursing as a clinical nurse specialist in psychiatric/mental health or nurse practitioner in psychiatric/mental health, in accordance with Texas Occupations Code, Chapter 301.

(5) Advocacy--Support for an individual or family member in expressing and resolving issues or concerns regarding access to or quality and appropriateness of services.

(6) Appeal--A mechanism for an independent review of an adverse determination.

(7) Assessment--A systematic process for measuring an individual's service needs.

(8) Child--An individual who is at least three years of age, but younger than 13 years of age.

(9) Competency--Demonstrated knowledge and skilled performance of a particular activity.

(10) Continuity of services--Services that ensure uninterrupted services are provided to an individual during a transition between service types (e.g., inpatient services, outpatient services) or providers, in accordance with applicable rules (e.g., Chapter 412, Subchapter D of this title (relating to Mental Health Services - Admission, Continuity, and Discharge)). These activities include:

(A) assisting with admissions and discharges;

(B) facilitating access to appropriate services and supports in the community, including identifying and connecting the individual with community resources;

(D) promoting implementation of the individual's treatment plan or continuing care plan; and

(E) facilitating coordination and follow-up between the individual and the individual's family, as well as with available community resources.

(11) COPSD or co-occurring psychiatric and substance use disorders--The co-occurring diagnoses of psychiatric disorders and substance use disorders.

(12) Credentialing--A process to review and approve a staff member's educational status, experience, and licensure status (as applicable) to ensure that the staff member meets the departmental requirements for service provision. The process includes primary source verification of credentials, establishing and applying specific criteria and prerequisites to determine the staff member's initial and ongoing competency and assessing and validating the staff member's qualification to deliver care. Re-credentialing is the periodic process of reevaluating the staff's competency and qualifications.

(13) Crisis--A situation in which:

(A) the individual presents an immediate danger to self or others; or

(B) the individual's mental or physical health is at risk of serious deterioration; or

(C) an individual believes that he or she presents an immediate danger to self or others or that his or her mental or physical health is at risk of serious deterioration.

(14) Crisis services--Mental health community services or other necessary interventions provided to an individual in crisis.

(15) CSSP or community services specialist--A staff member who, as of August 31, 2004:

(A) received:

(i) a high school diploma; or

(ii) a high school equivalency certificate issued in accordance with the law of the issuing state;

(B) had three continuous years of documented full-time experience in the provision of mental health rehabilitative services or case management services; and

(C) demonstrated competency in the provision and documentation of mental health rehabilitative or case management services in accordance with Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services) and Chapter 412, Subchapter I of this title (relating to Mental Health Case Management Services).

(16) Cultural competency--Demonstrated knowledge and skill by a staff member to effectively respond to an individual's needs through knowledge of communication, actions, customs, beliefs, and values, within the individual's racial, ethnic, religious beliefs, disability, and social groups.

(17) Department--Department of State Health Services (DSHS).

(18) Department-approved algorithm--An evidence-based process for providing psychiatric care to adults with severe and persistent mental illnesses and children and adolescents with serious emotional disturbance, consisting of consensus-derived guidelines for medication treatment, training and support for physicians, standardized documentation, and patient and family education.

(19) DSM--The current edition of the Diagnostic Statistical Manual of Mental Disorders published by the American Psychiatric Association.

(20) Emergency care services--Mental health community services or other necessary interventions directed to address the immediate needs of an individual in crisis in order to assure the safety of the individual and others who may be placed at risk by the individual's behaviors, including, but not limited to, psychiatric evaluations, administration of medications, hospitalization, stabilization or resolution of the crisis.

(21) Face-to-face--A contact with an individual that occurs in person. Face-to-face does not include contacts made through the use of video conferencing or telecommunication technologies, including telemedicine.

(22) Family member--Any person who an individual identifies as being a member of their family.

(23) Family partner--An experienced, trained primary caregiver (i.e., parent of an individual with a mental illness or serious emotional disturbance) who provides peer mentoring, education, and support to the caregivers of a child who is receiving mental health community services.

(24) HIPAA--The Health Insurance Portability and Accountability Act, 42 U.S.C. §1320d et seq.

(25) Identifying information--The name, address, date of birth, social security number, or any information by which the identity of an individual can be determined either directly or by reference to other publicly available information. The term includes medical records, graphs, and charts that contain an individual's information; statements made by the individual either orally or in writing while receiving mental health community services; videotapes, audiotapes, photographs, and other recorded media; and any acknowledgment that an individual is receiving or has received services from a state facility, LMHA, MCO, or provider.

(26) Indicator--A defined, measurable variable used to monitor the quality or appropriateness of an important aspect of an individual's care or service or an organization's performance of related functions, processes, or outcomes. Indicators can measure activities, events, occurrences, or outcomes for which data can be collected to allow comparison with a threshold, a benchmark, or prior performance.

(27) Individual--A person who is seeking or receiving mental health community services from or through a provider.

(28) LAR or legally authorized representative--A person authorized by law to act on behalf of an individual with regard to a matter described in this subchapter, including, but not limited to, a parent, guardian, or managing conservator.

(29) LCDC or licensed chemical dependency counselor--A counselor licensed by the department pursuant to the Texas Occupations Code, Chapter 504.

(30) LCSW or licensed clinical social worker--A staff member who is licensed as a clinical social worker by the Texas State Board of Social Worker Examiners in accordance with the Texas Occupations Code, Chapter 505.

(31) LMFT or licensed marriage and family therapist--A staff member who is licensed as a licensed marriage and family therapist by the Texas State Board of Examiners of Marriage and Family Therapists in accordance with Texas Occupations Code, Chapter 502.

(32) LMHA or local mental health authority--An entity designated as the local mental authority by the department in accordance with the Texas Health and Safety Code, §533.035(a).

(33) LOC or level of care--A designation given to the department's standardized packages of mental health community services, based on the uniform assessment and the utilization management guidelines, which recommend the type, amount, and duration of mental health community services to be provided to an individual.

(34) LPC or licensed professional counselor--A staff member who is licensed as a licensed professional counselor by the Texas State Board of Examiners of Professional Counselors in accordance with Texas Occupations Code, Chapter 503.

(35) LPHA or licensed practitioner of the healing arts--A staff member who is:

(A) a physician;

(B) a licensed professional counselor;

(D) a licensed psychologist;

(E) an advanced practice nurse; or

(F) a licensed marriage and family therapist.

(36) LVN or licensed vocational nurse--A staff member who is licensed as a licensed vocational nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.

(37) Management information system--An information system designed to supply an LMHA or MCO with information needed to plan, organize, staff, direct, and control their operations and clinical decision-making.

(38) MCO or managed care organization--An entity that has a current Texas Department of Insurance certificate of authority to operate as a Health Maintenance Organization (HMO) in the Texas Insurance Code, Chapter 843, or as an approved nonprofit health corporation in the Texas Insurance Code, Chapter 844, and that provides mental health community services pursuant to a contract with the department.

(39) Medical necessity--The need for a service that:

(A) is reasonable and necessary for the diagnosis or treatment of a mental health disorder or a co-occurring psychiatric and substance use disorder (COPSD) in order to improve or maintain an individual's level of functioning;

(B) is provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care;

(D) is provided at a level that is safe and appropriate for the individual's needs and facilitates the individual's recovery; and

(E) could not be omitted without adversely affecting the individual's mental or physical health or the quality of care rendered.

