Current through Reg. 50, No. 13; March 28, 2025
(a) Purpose.
The purpose of this section is to promote the public health, safety, and
welfare by providing for the development, establishment, and enforcement of
standards:
(1) for the habilitation of
residents based on an active treatment program in facilities governed by this
chapter; and
(2) for the
establishment, construction, maintenance, and operation of such facilities that
view an intellectual disability and related conditions within the context of a
developmental model in accordance with the principle of
normalization.
(b) Active
treatment. A facility regulated by the standards in this section is known as an
intermediate care facility for individuals with an intellectual disability or
related conditions (ICF/IID). A resident living in a facility has the same
civil rights, equal liberties, and due process of law as other individuals,
plus the right to receive active treatment and habilitation. A facility must
provide and promote services that enhance the development of each resident,
maximize their achievement through an interdisciplinary approach, and create an
environment, to the extent possible, that is normalized and normalizing. A
facility must:
(1) have the interdisciplinary
team (IDT) prepare and implement, for each resident, an individual program plan
(IPP) within 30 days after admission;
(2) ensure each resident receives a
continuous active treatment program consisting of needed interventions and
services in sufficient number and frequency to support the achievement of the
objectives identified in the IPP, as identified by the IDT; and
(3) ensure each resident's IPP is reviewed at
least annually by a qualified intellectual disability professional (QIDP) and
revised as necessary, including situations in which a resident has successfully
completed an objective identified in the IPP.
(c) Standards. Each ICF/IID must comply with
regulations promulgated by the United States Department of Health and Human
Services in
42 CFR, Part 483, Subpart I §§
483.400 -
483.480.
Additionally, HHSC adopts by reference the federal regulations governing
conditions of participation for the ICF/IID program as specified in
42 CFR
Part 483, Subpart I §§
483.410,
483.420,
483.430,
483.440,
483.450,
483.460,
483.470,
483.475,
and
483.480
as licensing standards.
(d)
Precertification training conference for new providers of service. Each new
provider must attend the precertification/prelicensure training conference
prior to licensing by HHSC. The purpose of the training is to ensure that
providers of services are familiar with the licensing requirements and to
facilitate the delivery of quality services to residents in facilities serving
persons with an intellectual disability or related conditions.
(1) A new provider is an entity that has not
had at least one year of administering services in a facility serving persons
with an intellectual disability or related conditions in Texas. All new
providers must attend a precertification training conference prior to the life
safety code survey.
(2) Each new
provider must designate at least one individual who will be involved with the
direct management of the facility to attend the training conference prior to a
health survey being scheduled.
(3)
Each new provider will be responsible for taking the required
training.
(e) Additional
requirements.
(1) Abuse, neglect, and
exploitation. A facility must develop and implement policies and procedures for
reporting abuse, neglect, and exploitation, and other reportable incidents, to
HHSC.
(2) Cardiopulmonary
resuscitation (CPR). A facility must ensure:
(A) at least one staff person per shift and
on duty is trained by a CPR instructor and certified by an organization, such
as the American Heart Association or the Red Cross, whose training includes a
hands-on in-person skills assessment; and
(B) that staff members maintain their
certification as recommended by the training organization.
(3) Behavior management. Seclusion of
residents may not be used.
(4)
Physical restraints.
(A) A facility must not
use a restraint:
(i) in a manner that:
(I) obstructs a resident's airway, including
the placement of anything in, on, or over the resident's mouth or
nose;
(II) impairs a resident's
breathing by putting pressure on the resident's torso;
(III) interferes with a resident's ability to
communicate;
(IV) extends a
resident's muscle groups away from each other;
(V) uses hyperextension of joints on a
resident; or
(VI) uses pressure
points or pain on a resident;
(ii) for disciplinary purposes, that is, as
retaliation or retribution;
(iii)
for the convenience of staff or other residents; or
(iv) as a substitute for effective treatment
or habilitation.
