TITLE 26. HEALTH AND HUMAN SERVICES

PART 1. HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 558. LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES

(Editor's note: In accordance with Texas Government Code, §2002.014, which permits the omission of material which is "cumbersome, expensive, or otherwise inexpedient," the figures in 26 TAC §558.602(h)(2)(D) and §558.602(h)(2)(D) are not included in the print version of the Texas Register. The figure is available in the on-line version of the September 18, 2026, issue of the Texas Register.)

The executive commissioner of the Texas Health and Human Services Commission (HHSC) proposes in Texas Administrative Code (TAC), Title 26, Chapter 558, concerning Licensing Standards for Home and Community Support Services Agencies, amendments to §§558.1 - 558.3, 558.11, 558.13, 558.15, 558.17, 558.19, 558.21, 558.23, 558.25, 558.27, 558.29, 558.30, 558.208, 558.210, 558.211, 558.213 - 558.220, 558.242 - 558.250, 558.252, 558.256, 558.257, 558.259, 558.260, 558.281 - 558.283, 558.285, 558.287 - 558.292, 558.295, 558.297, 558.321, 558.322, 558.401, 558.404, 558.405, 558.501, 558.503, 558.507, 558.521, 558.523, 558.525, 558.601, 558.602, 558.604, 558.701, 558.801, 558.812, 558.823, 558.834, 558.843, 558.857, 558.859, 558.861 - 558.863, 558.870, and 558.880; new §§558.251, 558.261, 558.304, 558.323, 558.330, 558.332, 558.334, 558.336, 558.338, 558.510, 558.527, 558.529, 558.914, 558.916, 558.918, 558.928, 558.930, 558.932, 558.936, 558.940, 558.942, 559.944, 558.946, 558.948, and 558.950; and the repeal of §§558.251, 558.527, and 558.871.

BACKGROUND AND PURPOSE

The purpose of the proposal is to implement House Bill (HB) 1009, HB 4696, Senate Bill (SB) 240, and SB 1849 enacted during the 88th Legislature, Regular Session, 2023, and SB 463 enacted during the 89th Legislature, Regular Session, 2025, to prescribe and streamline HHSC's process for investigating allegations of abuse, neglect, and exploitation of clients, and to ensure the rules reflect current industry practices and changes in service delivery models, licensure requirements, and enforcement procedures. The proposal also updates citations to the Texas Government Code as modified by HB 4611, 88th Legislature, Regular Session, 2023. HB 4611 made certain non-substantive revisions to Subtitle I, Title 4, Texas Government Code, which governs HHSC, Medicaid, and other social services as part of the legislature's ongoing statutory revision program. The updated citations became effective on April 1, 2025.

HB 1009 created Texas Health and Safety Code §253.0025 to require a home and community support services agency (HCSSA or agency) to suspend the employment of an unlicensed employee whom HHSC finds has engaged in reportable conduct while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review.

HB 4696 amended Texas Human Resources Code §48.252 to require allegations of abuse, neglect, and exploitation to be reported to HHSC rather than the Texas Department of Family and Protective Services (DFPS). HB 4696 also amended Texas Health and Safety Code §142.009(j) to state that a survey may (rather than must) be conducted within 18 months after a survey for an initial license and deleted the requirement that this visit must be made on-site.

SB 240 created Texas Health and Safety Code Chapter 331, to require a HCSSA providing licensed home health services to have a policy and prevention plan related to workplace violence if the HCSSA employs more than two registered nurses.

SB 463 amended Texas Health and Safety Code Chapter 331 to state that all HCSSAs must have a policy and prevention plan related to workplace violence if they employ two or more registered nurses.

SB 1849 created Texas Health and Safety Code Chapter 810, and with it the Interagency Reportable Conduct Search Engine, which is being implemented under the name Search Engine for Multiple Agency Reportable Conduct (SEMARC).

The proposal also deletes or updates obsolete references and contains non-substantive changes to improve readability and formatting.