(40) Medical record--The systematic, organized account, compiled by health care providers, of information relevant to the services provided to an individual. This includes an individual's history, present illness, findings on examination, treatment and discharge plans, details of direct and indirect care and services, and notes on progress.

(41) Mental health community services--All services medically necessary to treat, care for, supervise, and rehabilitate individuals who have a mental illness or emotional disorder or a COPSD. These services include services for the prevention of and recovery from such disorders, but do not include inpatient services provided in a state facility.

(42) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, dementia, substance use disorder, mental retardation, or pervasive developmental disorder) that:

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

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

(43) Peer provider--A staff member who:

(A) has received:

(i) a high school diploma; or

(ii) a high school equivalency certificate issued in accordance with the law of the issuing state;

(B) has at least one cumulative year of receiving mental health community services; and

(44) Physician--A staff member who is:

(A) licensed as a physician by the Texas Medical Board in accordance with Texas Occupations Code, Chapter 155; or

(B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Texas Medical Board.

(45) Physician assistant--A staff member who is licensed as a physician assistant by the Texas State Board of Physician Assistant Examiners in accordance with Texas Occupations Code, Chapter 204.

(46) Provider--Any person or legal entity that contracts with the department, an LMHA, or an MCO to provide mental health community services to individuals, including that part of an LMHA or MCO directly providing mental health community services to individuals. The term includes providers of mental health case management services and providers of mental health rehabilitative services.

(47) Psychologist--A staff member who is licensed as a psychologist by the Texas State Board of Examiners of Psychologists in accordance with Texas Occupations Code, Chapter 501.

(48) QMHP-CS or qualified mental health professional-community services--A staff member who is credentialed as a QMHP-CS who has demonstrated and documented competency in the work to be performed and:

(A) has a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major (as determined by the LMHA or MCO in accordance with §412.316(d) of this title (relating to Competency and Credentialing)) in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education, or early childhood intervention;

(B) is a registered nurse; or

(49) Recovery--The process by which a person becomes able or regains the ability to live, work, learn, and participate fully in his or her community.

(50) Referral--The process of identifying appropriate services and providing the information and assistance needed to access them.

(51) RN or registered nurse--A staff member who is licensed as a registered nurse by the Texas Board of Nursing in accordance with Texas Occupations Code, Chapter 301.

(52) Restraint--The same meaning as defined in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs).

(53) Routine care services--Mental health community services provided to an individual who is not in crisis.

(54) Safety monitoring--Ongoing observation of an individual to ensure the individual's safety. An appropriate staff person must be continuously present in the individual's immediate vicinity, provide ongoing monitoring of the individual's mental and physical status, and ensure rapid response to indications of a need for assistance or intervention. Safety monitoring includes maintaining continuous visual contact with frequent face-to-face contacts as needed.

(55) Screening Activities performed by a Qualified Mental Health Professional--Community Services (QMHP-CS) to gather triage information to determine the need for in-depth assessment. The QMHP-CS collects this information through face-to-face or telephone interviews with the individual or collateral. This service includes screenings to determine if the individual's need is emergent, urgent, or routine (which is conducted prior to the face-to-face assessment to determine the need for emergency services).

(56) Seclusion--The same meaning as defined in Chapter 415, Subchapter F of this title.

(57) Staff member--Anyone who works or provides services for an LMHA, MCO, or provider as an employee, contractor, intern, or volunteer.

(58) Support services--Mental health community services delivered to an individual, LAR, or family member(s) to assist the individual in functioning in the individual's chosen living, learning, working, and socializing environments.

(59) Telemedicine--The use of health care information exchanged from one site to another via electronic communications for the health and education of the individual or provider, and for the purpose of improving patient care, treatment, and services. This definition applies only for purposes of this subchapter and does not affect, modify, or relate in any way to other rules defining the term or regulating the service, or to any statutory definitions or requirements.

(60) Uniform assessment--An assessment tool developed by the department that includes, but is not limited to, the Adult Texas Recommended Assessment Guidelines (TRAG), the Children and Adolescent Texas Recommended Assessment Guidelines, and the department-approved algorithms.

(61) Urgent care services--Mental health community services or other necessary interventions provided to persons in crisis who do not need emergency care services, but who are potentially at risk of serious deterioration.

(62) Utilization management exception--The authorization of additional amounts of services based on medical necessity when the individual has reached the maximum service units of their currently authorized level of care (LOC).

(63) Utilization management guidelines--Guidelines developed by the department that establish the type, amount, and duration of mental health community services for each LOC.

(64) Volunteer--A person who receives no remuneration for the provision of time, individual attention, or assistance to individuals receiving mental health community services from entities or providers governed by this subchapter. Volunteers may include:

(A) community members;

(B) family members of individuals served when not acting in their capacity as a family member;

(D) individuals served when acting on behalf of another individual.

§412.304.Responsibility for Compliance.

(a) Compliance with Divisions 2 - 3 of this subchapter requires:

(1) the LMHA and MCO to comply with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter;

(2) the LMHA and MCO to obligate by contract the providers in their networks to comply with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter;

(3) the LMHA and MCO to monitor their providers for compliance with the applicable sections and subsections contained in Divisions 2 - 3 of this subchapter; and

(4) providers of mental health case management or mental health rehabilitative services to comply with §412.311(e) of this title (relating to Leadership), §412.312 of this title (relating to Environment of Care and Safety), §412.313 of this title (relating to Rights and Protection), §412.314(e) of this title (relating to Access to Mental Health Community Services), §412.315 of this title (relating to Medical Records System), and §412.316 of this title (relating to Competency and Credentialing), contained in Division 2 of this subchapter, and with all the sections in Division 3 of this subchapter.

(b) Providers must comply with the department's Utilization Management Guidelines, which are incorporated by reference, if contractually obligated to provide any mental health community services, including mental health rehabilitative, mental health case management, supported housing, supported employment, or Assertive Community Treatment (ACT). The department is responsible for monitoring compliance by providers that contract with the department and the LMHA and MCO are responsible for requiring and monitoring compliance of providers in their networks.

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 January 22, 2009.

TRD-200900278

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 2. ORGANIZATIONAL STANDARDS

25 TAC §§412.311 - 412.318

STATUTORY AUTHORITY

The proposed new rules affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.311.Leadership.

(a) Organizational planning and communication. The LMHA and MCO must define and implement organizational plans and systems as described in this subchapter (e.g., quality management plan, utilization management plan) and ensure that there are mechanisms in place that facilitate effective communication throughout the organization to promote the provision of quality mental health community services.

(b) Management of key processes and functions. The LMHA and MCO must define organizational and clinical processes and functions, including performance activities, as well as:

(1) allocate adequate, appropriate resources; and

(2) provide oversight for such processes and functions.

(c) Management information system. The LMHA, MCO, and provider must ensure their management information systems provide timely, accurate, and accessible information that supports clinical, administrative, and fiscal decision-making.

(d) Consumer advocacy. The LMHA and MCO must encourage and support advocacy for individuals accessing mental health community services.