(B) A
facility may use a restraint:
(i) in a
behavioral emergency;
(ii) as an
intervention in a behavior therapy program that addresses inappropriate
behavior exhibited voluntarily by a resident;
(iii) during a medical or dental procedure if
necessary to protect the resident or others and as a follow-up after a medical
or dental procedure or following an injury to promote the healing of
wounds;
(iv) to protect the
resident from involuntary self-injury; or
(v) to provide postural support to the
resident or to assist the resident in obtaining and maintaining normative
bodily functioning.
(C)
In order to decrease the frequency of the use of restraint and to minimize the
risk of harm to a resident, a facility must ensure that the IDT:
(i) with the participation of a physician, or
a physician assistant or an advanced practice nurse acting within the scope of
his or her practice, identifies:
(I) the
resident's known physical or medical conditions that might constitute a risk to
the resident during the use of restraint;
(II) the resident's ability to communicate;
and
(III) other factors that must
be taken into account if the use of restraint is considered, including the
resident's:
(-a-) cognitive functioning
level;
(-d-) emotional condition (including whether
a resident has a history of having been physically or sexually abused);
and
(ii) documents the conditions and
factors identified in accordance with clause (i) of this subparagraph, and, as
applicable, limitations on specific restraint techniques or mechanical
restraint devices in the resident's record; and
(iii) reviews and updates with a physician,
physician assistant, or licensed nurse, at least annually or when a condition
or factor documented in accordance with clause (ii) of this subparagraph
changes significantly, information in the resident's record related to the
identified condition, factor, or limitation.
(D) If a facility restrains a resident as
provided in subparagraph (B) of this paragraph, the facility must:
(i) take into account the conditions,
factors, and limitations on specific restraint techniques or mechanical
restraint devices documented in accordance with subparagraph (C)(ii) and (iii)
of this paragraph;
(ii) use the
minimal amount of force or pressure that is reasonable and necessary to ensure
the safety of the resident and others;
(iii) safeguard the resident's dignity,
privacy, and well-being; and
(iv)
not secure the resident to a stationary object while the resident is in a
standing position.
(E) If
a facility uses a restraint in a circumstance described in subparagraph (B)(i)
or (ii) of this paragraph:
(i) the facility
may only use a personal hold in which the resident's limbs are held close to
the body to limit or prevent movement and that does not violate the provisions
of subparagraph (A)(i) of this paragraph; and
(ii) if a resident rolls into a prone or
supine position during restraint, the facility must transition the resident to
a side, sitting, or standing position as soon as possible. A facility may only
use a prone or supine hold:
(I) as a
transitional hold, and only for the shortest period of time necessary to ensure
the protection of the resident or others;
(II) as a last resort, when other less
restrictive interventions have proven to be ineffective; and
(III) except in a small facility, when an
observer who is trained to identify risks associated with positional,
compression, or restraint asphyxiation and with prone and supine holds is
ensuring that the resident's breathing is not impaired.
(F) A facility must release a
resident from a restraint:
(i) as soon as the
resident no longer poses a risk of imminent physical harm to the resident or
others; or
(ii) if the resident in
restraint experiences a medical emergency, as soon as possible as indicated by
the medical emergency.
(G) If a facility restrains a resident as
provided in subparagraph (B)(i) of this paragraph, the facility must obtain a
written order authorizing the restraint from a health care professional acting
within his or her scope of practice by the end of the first business day after
the use of a restraint.
(H) A
facility must ensure that each resident and the resident's legally authorized
representative (LAR) are notified of HHSC rules and the facility's policies
related to restraint and seclusion.
(I) A facility may adopt policies that allow
less use of restraint than allowed by the rules of this chapter.
(5) Pharmacy services.
(A) All pharmacy services must comply with
the Texas State Board of Pharmacy requirements, the Texas Pharmacy Act, and
rules adopted thereunder, the Texas Controlled Substances Act, and Texas Health
and Safety Code, Chapter 483 (relating to Dangerous Drugs).
(B) All medications must be ordered orally or
in writing by a health care professional acting within the scope of his or her
practice. Oral orders may be taken only by a licensed nurse, a pharmacist,
physician assistant, or physician, and must be immediately transcribed and
signed by the individual taking the order. Oral orders must be signed by the
health care professional who ordered the medication within seven working days
after issuing the order.