SECTION-BY-SECTION SUMMARY

Edits are made throughout the chapter to delete or update references and non-substantive edits are made to improve readability and formatting.

Subchapter A, General Provisions

The proposed amendment to §558.1, Purpose and Scope, adds Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, as additional statutes that will be implemented by the rules.

The proposed amendment to §558.2, Definitions, adds definitions for terms and amends current definitions to clarify and define terms to reflect current industry practices and changes in service delivery models, licensure requirements, and enforcement procedures. The proposed amendment removes outdated or obsolete citations and references.

The proposed amendment to §558.3, License Fees, removes all the renewal license fees for a two-year license because now all renewal license fees are for a three-year license. The amendment updates the fee for an initial alternate delivery site license that includes a change of ownership from $1,000 to $1,500 to be consistent with the statutory three-year license term instead of the former two-year license term. The amendment also maintains consistency throughout the rules and promotes modernization by requiring applicants to submit applications and payment for licensure via the online portal.

Subchapter B, Criteria and Eligibility, Application Procedures, and Issuance of a License

The proposed amendment to §558.11, Criteria and Eligibility for Licensing, adds language to reflect changes in §558.604, related to licensure surrender, and allows HHSC to deny an application for an initial license or for renewal of a license if a person described in the rule, in the 12 months preceding the date of the application, has a history in any state or other jurisdiction of willfully operating an agency without a valid and active license.

The proposed amendment to §558.13, Obtaining an Initial License, adds language stating that an applicant may request to be licensed in any combination of the listed categories of services to ensure that the applicant is aware that it is not limited on which combination of services it may provide.

The proposed amendment to §558.15, Issuance of an Initial License, corrects references.

The proposed amendment to §558.17, Application Procedures for a Renewal License, updates references.

The proposed amendment to §558.19, Issuance of a Renewal License, removes extraneous language from subsections (b) and (c). The amendment removes existing subsections (e) and (f) that reference licensure expiration dates between December 31, 2020, and January 1, 2023, as these dates have passed. Removing existing subsections (e) and (f) also removes references to two-year license terms because now all license terms are three years. The amendment to subsection (a) removes references to subsections (e) and (f) that are proposed for removal.

The proposed amendment to §558.21, Denial of an Application or a License, adds that HHSC may deny a licensure application for a hospice inpatient unit that fails to meet the licensure requirements of a Life Safety Code inspection. Continued failure to meet the licensure requirements within 120 days after the initial Life Safety Code inspection will result in a proposed denial of the license and a referral of the application to HHSC Regulatory Enforcement.

The proposed amendment to §558.23, Change of Ownership, clarifies that the current license holder maintains responsibility under its license between the effective date of the change of ownership and the issuance of an initial license to the change of ownership applicant, who may operate the agency on behalf of the current license holder during such time period.

The proposed amendment to §558.25, Requirements for Change of Ownership, replaces a reference to "an initial license application" with a reference to "a change of ownership license application" to clarify the type of application that must be submitted. The amendment specifies what a complete change of ownership application includes. The amendment clarifies that a change of ownership license application is submitted through the online portal to be consistent with this same requirement in other rules for submitting a license application. The amendment also makes non-substantive changes to improve readability and clarity.

The proposed amendment to §558.27, Application and Issuance of an Initial Branch Office License, clarifies who is responsible for denying applications for licensure. The amendment also deletes extraneous language and corrects a grammatical error.

The proposed amendment to §558.29, Application and Issuance of an Alternate Delivery Site License, provides additional guidance regarding notification of readiness for a Life Safety Code survey and specifies that an agency must not admit Medicare beneficiaries before receiving Centers for Medicare & Medicaid Services (CMS) approval, and outlines exemptions and guidance related to the accreditation process. The amendment also updates a reference.