(e) Conflict of interest and dual relationships. The LMHA and MCO must develop and implement policies and procedures to ensure that all staff members refrain from activities and relationships whereby personal, financial, professional, or other relationships could compromise or interfere with independent judgment creating a conflict of interest or otherwise having the potential to harm or exploit individuals and families.

(f) Collaboration with other health care agencies and community resources. The LMHA and MCO must demonstrate efforts to collaborate with other health care agencies and community resources to address the physical and behavioral health care needs of individuals, as well as to ensure that these needs are met.

§412.312.Environment of Care and Safety.

(a) Safe environment. The LMHA, MCO, and provider must:

(1) ensure service delivery sites (including, but not limited to, facilities and vehicles) are safe, sanitary, and free from hazards, including but not limited to:

(A) hand washing facilities and supplies in restrooms and in areas where staff have routine physical contact with individuals (e.g., exam rooms, medication areas, laboratories);

(B) a utility area with necessary equipment for the safe and required cleaning or disposal of instruments, equipment, and sharps;

(C) locked areas for storing drugs, needles, syringes, hazardous materials, other potentially dangerous equipment, and toxic chemical products; and

(D) adequate prevention of exposure to tobacco smoke and other environmental pollutants.

(2) ensure delivery sites are prepared to manage onsite life threatening emergencies, and that each site will have:

(A) a written plan for the management of onsite medical emergencies requiring ambulance services, hospitalization, or hospital treatment;

(B) emergency resuscitative drugs, supplies, and equipment appropriate to the needs of individuals and staff qualifications;

(D) documented disaster drills appropriate for local conditions.

(3) comply with the most current edition of the National Fire Protection Association's Life Safety Code, and related codes, standards, and other applicable requirements;

(4) implement an infection control plan and procedures for group residential services, clinics, and other areas where a high volume of people congregate, that address the prevention, education, management, and monitoring of significant infections. Components addressed in the plan must include:

(A) prevention and management of infection in the service delivery site(s);

(B) reporting of reportable diseases as required by Chapter 97, Subchapter A of this title (relating to Control of Communicable Diseases);

(C) compliance with the Human Immunodeficiency Virus Services Act (Texas Health and Safety Code, §85.001 et seq.), the Communicable Disease Prevention and Control Act (Texas Health and Safety Code, §81.001 et seq.), and other applicable laws (e.g., the Americans with Disabilities Act of 1990, 42 U.S.C. §12101 et seq.; and the Rehabilitation Act of 1973, 29 U.S.C. §701 et seq.);

(D) identification of illnesses and conditions for which an individual's participation in mental health community services is safely allowed;

(E) identification of illnesses and conditions for which an individual's participation in mental health community services is restricted and the procedures for minimizing exposure and facilitating an individual's transfer to a more appropriate setting;

(5) implement safeguards regarding hazardous equipment and weather; and

(6) implement procedures for the disposal of biohazardous wastes that minimize the risks of contamination, injury, and disease transmission.

(b) Sufficient staff. The provider must have sufficient number of qualified and competent staff members on duty to ensure the safety of individuals and adequacy of mental health community services, including responding to crises during the provision of mental health community services.

(c) Compliance with state and federal law. The provider must comply with all applicable state and federal law and regulations, including those relating to:

(1) blood borne pathogens;

(2) food borne pathogen exposure controls; and

(3) tuberculosis exposure controls.

(d) Limited use of restraint or seclusion.

(1) Restraint. In outpatient settings, a provider may only use restraint if the intervention is:

(A) necessary to address a behavioral health emergency, as defined in Chapter 415, Subchapter F of this title (relating to Interventions in Mental Health Programs); and

(B) performed according to the department's rules described in Chapter 415, Subchapter F of this title.

(2) Seclusion. Seclusion is prohibited in outpatient settings with the exception of partial hospitalization programs for children or adolescents. A provider may only use seclusion in those programs if the conditions in paragraph (1)(A) - (B) of this subsection are met.

§412.313.Rights and Protection.

(a) Non-coercive policy. The LMHA, MCO, and provider must ensure that an individual's refusal of a particular mental health community service (e.g., psychoactive medication) does not preclude the individual from accessing other medically necessary mental health community services.

(b) Non-discrimination. The LMHA, MCO, and provider may not unlawfully discriminate against any individual based on race, color, national origin, religion, sex, age, or disability. The LMHA and MCO and provider may not deny medically necessary mental health community services based on an individual's sexual orientation or political affiliation.

(c) Initial and ongoing eligibility. In determining an individual's initial and ongoing eligibility for any service, an LMHA, MCO, and provider may not exclude an individual based on the following factors:

(1) the individual's past or present mental illness or substance use diagnosis or services;

(2) the individual's past or present involvement in the criminal or juvenile justice system;

(3) medications prescribed to the individual in the past or present;

(4) the presumption of the individual's inability to benefit from treatment;

(5) the individual's use or continued use of alcohol, tobacco, or other drugs; or

(6) the individual's level of success in prior treatment episodes.

(d) Protection against abuse, neglect, and exploitation. The LMHA, MCO, and provider must comply with the requirements described in Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers).

(e) Dignity and rights. The LMHA, MCO, and provider must implement procedures that address the rights of individuals in compliance with applicable state and federal laws, regulations, and department rules described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services), and must provide individuals the right to choose from the list of providers within the LMHA's or MCO's network if there is more than one provider available.

(f) Charges for mental health community services. The LMHA and MCO and provider must comply with all applicable federal and state laws and department rules described in Chapter 412, Subchapter C of this title (relating to Charges for Community Services) regarding the establishment of charges and the collection of fees for the provision of mental health community services.

(g) Confidentiality. The LMHA and MCO and provider must comply with all applicable federal and state laws, rules, and regulations governing confidentiality of identifying information of individuals with mental illness and/or substance use disorders, including those described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and 42 Code of Federal Regulations (CFR) Part 2 (Confidentiality of Alcohol and Drug Abuse Patient Records).

(h) Research. If the LMHA or MCO or provider conducts research, then the research must be conducted in accordance with applicable state and federal laws, rules, and regulations, including 45 CFR Part 46 (Protection of Human Subjects).

§412.314.Access to Mental Health Community Services.

(a) Adequate provider network. The LMHA and MCO must maintain a provider network that is adequate and qualified to provide all mental health community services that the LMHA and MCO are required to provide under a contract with the department.

(b) Crisis screening and response system. The LMHA and MCO must have a crisis screening and response system in operation 24 hours a day, every day of the year, that is available to individuals throughout its contracted service delivery area. The telephone system to access the crisis screening and response system must include a toll-free crisis hotline number and be easily accessible and well publicized. Calls to the crisis hotline must be answered by a hotline staff member who is trained in compliance with this subchapter. The hotline must have teletypewriter (TTY) capabilities or other assistive technology that is available and effective.

(c) Telephone access. In addition to the crisis screening and response system described in subsection (b) of this section, the LMHA and MCO must ensure the availability of a telephone system and call center that allows individuals to contact the LMHA or MCO through a toll-free number that must:

(1) operate without using telephone answering equipment at least on business days during normal business hours, except on national holidays, due to uncontrollable interruption of service, or with prior approval of the department;

(2) have sufficient staff to operate efficiently;

(3) collect, document, and store detailed information, including special needs information, on all telephone inquiries and calls;

(4) during times other than those described in paragraph (1) of this subsection provide electronic call answering methods that include an outgoing message providing the crisis hotline telephone number, in languages relevant to the service area, for callers to leave a message; and

(5) return routine calls before the end of the next business day for all messages left after hours.