(C) A
facility, with input from the consultant pharmacist and a health care
professional acting within the scope of his or her practice, must develop and
implement procedures regarding automatic stop orders for medications. These
procedures must be utilized when the order for a medication does not specify
the number of doses to be given or the time for discontinuance or
re-order.
(6) Specialized
nutrition support (delivery of parenteral nutrients and enteral feedings by
nasogastric, gastrostomy, or jejunostomy tubes) must be given:
(A) by a health care professional acting
within the scope of his or her practice or by a person to whom a health care
professional has properly delegated performance of the task; and
(B) in accordance with an order issued by a
health care professional acting within the scope of his or her
practice.
(7)
Self-administration of medication and emergency medication kits.
(A) A resident who has demonstrated the
competency for self-administration of medication must have access to and
maintain his or her own medication. The resident must have an individual
storage space that permits him or her to store the medication under lock and
key.
(B) A resident may participate
in a self-administration of medication training program if the IDT determines
that self-administration of medication is an appropriate objective. A resident
participating in a self-administration of medication training program must have
training in coordination with and as part of the resident's total active
treatment program. The resident's training plan must be evaluated as necessary
by a licensed nurse. The supervision and implementation of a
self-administration of medication training program may be conducted by staff
described in §
551.43(a)(1), (3), and
(4) of this subchapter (relating to
Administration of Medication).
(C)
A facility may maintain a supply of controlled substances in an emergency
medication kit for a resident's emergency medication needs, as outlined under
§
551.324 and §
551.325 of this chapter (relating
to Emergency Medication Kit and Controlled Substances).
(8) Infection prevention and control.
(A) A facility must establish, implement,
enforce, and maintain an infection prevention and control policy and procedure
designated to provide a safe, sanitary, and comfortable environment and to help
prevent the development and transmission of disease and infection.
(B) A facility must comply with rules
regarding special waste in 25 TAC Chapter 1, Subchapter K (relating to
Definition, Treatment, and Disposition of Special Waste from Health-Care
Related Facilities).
(C) A facility
must immediately report the name of any resident of a facility with a
reportable disease, as specified in 25 TAC Chapter 97, Subchapter A (relating
to Control of Communicable Diseases) to the city health officer, county health
officer, or health unit director having jurisdiction, and implement appropriate
infection control procedures as directed by the local health
authority.
(D) A facility must
have, implement, enforce, and maintain written policies for the control of
communicable disease among employees and residents, which must address
tuberculosis (TB) screening and the provision of a safe and sanitary
environment for residents and employees.
(i)
If an employee contracts a communicable disease that is transmissible to
residents through food handling or direct resident care, the facility must
exclude the employee from providing these services for the applicable period of
communicability.
(ii) A facility
must maintain evidence of compliance with local and state health codes or
ordinances regarding employee and resident health status.
(iii) A facility must screen all employees
for TB within two weeks of employment and annually, according to the Centers
for Disease Control and Prevention (CDC) screening guidelines. A person who
provides services under an outside resource contract must, upon request of the
facility, provide evidence of compliance with this requirement.
(iv) A facility's policies and practices for
resident TB screening must ensure compliance with the recommendations of a
resident's attending physician and consistency with CDC guidelines.
(E) A facility's infection
prevention and control program established under subparagraph (A) of this
subsection must include written policies and procedures for:
(i) monitoring of key infectious agents,
including multidrug-resistant organisms, as those terms are defined in §
551.3 of this chapter (relating to
Definitions);
(ii) wearing personal
protective equipment, such as gloves, a gown, or a mask based on anticipated
exposure, and properly cleaning hands before and after touching another
resident;
(iii) cleaning and
disinfecting environmental surfaces, including doorknobs, handrails, light
switches, and handheld electronic control devices;
(iv) using universal precautions for blood
and bodily fluids; and
(v) removing
soiled items (such as used tissues, wound dressings, adult briefs, and soiled
linens) from the environment at least once daily, or more often if an infection
or infectious disease is present or suspected.