The proposed amendment to §558.30, Operation of an Inpatient Unit at a Parent Agency, updates the section title to "Operation of a Hospice Unit at a Parent Agency." The amendment adds that an applicant for an initial license to provide hospice services must not have an enforcement action pending against the license. The amendment adds that before HHSC considers whether the application is complete, HHSC determines if the agency is in compliance with the Life Safety Code Requirements in proposed new Division 9 under Subchapter H. The amendment requires the agency, after HHSC issues a license authorizing the hospice inpatient unit, to admit and provide services to a client, and unless exempt as described in the rule, to submit a request for an initial health survey. The proposed amendment also requires an agency to submit the Notification of Readiness for a Health Survey (HHSC Form 2020), in place of Notification of Readiness for a Health Survey (HHSC Form 2020-A).

Subchapter C, Minimum Standards for All Home and Community Support Services Agencies

Division 2, Conditions of a License

The proposed amendment to §558.208, Reporting Changes in Application Information and Fees, updates language to reflect that applications may be submitted online and requires an agency to report a change in accreditation status after HHSC issues a license. The amendment updates the rule by adding that the application required to report a change must be submitted through the online portal. The amendment clarifies a reference and makes non-substantive edits for clarity.

The proposed amendment to §558.210, Agency Operating Hours, updates the section title to "Agency Place of Business and Operating Hours." The amendment specifies parameters and limitations for an agency's place of business and describes the requirements that must be met if the place of business is in a co-working workspace. Additionally, the proposed language outlines the requirements for what must be displayed on an agency's notice or sign.

The proposed amendment to §558.211, Display of License, clarifies that the most current license must be displayed in each place of business. If the information on the license is officially amended, the agency will receive a new license to reflect the changes, which must be posted to provide public notice of the change.

The proposed amendment to §558.213, Agency Relocation, clarifies the procedure for reporting a change in physical location to now specify that a relocation application must be submitted through the online portal. The amendment describes the requirements for an agency with a hospice inpatient unit to relocate the unit. The amendment makes non-substantive changes to improve readability.

The proposed amendment to §558.214, Notification Procedures for a Change in Agency Contact Information and Operating Hours, adds the requirement to submit applications through the online portal to maintain consistency throughout the rules and promote modernization.

The proposed amendment to §558.215, Notification Procedures for an Agency Name Change, adds the requirement to submit applications through the online portal to maintain consistency throughout the rules and promote modernization. The amendment also makes non-substantive changes to improve readability.

The proposed amendment to §558.216, Change in Agency Certification Status, adds a provision regarding the procedures when an agency voluntarily withdraws from the Medicare program but continues to provide services under a licensed-only category, such as licensed home health, hospice, or personal assistance services. The amendment also clarifies that a written notice of voluntary closure must be included if an agency voluntarily withdraws from the Medicare program based on permanent closure.

The proposed amendment to §558.217, Agency Closure Procedures and Voluntary Suspension of Operations, adds guidance about how an agency must notify HHSC of closure or voluntary suspension, instructions regarding how to preserve client records in the event of a closure or voluntary suspension, the consequences an agency will face should it fail to comply with the section, and how an agency may resume operations following a voluntary suspension of operations. The amendment also updates references.

The proposed amendment to §558.218, Agency Organizational Changes, updates language to reflect application submission options via online methods. The amendment updates a reference.

The proposed amendment to §558.219, Procedures for Adding or Deleting a Category to the License, clarifies which HHSC unit is responsible for approving and denying applications that request to add or delete categories of service to a license. The amendment specifies that an agency must not provide services before receiving an updated license with the new category of service listed.

The proposed amendment to §558.220, Service Areas, updates language to reflect application submission options via online methods, provides clarification to providing services to clients who reside outside of a licensed service area, incorporates language regarding compliance when providing teleservices and specifies the location requirements for branch offices or alternate delivery sites.

Subchapter C, Minimum Standards for All Home and Community Support Services Agencies

Division 3, Agency Administration

The proposed amendment to §558.242, Organizational Structure and Lines of Authority, clarifies which positions may be considered a controlling person in the agency's organizational structure.