(d) Timely services based on need. The LMHA and MCO must arrange mental health services for an individual within the following time frames.

(1) Crisis services.

(A) Hotline calls. For all calls to the toll-free crisis hotline:

(i) the call must be answered by a staff member within 30 seconds, on average, at least 95 percent of the time; and

(ii) if the call is identified as a potential crisis, a QMHP-CS must begin a telephone screening immediately but no later than one minute after the call is so identified.

(B) Emergency care services. If during a screening it is determined that an individual is experiencing a crisis that may require emergency care services, the QMHP-CS must:

(i) take immediate action to address the emergency situation to ensure the safety of all parties involved;

(ii) activate the immediate screening and assessment processes as described in §412.321 of this title (relating to Crisis Services); and

(iii) provide or obtain mental health community services or other necessary interventions to stabilize the crisis.

(C) Urgent care services. If the screening indicates that an individual needs urgent care services, a QMHP-CS must within eight hours of the initial incoming hotline call or notification of a potential crisis situation:

(i) perform a face-to-face assessment; and

(ii) provide or obtain mental health community services or other necessary interventions to stabilize the crisis.

(2) Routine care services. If the screening indicates that an individual needs routine care services, a QMHP-CS must perform a uniform assessment within 14 days after the screening. If the assessment indicates an LOC for routine care services, the individual must begin receiving services immediately. When the provision of the service package is not possible because services are at capacity, the individual must be referred to an available practitioner appropriate to meet the individual's needs or be placed on a waiting list for services, subject to the following exceptions:

(A) individuals eligible for Medicaid who are determined to be in need of Mental Health Case Management, under Chapter 412, Subchapter I of this title, or Mental Health Rehabilitative Services, under Chapter 419, Subchapter L of this title, cannot be placed on a waiting list and must be served.

(B) individuals eligible for Medicaid who are determined to need services other than Mental Health Case Management, under Chapter 412, Subchapter I of this title, and Mental Health Rehabilitative Services, under Chapter 419, Subchapter L of this title, must be referred to appropriate, available practitioners of that service. Only if an appropriate Medicaid practitioner is not available may the individual be placed on a waiting list. All efforts undertaken to refer Medicaid individuals must be documented.

(e) Communication with individuals. The LMHA, MCO, and provider must ensure effective communication with the individual and LAR (if applicable) in an understandable format as appropriate to meet the needs of individuals, which may require using:

(1) interpretative services;

(2) translated materials; or

(3) a staff member who can effectively respond to the cultural (e.g., customs, beliefs, actions, and values) and language needs of the individual and LAR (if applicable).

(f) Service information. The LMHA and MCO must proactively disseminate to individuals and their LAR (if applicable) information about mental illness and the LMHA's or MCO's mental health community services in a format and language that is easily understood and based on the demographics for any group comprising more than 10 percent of the population in the local service area. Information about mental illness and the LMHA's or MCO's community services must be in a format and language that is easily understood by individuals with a disability (e.g., deafness, hard of hearing, and blindness).

(g) Access to emergency medical and crisis services. The LMHA and MCO must develop procedures for its providers' use in accessing emergency medical and crisis services for individuals.

(h) Continuity of services. The LMHA and MCO must ensure that individuals:

(1) are provided continuity of services as defined by the department; and

(2) are informed of whom to contact regarding continuity and coordination of their services, in accordance with Chapter 412, Subchapter D of this title (relating to Mental Health Services--Admission, Continuity, and Discharge).

(i) Referral for physical health services. If a nursing or medical assessment indicates physical health needs outside the scope of the provider's competency, credentialing, or capacity to treat, the LMHA and MCO must make and document appropriate referrals to other healthcare providers and provide adequate follow up at subsequent visits to confirm access to the referrals.

§412.315.Medical Records System.

(a) Maintenance of medical records. The LMHA, MCO, and the provider must ensure:

(1) protection against unauthorized access, disclosure, modification or destruction of medical records, whether accidental or deliberate;

(2) the availability, integrity, utility, authenticity, and confidentiality of information within the medical record;

(3) a current, organized, legible, and comprehensive records system that:

(A) conforms to good professional practice;

(B) permits effective clinical review and audit; and

(4) a medical records system with sufficient redundancy to ensure access to individual records; and

(5) compliance with applicable federal and state laws, rules, and regulations, including HIPAA, 42 CFR Part 2, and the requirements described in Chapter 414, Subchapter A of this title (relating to Protected Health Information).

(b) Disaster recovery plan. The LMHA, MCO, and the provider must maintain a written disaster recovery plan for information resources that will ensure service continuity.

§412.316.Competency and Credentialing.

(a) Competency of staff members, including volunteers. The LMHA, MCO, and provider must implement a process to ensure the competency of staff members prior to providing services that, at a minimum:

(1) ensures services are provided by staff members who are operating within the scope of their license, job description, or contract specification;

(2) ensures that the mental health community services provided by peer providers are limited to mental health rehabilitative, supported employment, supported housing, parent support group, and family partner services; and

(3) defines competency-based expectations for each position as follows:

(A) required competencies must be included for all staff members, including adequate, accurate knowledge of:

(i) the nature of severe and persistent mental illness and serious emotional disturbances;

(ii) the recovery and resiliency model of mental illness and serious emotional disturbance;

(iii) the dignity and rights of an individual, as described in Chapter 404, Subchapter E of this title (relating to Rights of Persons Receiving Mental Health Services);

(iv) identifying, preventing, and reporting abuse, neglect, and exploitation, in accordance with Chapter 414, Subchapter L of this title (relating to Abuse, Neglect, and Exploitation in Local Authorities and Community Centers);

(v) individual confidentiality, as described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and other relevant state and federal laws affecting confidentiality of medical records, including Title 42 CFR Part 2;

(vi) interacting with an individual who has a physical disability such as a hearing or visual impairment;

(vii) responding to an individual's language and cultural needs through knowledge of customs, beliefs, and values of various, racial, ethnic, religious, and social groups;

(viii) exposure control of blood borne pathogens;

(ix) identification of an individual as being in a crisis and accessing emergency or urgent care services;

(x) proper documentation of services provided; and

(xi) planning and training for responding to severe weather, disasters, and bioterrorism;

(B) critical competencies must be included for positions in which a staff member's primary job duties are related to individual service contacts and interactions and include, but are not limited to, adequate and accurate knowledge of:

(i) cardio pulmonary resuscitation (CPR);

(ii) first aid;

(iii) safe management of verbally and physically aggressive behavior;

(iv) utilization of assistive technology such as communication devices with individuals who are deaf or hard of hearing; and

(v) seizure response and assessment;

(C) specialty competencies must be included for positions in which a staff member performs specialized services and tasks and include adequate and accurate knowledge of specialized services and tasks, such as:

(i) the requirements of this subchapter;

(ii) age appropriate clinical assessment including the uniform assessment;

(iii) age appropriate engagement techniques (e.g., motivational interviewing);

(iv) use of telemedicine equipment;

(v) the utilization management guidelines;

(vi) developing and implementing an individualized treatment plan;

(vii) appropriate actions to take in a crisis (e.g., screening, intervention, management and if applicable, suicide/homicide precautions);

(viii) services for co-occurring psychiatric and substance use disorders described in Chapter 411, Subchapter N of this title (relating to Standards for Services to Individuals with Co-Occurring Psychiatric and Substance Use Disorders (COPSD));

(ix) accessing resources within the local community;

(x) strategies for effective advocacy and referral for an individual;

(xi) infection control;

(xii) recognition, reporting, and recording of side effects, contraindications, and drug interactions of psychoactive medication;

(xiii) age appropriate rehabilitative approaches;

(xiv) proficiency in specimen collection;

(xv) the peer-provider or consumer-operated service model;

(xvi) assessment and intervention with children, adolescents, and families; and

(xvii) clinical specialties directly related to the services to be performed.