(F) A facility must establish, implement,
enforce, and maintain written policies and procedures for making a rapid
influenza diagnostic test, as defined in §
551.3 of this chapter (relating to
Definitions), available to a resident who is exhibiting flu-like
symptoms.
(G) Staff must handle,
store, process, and transport linens to prevent the spread of
infection.
(H) A facility must use
universal precautions in the care of all residents.
(9) Water activities. A facility must ensure
the safety of all residents who participate in facility-sponsored events. For
this section, a water activity is defined as an activity which occurs in or on
water that is knee deep or deeper on the majority of residents participating in
the event. To ensure the safety of all individuals who participate, the
requirements in subparagraphs (A) - (F) of this paragraph apply.
(A) A facility must develop a policy
statement regarding the water sites utilized by the facility. Water sites
include lakes, amusement parks, and pools.
(B) A minimum of one staff person, who is
certified and has demonstrated proficiency in CPR must be on duty and at the
site when residents are involved in water activities.
(C) A minimum of one person with demonstrated
proficiency in water life-saving skills must be on duty and at the site when
activities take place in or on water that is deep enough to require swimming
for life-saving retrieval. This person must maintain supervision of the
activity for its duration.
(D) A
sufficient number of staff or a combination of staff and volunteers must be
available to meet the safety requirements of the group and specific
residents.
(E) Each resident's IPP
must address each person's needs for safety when participating in water
activities including medical conditions; physical disabilities and behavioral
needs which could pose a threat to safety; the ability of residents to follow
directions and instructions pertaining to water safety; the ability of
residents to swim independently; and, when called for, special
precautions.
(F) If the IDT
recommends the use of a flotation device as a precaution for any resident to
engage in water activities, it must be identified and the precautions outlined
in the IPP. The device must be approved by the United States Coast Guard or be
a specialized therapy flotation device utilized in the individual's therapy
program.
(10)
Communication. A facility may not prohibit a resident or employee from
communicating in the person's native language with another resident or employee
for acquiring or providing care, training, or treatment.
(11) Physical exams. A facility must ensure
that a resident is given at least one physical exam on a yearly basis by:
(A) a person licensed to practice medicine in
accordance with Texas Occupations Code, Chapter 155 (relating to License to
Practice Medicine);
(B) a person
licensed as a physician assistant in accordance with Texas Occupations Code,
Chapter 204 (relating to Physician Assistants); or
(C) a person licensed to practice
professional nursing in accordance with Texas Occupations Code, Chapter 301
(relating to Nurses), and authorized by the Texas Board of Nursing to practice
as an advanced practice nurse.
(f) Governing body and management. A facility
must establish a governing body and the governing body must adopt, implement,
and enforce the facility's policies and procedures. The governing body must
review and update the facility policies and procedures at least
annually.
(g) Client protections. A
facility must ensure the rights of a resident and through oversight, policy,
and investigative procedures to ensure a resident is free from all abuse,
neglect, and exploitation.
(h)
Facility staffing. A facility must ensure a resident receives professional and
non-professional program services needed to implement the active treatment
program defined by a resident's IPP.
(i) Active treatment services. A facility
must ensure a resident receives a continuous active treatment program, which
includes aggressive, consistent implementation of a program of specialized and
generic training, treatment, health services, and related services in the IPP
created by the IDT.
(j) Client
behavior and facility practices. A facility must develop and implement written
policies and procedures for the management of conduct between staff and
residents and the management of inappropriate resident behavior.
(k) Health care services. A facility must
provide or obtain preventative and general medical care for a resident and
ensure a resident receives nursing services in accordance with the resident's
needs.
(l) Physical environment. A
facility must provide sufficient space and equipment in dining, living, health
services, recreation, and program areas to enable staff to provide a resident
with needed services as required or identified in a resident's IPP.
Additionally, a facility must ensure all fire safety and surrounding safety
conditions are maintained in accordance with federal, state, and local
regulations.
(m) Emergency
preparedness. A facility must establish and maintain an emergency preparedness
program that meets all federal, state, and local emergency preparedness
requirements.
(n) Dietetic
services. A facility must ensure a resident receives a nourishing,
well-balanced diet including any modified or specifically prescribed
diets.