The proposed amendment to §558.243, Administrative and Supervisory Responsibilities, updates language to reflect application submission options via online methods, updates language to include when a license holder with multiple categories of services may share a single administrator and alternate administrator and explains date of designation. The amendment updates language to include that it is the administrator's responsibility to develop and implement an acceptable plan of correction in response to cited deficiencies and violations. The amendment incorporates telecommunications as a method through which the supervising or alternate supervising nurse may be available to agency personnel. The amendment further updates language to ensure compliance with Texas Health and Safety Code Chapter 331 regarding a written workplace violence prevention policy and plan and the establishment of a workplace violence prevention committee and updates references. The amendment also implements language from SB 240 stating that agencies providing licensed home health services that employ two or more nurses must adopt, implement, and enforce a written workplace violence prevention policy and plan and a committee to oversee it.

The proposed amendment to §558.244, Administrator Qualifications and Conditions and Supervising Nurse Qualifications, adds presurvey training completion deadlines before the date of designation for an administrator and alternate administrator and details who is required to complete the presurvey training. The amendment prohibits the employability of an administrator or alternate administrator who has been involved in a final enforcement action by HHSC. The amendment defines the terms "period of time" and "enforcement action" for the purposes of the section. The amendment details when enforcement action is to take effect should an agency appeal enforcement action.

The proposed amendment to §558.245, Staffing Policies, updates language to require that an agency's written staffing procedures include a process for searches of the medication aide registry (MAR), if applicable, and the SEMARC, in addition to the nurse aide registry (NAR). The amendment also clarifies that evaluation of competencies may be performed via telecommunications for purposes of compliance. The amendment also states that agency training may be conducted virtually with competencies demonstrated and evaluated in person.

The proposed amendment to §558.246, Personnel Records, updates language to clarify that personnel records are required for all employees and volunteers regardless of position and details what documentation personnel records must contain. The amendment also updates language to state that personnel records for an unlicensed employee or unlicensed volunteer whose duties would or do include contact with a client must include a printed or electronic copy of the results of the initial and annual searches of the MAR, if applicable, and the SEMARC established under Texas Health and Safety Code Chapter 810, in addition to the NAR. Updated language specifies that the rule is in accordance with §558.305, Standards for Electronic Record Maintenance and Storage; §558.259, Initial Educational Training in Administration of Agencies; and §558.260, Continuing Education in Administration of Agencies.

The proposed amendment to §558.247, Verification of Employability and Use of Unlicensed Persons, updates the section title to "Verification of Employability and Use of Persons as Employees, Volunteers, and Contractors." The amendment clarifies how an agency must conduct initial and annual verifications of employability for a person, including a check of the SEMARC, MAR, if applicable, and NAR and specifies the requirements of an initial criminal history check. The amendment implements Texas Health and Safety Code Chapter 810, which requires a HCSSA, as a designated user under §810.004(b)(1)(A), to conduct a search of SEMARC to determine whether an individual who may have access to a client has engaged in reportable conduct and, if the individual has engaged in reportable conduct, whether the individual is ineligible for employment, a volunteer position, or a contract with the agency. The amendment implements Texas Health and Safety Code §253.0025 in §558.247(h)(7) by adding the requirement for an agency to suspend the employment or contract of a person whom has engaged in reportable conduct while the person exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review conducted in accordance with Texas Health and Safety Code §253.004 or §253.005, pending a final decision by an administrative law judge. The updated language also provides guidelines for hiring on a temporary or interim basis in an emergency when background checks are pending and provides the criteria for the immediate hire as permitted by Texas Health and Safety Code Chapter 250. The amendment deletes language that is outdated.

The proposed amendment to §558.248, Volunteers, provides guidance on which roles agencies can place volunteers in.