(D) crisis hotline competencies must be included for positions in which a staff member routinely answers the crisis hotline and include adequate and accurate knowledge of:

(i) the nature of severe and persistent mental illness and serious emotional disturbances and COPSD;

(ii) behavioral health crisis situations;

(iii) operating a telephone system to access behavioral health crisis screening and response;

(iv) age appropriate crisis intervention and response;

(v) utilization of assistive technology such as communication devices with individuals who are deaf or hard of hearing;

(vi) advocacy for treatment in the most clinically appropriate, available environment; and

(vii) applicable privacy laws, rules, and regulations including those described in Chapter 414, Subchapter A of this title (relating to Protected Health Information) and in Title 42 CFR Part 2.

(E) telemedicine competencies must be included for positions in which a staff member's job duties are related to assisting with telemedicine services and include adequate and accurate knowledge of:

(i) operation of the telemedicine equipment; and

(ii) how to use the equipment to adequately present the individual.

(4) requires staff members to demonstrate competencies in the following manner:

(A) all staff members must demonstrate required competencies before contact with individuals, confidential information, or protected health information and periodically throughout the staff member's tenure of employment or association with the LMHA, MCO, or provider;

(B) all staff members in positions that require critical competencies must demonstrate the critical competencies before contact with individuals and periodically throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider;

(C) all staff members in positions that require specialty competencies must demonstrate the specialty competencies before providing the specialized service(s) or performing the specialized task(s) and periodically throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider; and

(D) all staff members in positions that require crisis hotline competencies must demonstrate those competencies before providing crisis hotline services and at least annually throughout the staff member's or volunteer's tenure of employment or association with the LMHA, MCO, or provider.

(b) Competency of crisis services providers. The LMHA and MCO must develop and implement policies and procedures governing the provision of crisis services to ensure that providers with which they contract or employ for the provision of crisis services are trained in:

(1) crisis access and age appropriate assessment and intervention services;

(2) advocacy for the most clinically appropriate, available environment; and

(3) community referral resources.

(1) implement a timely credentialing and re-credentialing process for all its licensed staff members, peer providers, family partners, and every QMHP-CS and CSSP;

(2) ensure that documentation verifying a staff member's credentialing and re-credentialing is maintained in the staff member's personnel records;

(3) have a process for staff members to appeal credentialing and re-credentialing decisions; and

(4) require providers to:

(A) use the LMHA's or MCO's credentialing and re-credentialing and appeals processes for all of the provider's licensed staff, QMHP-CSs, CSSPs, peer providers, family partners, and utilization management job functions; or

(B) implement a credentialing and re-credentialing process for all of the provider's licensed staff, QMHP-CSs, CSSPs, peer providers, family partners, and utilization management job functions that meets the LMHA's or MCO's credentialing and re-credentialing criteria and have a process for those staff members to appeal credentialing and re-credentialing decisions.

(d) Additional requirements for credentialing a QMHP-CS. For credentialing as a QMHP-CS who is not a registered nurse, the credentialing and re-credentialing process described in subsection (c) of this section must include:

(1) determining the minimum number of coursework hours that is equivalent to a major and whether a combination of coursework hours in the specified areas is acceptable;

(2) reviewing the individual's coursework; and

(3) justifying and documenting the credentialing decisions; or

(4) completing an alternative credentialing process identified by the department.

(e) Additional requirements for credentialing as a CSSP. For credentialing as a CSSP, the credentialing and re-credentialing process described in subsection (c) of this section must include:

(1) verifying a high school diploma or high school equivalent certificate issued in accordance with the law of the issuing state;

(2) verifying three continuous years of documented full-time experience in the provision of mental health case management or rehabilitative services prior to August 31, 2004;

(3) reviewing the staff member's provision and documentation of mental health case management or rehabilitative services; and

(4) certifying, justifying, and documenting the credentialing decisions.

(f) Additional requirements for credentialing as a peer provider. For credentialing as a peer provider, the credentialing and re-credentialing process described in subsection (c) of this section or the alternative credentialing by an organization recognized by the department must, at minimum, include:

(1) verifying a high school diploma or high school equivalent certificate issued in accordance with the law of the issuing state;

(2) verifying at least one cumulative year of receiving mental health community services for a disorder that is treated in the target population for Texas;

(3) demonstration of competency in the provision and documentation of mental health rehabilitative services, supported employment, or supported housing; and

(4) justifying and documenting the credentialing decisions.

(g) Additional requirements for utilization management job functions. For credentialing as a staff member who performs utilization management job functions, the credentialing and re-credentialing process described in subsection (c) of this section must include:

(1) the staff member's job description indicating the performance of utilization management functions;

(2) if the staff member is not the utilization management physician, the staff member's job description indicating they neither provide services nor supervise service providers;

(3) documenting licenses;

(4) documenting training and supervision received; and

(5) justifying and documenting credentialing decisions.

(h) Maintaining documented personnel information. The LMHA, MCO, and provider must maintain personnel files for each staff member that include:

(1) a current, signed job description for each staff member;

(2) documented, periodic performance reviews;

(3) copies of current credentials and training; and

(4) criminal background checks.

§412.317.Quality Management.

(a) Quality management plan. The LMHA and MCO must develop a written quality management plan that includes:

(1) the quality management program description and work plan;

(2) measurable objective indicators to detect the need for improvement;

(3) procedures and timelines for taking appropriate action when problems are identified; and

(4) approval by the LMHA or MCO governing body.

(b) Quality management program. The LMHA and MCO must implement a quality management program that includes:

(1) a structure that ensures the program is implemented system-wide;

(2) allocation of adequate resources for implementation;

(3) oversight by professionals with adequate and appropriate experience in quality management;

(4) activities and processes that address identified clinical and organizational problems including fidelity and data integrity;

(5) periodic reporting of quality management program activities to its governing body, providers and other appropriate staff members and community stakeholders such as peer and family organizations;

(6) processes to systematically monitor, analyze, and improve performance of provider services and outcomes for individuals;

(7) review of the provider's treatment to determine:

(A) whether it is consistent with the department's approved evidenced-based practices and the fidelity manual; and

(B) the accuracy of assessments and treatment planning;

(8) ongoing monitoring of the quality of crisis services, access to services, service delivery, and continuity of services;

(9) provision of technical assistance to providers related to quality oversight necessary to improve the quality and accountability of provider services;

(10) use of reports and data from the department to inform performance improvement activities and assessment of unmet needs of individuals, service delivery problems, and effectiveness of authority functions for the local service area;

(11) mechanisms to measure, assess, and reduce incidents of abuse, neglect, and exploitation;

(12) mechanisms to improve individuals' rights protection processes;

(13) risk management processes such as competency determinations, and the management and reporting of incidents and deaths; and

(14) coordination of activities and information management with the utilization management (UM) program, including participation in UM oversight activities.

(c) The LMHA and MCO must establish an integrated system to sufficiently monitor the quality management program for effectiveness on a regular basis and update the quality management plan as needed.

§412.318.Utilization Management.

(a) Utilization management plan. The LMHA and MCO must develop a written utilization management plan that includes:

(1) the utilization management program plan description and work plan;

(2) requirements relating to the utilization management committee credentials, job functions, meetings, and training;

(3) how the utilization management program's effectiveness in meeting goals will be evaluated;

(4) how improvements will be made on a regular basis;

(5) the oversight and control mechanisms to ensure that UM activities meet required standards when they are delegated to an administrative services organization or a DSHS-approved entity; and

(6) approval by the LMHA or MCO governing body.

(b) Utilization management program. The LMHA and MCO must implement a utilization management program under the direction of a psychiatrist licensed in Texas as required by its contract with the department, and in accordance with the utilization management guidelines, as updated and amended.

(c) Authorization of services. The LMHA and MCO must ensure that it has a timely authorization system in place to ensure medically necessary services are delivered without delay and with prior authorization, except that the delivery of crisis services does not require prior authorization but rather must be authorized subsequent to delivery. The LMHA and MCO will review requests for authorization of services, determine if services should be authorized and if so which services to authorize. Services must be authorized using the department's utilization management guidelines and based on the uniform assessment, diagnosis, additional clinical information submitted by the requestor, and clinical judgment. The determination and documentation of services to be authorized will occur according to the following timeframes:

(1) crisis intervention services--within two business days of the date of service;

(2) inpatient services--within sufficient time to ensure medically necessary services are delivered without delay;

(3) all other mental health community services, including outpatient and add-on services upon receipt but no later than three business days and prior to service delivery; and

(4) reauthorization for continuing services according to established timeframes in the utilization management guidelines, as updated and amended.

(d) Appeal and Medicaid fair hearing procedures. The LMHA and MCO must implement procedures to give notice of the right to a timely and objective appeal process for all individuals receiving community mental health services, in accordance with §401.464 of this title (relating to Notification and Appeals Process). For individuals eligible for Medicaid, the LMHA and MCO must implement procedures that provide notice of the right to request a fair hearing, as described in Title 1, Chapter 357, Subchapter A (relating to Uniform Fair Hearing Rules for the Medicaid, TANF, and Food Stamp Programs), to an individual whose service or benefits are denied, reduced, suspended, or terminated. The procedures regarding notice of the right to a Medicaid fair hearing must comply with department policy, which may be included in contract provisions.

(e) Waiting list maintenance requirements. The LMHA must comply with the department's policy on waiting list maintenance requirements, which may be included in contract provisions and is subject to the requirements set forth in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services).

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 January 22, 2009.

TRD-200900280

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972

DIVISION 3. STANDARDS OF CARE

25 TAC §§412.321 - 412.327

STATUTORY AUTHORITY

The proposed new rules affect Texas Government Code, §531.0055; and Texas Health and Safety Code, §§533.047, 534.053, 534.058, and 1001.075.

§412.321.Crisis Services.

(a) Coordinating provision of crisis services. The LMHA and MCO must develop and implement policies and procedures governing the provision of crisis services that:

(1) identify providers' roles and responsibilities in responding to a crisis;

(2) describe the coordination of crisis services to be required among providers of crisis services, law enforcement, the judicial system, and other community entities; and

(3) comply with Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services).

(b) Immediate screening and assessment.

(1) Screening and assessment. All providers of crisis services must be available 24 hours a day, every day of the year, to perform immediate screenings and assessments of individuals in crisis, including assessments to determine risk of deterioration and immediate danger to self or others. Crisis assessments cannot be delegated to law enforcement officials.

(2) QMHP-CS assessment. Individuals experiencing a crisis, as determined by a QMHP-CS screening, must be assessed face-to-face or via telemedicine by someone who is at least credentialed as a QMHP-CS within one hour after the individual presents to the provider in a crisis, either via the crisis hotline or a face-to-face encounter (e.g., walk-in). The QMHP-CS must provide ongoing crisis services until the crisis is resolved or the individual is placed in a clinically appropriate environment.

(d) Physician assessment. If the individual requires emergency care services, as determined by the QMHP-CS's assessment of risk of deterioration and danger as described in subsection (b) of this section, then the provider of crisis services must have a physician, preferably a psychiatrist, perform a face-to-face or telemedicine assessment of the individual as soon as possible, but not later than 12 hours after the QMHP-CS's assessment to determine the need for emergency services.

(e) Documenting crisis services. The provider of crisis services must maintain documentation of the crisis services, including:

(1) the date the service was provided;

(2) the beginning and end time of the crisis contact;

(3) the name and any other identifying information of the individual to whom the service was provided (if given);

(4) the location where the service was provided;

(5) the behavioral description of the presenting problem;

(6) lethality (e.g., suicide, violence);

(7) substance use or abuse;

(8) trauma, abuse, or neglect;

(9) the outcome of the crisis (e.g., individual in hospital, individual with friend and scheduled to see doctor at 9:00 a.m. the following day);

(10) the names and titles of staff members involved;

(11) all actions (including rehabilitative interventions and referrals to other agencies) used by the provider to address the problems presented;

(12) the response of the individual, and if appropriate, the response of the LAR and family members;

(13) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA or a QMHP-CS;

(14) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service; and

(15) follow up activities, which may include referral to another provider.

(f) Communication of crisis contacts. If an individual who is currently receiving mental health services has experienced a crisis and has been assessed in accordance with subsection (b) of this section, the provider of crisis services must communicate in writing (e.g., e-mail or fax) the details of the crisis contact to the provider of ongoing mental health services to ensure that the individual receives continuity of care and treatment and include such communication in the medical record. This crisis contact communication:

(1) may not disclose any substance abuse-related information unless disclosed in compliance with federal law as described in 42 CFR Part 2;

(2) must take place no later than the next business day after conclusion of the crisis contact; and

(3) may disclose mental health information for the purpose of continuity of care and treatment without the individual's consent if disclosure is made in accordance with:

(A) Texas Health and Safety Code, §533.009 (relating to Exchange of Patient and Client Records), when the provider of ongoing services is part of the department's service delivery system; or

(B) in accordance with Texas Health and Safety Code, §611.004(a)(7) (relating to the Authorized Disclosure of Confidential Information other than in Judicial or Administrative Proceeding), when the provider of ongoing services is not part of the department's service delivery system.

§412.322.Provider Responsibilities for Treatment Planning and Service Authorization.