The proposed amendment to §558.249, Self-Reported Incidents of Abuse, Neglect, and Exploitation, updates the section title to "Incidents of Abuse, Neglect, and Exploitation." The amendment deletes the requirement for an agency to report abuse, neglect, and exploitation to DFPS and instead requires reporting to HHSC. Additionally, the definitions for "abuse," "neglect," and "exploitation" have been included in the definitions section §558.2; therefore, the amendment deletes the references to 26 TAC Chapter 711 and 40 TAC Chapter 705 that initially assigned meanings to those definitions. The proposed amendment also clarifies that to report abuse "immediately" means to report it no later than one hour after suspecting or learning of the incident.

The proposed amendment to §558.250, Agency Investigations, clarifies what information must be included in the HHSC Provider Investigation Report and includes two examples of retaliatory actions.

Proposed new §558.251, Reporting Abuse, Neglect, and Exploitation, requires each employee, contractor, volunteer, client, and legally authorized representative be trained and are knowledgeable on how to protect from and report abuse, neglect, and exploitation (ANE). The rule further states that each employee, contractor, and volunteer sign an acknowledgement that clients are to be free from ANE and that each employee, contractor, and volunteer understand that they may be criminally liable under Texas Human Resources Code Chapter 48 for failure to report suspected ANE.

The proposed repeal of §558.251 deletes the rule as no longer necessary because the content of the rule has been added to proposed new §558.261 and will allow for proposed new §558.251, Reporting Abuse, Neglect, and Exploitation.

The proposed amendment to §558.252, Financial Solvency and Business Records, clarifies that an agency must have sufficient funds to cover all planned services for clients receiving care. The amendment specifies that an agency must maintain business records either in hardcopy or electric form.

The proposed amendment to §558.256, Emergency Preparedness Planning and Implementation, clarifies the requirement that if a client, whom the agency identifies may need evacuation assistance, wants to register with the State of Texas Emergency Assistance Registry (STEAR), the agency must provide the client with the amount of assistance the client requests to complete the registration process for evacuation assistance if STEAR is available in the service area. The amendment removes the option to fax information and updates a reference.

The proposed amendment to §558.257, Medicare Certification Optional, clarifies the requirement that HHSC must receive written approval from CMS via the Medicare Administrative Contractor before amending the licensing status of an agency to include certified home health services to its category of service and before HHSC entering the hospice provider number into the online portal.

The proposed amendment to §558.259, Initial Educational Training in Administration of Agencies, clarifies that the section applies to all newly designated administrators and alternate administrators. The proposed amendment specifies who is considered a newly designated administrator or alternate administrator, outlines the timeframe to complete the 24 hours of educational training, and clarifies the agency's requirement for documentation of administrator and alternate administrator training. The amendment removes language stating the initial educational training must be approved by HHSC or recognized by a state or national organization or association.

The proposed amendment to §558.260, Continuing Education in Administration of Agencies, clarifies that the section applies to all administrators and alternate administrators in the second through subsequent years of designation to the position. The proposed amendment specifies that an administrator or alternate administrator with a break in designation longer than 12 months from the date of the administrator or alternate administrator's last designation to the position is considered a newly designated administrator and clarifies the requirements for what topics the 12 hours of continuing education must include. The amendment also deletes language that is outdated.

Proposed new §558.261, Peer Review, moves the repealed peer review language from §558.251 into this section. This was done to allow the new §558.251, Reporting Abuse, Neglect and Exploitation to follow §558.249, Incidents of Abuse, Neglect and Exploitation and §558.250, Agency Investigations.

Subchapter C, Minimum Standards for All Home and Community Support Services Agencies

Division 4, Provision and Coordination of Treatment Services

The proposed amendment to §558.281, Client Care Policies, provides clarity to the elements that must be included in the agency's written policy that specifies client care practices.

The proposed amendment to §558.282, Client Conduct and Responsibility and Client Rights, adds a provision that at the time of admission, an agency must provide the client a handout regarding the client's rights. The amendment also adds clarity to some of the provisions outlined for client rights.