(a) Assessment and documentation. At the first routine face-to-face or telemedicine contact with an individual seeking routine care services, as described in §412.314(d)(2) of this title (relating to Access to Mental Health Community Services), a QMHP-CS with appropriate supervision and training must perform an assessment of the individual. The assessment must be documented and must include:

(1) the individual's identifying information;

(2) completion of the appropriate uniform assessment(s) and assessment guideline calculations;

(3) present status and relevant history, including education, employment, housing, legal, military, developmental, and current available social and support systems;

(4) co-occurring mental illness, emotional disturbance, substance abuse, chemical dependency, or developmental disorder;

(5) relevant past and current medical and psychiatric information, which may include trauma history;

(6) information from the individual and LAR (if applicable) regarding the individual's strengths, needs, natural supports, describe community participation, responsiveness to previous treatment, as well as preferences for and objections to specific treatments;

(7) if the individual is an adult without an LAR, the needs and desire of the individual for family member involvement in treatment and mental health community services;

(8) the identification of the LAR's or family members' need for education and support services related to the individual's mental illness or emotional disturbance and the plan to facilitate the LAR's or family members' receipt of the needed education and support services;

(9) recommendations and conclusions regarding treatment needs; and

(10) date, signature, and credentials of staff member completing the assessment.

(b) Diagnostics. The diagnosis of a mental illness must be:

(1) rendered by an LPHA, acting within the scope of his/her license, who has interviewed the individual, either face-to-face or via telemedicine;

(2) based on all five axes of the current DSM;

(3) documented in writing, including the date, signature, and credentials of the person making the diagnosis; and

(4) supported by and included in the assessment.

(c) Provision of services. The LMHA, MCO, and provider must require each provider to implement procedures to ensure that individuals are provided mental health community services based on:

(1) the department's uniform assessment and utilization management guidelines;

(2) medical necessity as determined by an LPHA; and

(3) health management needs as determined by a physician, physician assistant, or registered nurse.

(d) Prerequisites to provision of services.

(1) Routine care services. For routine care services, before providing mental health community services to an individual, the provider must:

(A) obtain authorization from the department or its designee for the type(s), amount, and duration of mental health community services to be provided to the individual in accordance with the appropriate uniform assessment and utilization management guidelines;

(B) obtain a determination of medical necessity from an LPHA; and

(C) in collaboration with the individual and their LAR (if applicable), develop a treatment plan for the individual that includes a list of the type(s) of mental health community services authorized in accordance with subparagraph (A) of this paragraph.

(2) Crisis services. For crisis services, as described in §412.321 of this title (relating to Crisis Services), a provider must deliver services in accordance with the utilization management guidelines and authorization of services and timeframes described in §412.318(c) of this title (relating to Utilization Management). A diagnosis is not required when services are delivered in crisis situations.

(e) Content and timeframe of treatment plan. Each provider must develop a written treatment plan, in consultation with the individual and their LAR (if applicable), within 10 business days after the date of receipt of notification from the department or its designee that the individual is eligible and has been authorized for routine care services.

(1) At minimum, a staff member credentialed as a QMHP-CS is responsible for completing and signing the treatment plan. The treatment plan must reflect input from each of the disciplines of treatment to be provided to the individual based upon the assessment. The treatment plan must include:

(A) a description of the presenting problem;

(B) a description of the individual's strengths;

(D) a description of the individual's co-occurring substance use or physical health disorder, if any;

(E) a description of the recovery goals and objectives based upon the assessment, and expected outcomes of the treatment in accordance with paragraph (2) of this subsection;

(F) the expected date by which the recovery goals will be achieved;

(G) a list of resources for recovery supports, (e.g., community volunteer opportunities, family or peer organizations, 12-step programs, churches, colleges, or community education); and

(H) a list of the type(s) of services within each discipline of treatment that will be provided to the individual (e.g., psychosocial rehabilitation, medication services, substance abuse treatment, supported employment), and for each type of service listed, provide:

(i) a description of the strategies to be implemented by staff members in providing the service and achieving goals;

(ii) the frequency (e.g., weekly, twice a month, monthly), number of units (e.g., 10 counseling sessions, two skills training sessions), and duration of each service to be provided (e.g., .5 hour, 1.5 hours); and

(iii) the credentials of the staff member responsible for providing the service.

(2) The goals and objectives with expected outcomes required by paragraph (1)(E) of this subsection must:

(A) specifically address the individual's unique needs, preferences, experiences, and cultural background;

(B) specifically address the individual's co-occurring substance use or physical health disorder, if any;

(D) be objective and measurable using quantifiable criteria; and

(E) reflect the individual's self-direction, autonomy, and desired outcomes.

(3) The individual and LAR (if applicable) must be provided a copy of the treatment plan and each subsequent treatment plan reviewed and revised.

(f) Review of treatment plan.

(1) Each provider must:

(A) review the individual's treatment plan prior to requesting an authorization for the continuation of services:

(B) review the treatment plan in its entirety, as permitted under confidentiality laws by considering input from the individual, the individual's LAR (if applicable), and each of the disciplines of treatment;

(D) document progress on all goals and objectives and any recommendation for continuing services, any change from current services, and any discharge from services.

(2) In addition to the required review under paragraph (1) of this subsection, a provider may review the treatment plan in the following instances:

(A) if clinically indicated; and

(B) at the request of the individual or the LAR (if applicable), or the primary caregiver of a child or adolescent.

(3) Any time the treatment plan is reviewed, the provider must:

(A) meet with the individual either face to face or via telemedicine to solicit and consider input from the individual regarding a self-assessment of progress toward the recovery goals, as described in subsection (e)(1)(E) of this section;

(B) solicit and consider the input from each of the disciplines of treatment in assessing the individual's progress toward the recovery goals and objectives with expected outcomes, described in subsection (e)(1)(E) of this section;

(C) solicit and consider input from the LAR (if applicable) or primary caregiver, if the individual is a child or adolescent regarding the level of satisfaction with the services provided; and

(D) document all the input described in subparagraphs (A) - (C) of this paragraph.

(g) Revisions to the treatment plan. If, after any review of the treatment plan, the provider determines it does not adequately address the needs of the individual, the provider must appropriately revise the content of the plan.

(h) Discharge Summary. Not later than 21 calendar days after an individual's discharge, whether planned or unplanned, the provider must document in the individual's medical record:

(1) a summary, based upon input from all the disciplines of treatment involved in the individual's treatment plan, of all the services provided, the individual's response to treatment, and any other relevant information;

(2) recommendations made to the individual or their LAR (if applicable) for follow up services, if any; and

(3) the individual's last diagnosis, based upon all five axes of the current DSM.

§412.323.Medication Services.

(a) Prescribing of psychoactive medication. The LMHA and MCO must ensure that psychoactive medication is prescribed in accordance with Chapter 415, Subchapter A of this title (relating to Prescribing of Psychoactive Medication).

(b) Medication service delivery. The LMHA, MCO, and provider must implement written procedures to ensure safe medication-related service delivery that include, but are not limited to, the following.

(1) A procedure for physician delegation of medical acts to non-physicians. The procedure must address delegation protocols to advanced practice nurses and/or physician assistants, delegation of medical acts to nursing and/or unlicensed staff, and the frequency of physician supervision over the staff member to whom a delegation is made. The procedure must provide a method to ensure the staff members are acting within the scope of their license and is qualified and trained to perform the medical act.

(2) A procedure for RNs to make assignments to LVNs or delegate to unlicensed staff members nursing acts for the care of stable individuals with common, well-defined health problems with predictable outcomes. The procedure must address the types of nursing acts that may be delegated, the method to ensure the staff member is trained and qualified to perform a delegated nursing act, and the frequency of nursing supervision of the unlicensed staff member in accordance with Texas Occupations Code, Chapter 301 (relating to the Nursing Practice Act).