The proposed amendment to §558.283, Advance Directives, adds clarity to provisions that outline what must be included in a written policy regarding implementation of advance directives. The amendment also removes the provision that assesses a $500 administrative penalty for a violation of this section without an opportunity to correct.

The proposed amendment to §558.285, Infection Control, adds a provision that an agency's written infection control policy must address measures the agency will take to prevent the spread of communicable and infectious diseases, including the usage of personal protective equipment. The proposed amendment also states that an agency must designate an infection control officer and outlines what is required of the job position.

The proposed amendment to §558.287, Quality Assessment and Performance Improvement, adds clarity to provisions that outline what must be included in the quality assessment and performance improvement (QAPI) program and the frequency of the QAPI Committee meeting.

The proposed amendment to §558.288, Coordination of Services, states that coordination of services among an agency and all providers of teleservices must be included in an agency's adopted and enforced written policy. The proposed amendment also provides that if the agency will provide temporary services for a client who is traveling, it must adopt and enforce a written policy regarding the coordination of service delivery on a temporary basis.

The proposed amendment to §558.289, Independent Contractors and Arranged Services, adds a requirement to ensure that the agency or the contracting agency or organization conduct MAR, NAR, and SEMARC checks of unlicensed persons. The amendment also updates a reference.

The proposed amendment to §558.290, Backup Services and After-Hours Care, clarifies that for the purposes of this section, a client's designee is the individual that the client or client's legally authorized representative determines can provide services when the agency is unable to provide an employee, volunteer, or contractor. The proposed language clarifies the requirements for an agency's written policy to ensure that backup services are available when an agency employee or contractor is not available to deliver the services. The amendment also adds provisions related to when an agency must offer backup services.

The proposed amendment to §558.291, Agency Dissolution, updates a reference.

The proposed amendment to §558.292, Agency and Client Agreement and Disclosure, requires that a client's legally authorized representative also be provided a written agreement of services. The amendment also updates a reference.

The proposed amendment to §558.295, Client Transfer or Discharge Notification Requirements, updates language to specify that in the event of a discharge the agency must notify the client's primary care physician and includes that written notification may be provided via electronic correspondence that complies with the Health Insurance Portability and Accountability Act.

The proposed amendment to §558.297, Receipt of Physician Orders, updates the section title to "Receipt of Practitioner Orders." The amendment updates language to include practitioner. The amendment incorporates secure electronic transmission as a means to accept physician or practitioner orders.

Proposed new §558.304, Standards for Electronic Record Maintenance and Storage, adds language to ensure agencies maintain accuracy and confidentiality of electronic records and establish a system or arrangement for preservation of inactive electronic records.

Subchapter C, Minimum Standards for All Home and Community Support Services Agencies

Division 5, Branch Offices and Alternate Delivery Sites

The proposed amendment to §558.321, Standards for Branch Offices, updates language to incorporate online submission methods and states that all electronic records must be maintained in accordance with §558.305. The amendment also states that supervisory visits may be completed virtually with at least one on-site visit conducted quarterly and that all agency policy and procedures be readily accessible to both the parent agency and branch office.

The proposed amendment to §558.322, Standards for Alternate Delivery Sites, provides that all electronic records must be maintained in accordance with §558.305 and corrects a grammatical error.

Proposed new §558.323, Standards for Administrative Support Sites, states that a parent agency is responsible for ensuring that its administrative support site complies with licensing standards. The language outlines the reasons an administrative support site does not require a license or fee and specifies that should it deliver any home health, hospice, or personal assistance services from the location, it will be considered an operating a branch or alternate delivery site. The rule outlines which administrative office and support functions may be and must not be conducted from the administrative support site.

Subchapter C, Minimum Standards for All Home and Community Support Services Agencies

Division 6, Telehealth, Telemedicine, Telemonitoring, and Telecommunication

Proposed new Division 6 under Subchapter C, Telehealth, Telemedicine, Telemonitoring, and Telecommunication, outlines the applicability and general standards for an agency providing services via telehealth, telemedicine, telemonitoring, and telecommunications, also referred to throughout Subchapter C as teleservices.