(3) A procedure for medication administration by licensed medical or nursing staff that addresses who may access and administer medications, timely administration, documentation of administration, and monitoring of administration, and that complies with applicable professional licensing standards and rules.

(4) A procedure for medication handling that addresses:

(A) dispensing;

(B) labeling and record keeping of sample medications;

(D) patient assistance/indigent medication program;

(E) mechanisms to ensure safe temperature-controlled storage and transport of medication;

(F) controlled drugs;

(G) disposal/destruction of medication; and

(H) locked areas and maintaining security.

(5) A procedure by which a physician, a physician's assistant, or an RN assesses and determines whether an individual can self-administer medication and whether it can be done without supervision.

(6) A procedure for training and assessing the competency of staff members to perform supervision of self-administration of medication, including:

(A) medication actions;

(B) target symptoms;

(D) potential toxicity;

(E) side effects;

(F) adverse reactions;

(G) proper storage of medications; and

(H) reporting and documentation requirements.

(7) A procedure for providing appropriate supervision of staff members who are supervising self-administration of medication.

(8) A procedure for medication errors that defines the most common types of medication errors and provides for:

(A) the accurate documentation of medication errors;

(B) the reporting of medication errors to the physician within one hour of their occurrence;

(D) a mechanism for analyzing both individual medication errors and trends for quality improvement; and

(E) the reporting of medication errors, as appropriate.

§412.324.Additional Standards of Care Specific to Mental Health Community Services for Children and Adolescents.

(a) Administration of the uniform assessment. The uniform assessment must be administered face-to-face or via telemedicine with the individual and the LAR (if applicable) or primary caregiver as clinically appropriate according to the child's or adolescent's age, functioning, and current living situation.

(b) Age and developmentally appropriate mental health community services. All mental health community services delivered to children and adolescents by a provider must be, for each child and adolescent, age-appropriate, developmentally appropriate, and consistent with academic development.

(c) Separation of individuals by age. A provider that delivers mental health community services to children and adolescents in group settings (e.g., residential, day programs, group therapy, partial hospitalization, and inpatient) must separate children and adolescents from adults. The provider must further separate children from adolescents according to age and developmental needs, unless there is a clinical or developmental justification in the medical record.

(d) Transition to mental health community services for adults. The provider must develop a transition plan for each adolescent who will need mental health community services for adults. The transition plan must be developed in consultation with the adolescent (and LAR if applicable) and future providers with adequate time to allow both current and future providers to transition the adolescent into adult services without a disruption in services. The transition plan must include:

(1) a summary of the mental health community services and treatment the adolescent received as a child and adolescent;

(2) the adolescent's current status (e.g., diagnosis, medications, uniform assessment guideline calculation, and unmet needs);

(3) information from the adolescent and the LAR regarding the adolescent's strengths, preferences for mental health community services, and responsiveness to past interventions;

(4) a description of the mental health community services the adolescent will receive as an adult;

(5) a list of resources for other recovery supports such as volunteer opportunities, family or peer organizations, 12-step programs, churches, colleges, or community education;

(6) documentation that the adolescent's services continued throughout the transition without disruptions; and

(7) documentation of the follow up to ensure successful transition to adult services.

§412.325.Telemedicine Services.

The LMHA, MCO, and provider must ensure that if a provider uses telemedicine, it is implemented in accordance with written procedures and using a protocol approved by the LMHA's or MCO's medical director. Procedures regarding the provision of telemedicine service must include the following requirements:

(1) clinical oversight by the LMHA's or MCO's medical director or designated physician responsible for medical leadership;

(2) contraindications for telemedicine use;

(3) qualified people to ensure the safety of the individual being served by telemedicine at the remote site; and

(4) use by credentialed or licensed providers who provide clinical care within the scope of their credential or license.

§412.326.Documentation of Service Provision.

(a) Progress note content. Except for crisis services as described in §412.321 of this title (relating to Crisis Services) and day programs for acute needs as described in Chapter 419, Subchapter L of this title (relating to Mental Health Rehabilitative Services), and case management services as described in Chapter 412, Subchapter I of this title (relating to Mental Health Case Management Services), a provider must document the provision of all other mental health community services, each service encounter and include at least the following:

(1) the name of the individual to whom the service was provided, including the LAR or primary caregiver, if applicable;

(2) the type of service provided;

(3) the date the service was provided;

(4) the begin and end time of the service;

(5) the location where the service was provided;

(6) a summary of the activities that occurred;

(7) the modality of the service provision (e.g., individual, group);

(8) the method of service provision (e.g., face-to-face, phone, telemedicine);

(9) the training methods used, if applicable (e.g., instructions, modeling, role play, feedback, repetition);

(10) the title of the curriculum being used, if applicable;

(11) the treatment plan objective(s) that was the focus of the service;

(12) the progress or lack of progress in achieving treatment plan goals;

(13) the signature of the staff member providing the service and a notation as to whether the staff member is an LPHA, a QMHP-CS, a pharmacist, a CSSP, an LVN, a peer provider or otherwise credentialed, as required for that service; and

(14) any pertinent event or behavior relating to the individual's treatment which occurs during the provision of the service.

(b) Frequency of documentation. The documentation required in subsection (a) of this section must be made within two business days after each contact that occurs to provide mental health community services.

(c) Retention. Documentation must be retained in compliance with applicable federal and state laws, rules, and regulations.

§412.327.Supervision.

(a) Clinical supervision. Clinical supervision must be accomplished by an LPHA or a QMHP-CS as follows:

(1) by conducting a documented meeting with the staff member being supervised at least monthly; and

(2) for peer providers, by conducting an additional monthly documented observation of the peer provider providing mental health community services.

(b) Policies and procedures. The LMHA or MCO will develop and implement written policies and procedures for supervision of all applicable levels of staff members providing services to individuals.

(c) Licensed staff member supervision. All licensed staff members must be supervised in accordance with their practice act and applicable rules.

(d) QMHP-CS supervision. A QMHP-CS's designated clinical duties must be clinically supervised by:

(1) a QMHP-CS; or

(2) an LPHA if the QMHP-CS is clinically supervising the provision of mental health community services.

(e) CSSP supervision. A CSSP's designated clinical duties must be clinically supervised by a QMHP-CS. The CSSP must have access to clinical consultation with an LPHA when necessary.

(f) Family partner supervision. A family partner is supervised by the mental health children's director, clinic director, case management supervisor, or wraparound supervisor.

(g) Peer provider supervision. A peer provider's designated clinical duties must be clinically supervised by an LPHA.

(h) Peer review. The LMHA, MCO, and provider must implement a peer review process for licensed staff members that:

(1) promotes sound clinical practice;

(2) promotes professional growth; and

(3) complies with applicable state laws (e.g., Medical Practice Act, Nursing Practice Act, Vocational Nurse Act) and rules.

(i) Documentation. All clinical supervision must be documented.

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 January 22, 2009.

TRD-200900282

Lisa Hernandez

General Counsel

Department of State Health Services

Earliest possible date of adoption: March 8, 2009

For further information, please call: (512) 458-7111 x6972