Proposed new §558.330, Applicability, states that for an agency to provide teleservices, it must be licensed as a home health, licensed, and certified home health, or hospice category of service. The proposed rule also states that an agency cannot provide teleservices and be licensed with a category of personal assistance services only. The proposed rule also states that agencies that provide teleservices must identify the extent to which the services will be utilized in the admission agreement.

Proposed new §558.332, General Standards for Teleservices, states that an agency must evaluate the client, family supports, and environment to determine if teleservices are appropriate for and in line with the client's needs and goals of care and provides what that evaluation must include. The rule specifies that an agency conducting a client's initial assessment, comprehensive assessment, or reassessment must ensure all aspects of the assessment can be accurately evaluated via teleservices and that if risk is identified to the client's health or safety during an assessment via teleservices, then an in-home visit must be completed. The rule states that employees and contractors who provide teleservices must meet all conditions for employment or contracting in accordance with §558.245. The rule specifies that teleservices must be conducted in a language and manner the client can understand, which may require the agency locate and coordinate with an interpreter or translator. The rule outlines how an agency must initially evaluate if teleservices are appropriate for a client and includes what an agency must assess in its annual evaluations of the teleservices program. The rule details that the agency must not require that the client accept teleservices if the client's preferred service delivery method is in-person and in-person services are available. The rule specifies that if the client's needs and goals are not being met using teleservices, then the agency must reevaluate the service delivery method for that client. The rule details that if an agency is unable to meet a client's needs, it must document its concerns and follow transfer and discharge requirements as applicable. The rule states that an agency must adopt and enforce policies and procedures related to the use of teleservices and identify who must be trained on the policies and procedures and how often they must complete the training.

Proposed new §558.334, Standards for Telehealth and Telemedicine, states that agency staff or contractors providing telemedicine and telehealth services must follow any state and federal requirements regarding the use of these services as dictated by the agency staff or contractors' applicable licensing boards, Texas Occupations Code, or TAC. The rule also states that agency staff or contractors providing telemedicine or telehealth services must maintain confidentiality of protected health information per federal and state law.

Proposed new §558.336, Standards for Telemonitoring, states that telemonitoring must be ordered by the primary care physician and must include the condition to be monitored, how often it must be monitored, any applicable parameters, and any additional instructions required as part of the telemonitoring. The rule states that the agency must adopt and enforce a policy for the delivery, installation, maintenance, and monitoring of the telemonitoring equipment. The rule requires the agency to comply with §558.247 and §558.289 if the agency uses contractor services to provide equipment delivery, installation, maintenance, or monitoring. The proposed rule outlines who the agency must provide education to on the use of home telemonitoring equipment. The rule states that a registered nurse must review any transmitted clinical data at intervals consistent with the client's needs and goals set by his or her physician, but provides that the agency may use a licensed vocational nurse to assist the registered nurse in providing nursing telemonitoring services. The rule requires the agency to maintain documentation of telemonitoring visits and data and establishes the need for further evaluation of goals and outcomes in the client's record, in addition to the requirements in §558.301.

Proposed new §558.338, Standards for Telecommunications, states that agency policies, procedures, contracting agreements, medical records, practitioner's orders, and arranged services agreements may be sent and received electronically. The rule states if an agency provides client admission, discharge, or required notifications via telecommunication or electronic correspondence, it must confirm receipt of the information with the client or the client's legally authorized representative. The language outlines which documents and notifications can be provided via telecommunications or electronic correspondence and the requirements that must be met should the agency choose to communicate this way.

Subchapter D, Additional Standards Specific to License Category and Specific to Special Services

The proposed amendment to §558.401, Standards Specific to Licensed Home Health Services, updates the rule to specify what the admission of a client must be based on and provides that it is the responsibility of the agency to communicate with the client's primary care physician or practitioner regarding any needs the agency will be unable to meet. The amendment specifies that the initial health assessment may be performed either in-person or via teleservices. The amendment specifies that services must be based on the orders of the primary care physician or practitioner and details who must prepare a care plan when a practitioner has not ordered skilled care for a client. The amendment specifies who must be consulted in the development of the care plan.

The proposed amendment to §558.404, Standards Specific to Agencies Licensed to Provide Personal Assistance Services, updates the rule to include that a personal assistance services agency must not provide nursing or skilled services to its clients and that a registered nurse must not perform nursing tasks identified by the Nurse Practice Act §301.002 as part of personal assistance services. The amendment outlines the limitation of nursing services that are to be performed by a registered nurse employed by a personal assistance services agency and states that a registered nurse must ensure that skills performed by unlicensed personnel as part of tube feedings and medication administration through a permanently placed gastrostomy tube are completed as outlined by Texas Board of Nursing rules and the memorandum of understanding between HHSC and the Texas Board of Nursing. The amendment also states that a registered nurse may determine through an in-person assessment which health-related tasks do not require delegation and details the steps to be taken should the task require delegation.

The proposed amendment to §558.405, Standards Specific to Agencies Licensed to Provide Home Dialysis Services, adds language to include "practitioner" as well as primary care physician to maintain consistency within the rules. The amendment also updates a reference, corrects date errors, and deletes old language.

Subchapter E, Licensure Surveys

Division 1, General

The proposed amendment to §558.501, Survey and Investigation Frequency, provides that HHSC conducts a Life Safety Code survey before issuing a license for an initial parent agency or alternate delivery site with a category of hospice services with an inpatient unit and otherwise clarifies HHSC authority.

The proposed amendment to §558.503, Exemption From a Survey, updates the section title to "Accreditation Process and Exemption from a Survey." The amendment states that all accreditation organizations with current HHSC approval will be listed on the HCSSA website. The amendment outlines the requirements that an agency must meet if it seeks exemption from a licensing survey via accreditation and provides that the agency must maintain documentation of accreditation organization surveys and outcomes available to be reviewed by HHSC as necessary.

The proposed amendment to §558.507, Agency Cooperation with a Survey, updates references and makes minor editing changes.

Proposed new §558.510, Prioritization of Abuse, Neglect, and Exploitation Investigations, provides an explanation of prioritization timeframes for investigations of abuse, neglect, and exploitation. The new rule also provides an overview of the investigation process.

Subchapter E, Licensure Surveys

Division 2, The Survey Process

The proposed amendment updates the title of the subchapter to "Licensure Surveys and Investigations of Abuse, Neglect, and Exploitation"

The proposed amendment to §558.521, Requirements for an Initial Survey, states an agency's inability to receive payer source authorization or contract for services does not alleviate the agency's responsibility to submit the letter of readiness within the required six months. The amendment also clarifies when the agency must admit and provide hospice services, per category of service or designation, after the effective date of an agency's initial license. The proposed amendment also clarifies that HHSC may take enforcement action if an agency fails to admit and provide services to at least one client within six months of the issuance of an agency's initial license. The amendment removes subsection (g) because the information has been relocated in §558.503.

The proposed amendment to §558.523, Personnel Requirements for a Survey, clarifies existing language to update references and adds additional forms of communication that may be used to contact the administrator, alternate administrator, supervising nurse, or alternate supervising nurse.

The proposed amendment to §558.525, Survey Procedures, clarifies that during a survey, an HHSC representative conducts at least three visits to a hospice inpatient unit to determine compliance with licensing requirements and conducts interviews with clients, staff, contractors, volunteers, and others, as applicable.

Proposed new §558.527, Plan of Removal, states that during an on-site inspection, if HHSC finds that a violation has created an immediate threat to the health and safety of a client, the agency must submit a plan of removal. The amendment also outlines what the plan of removal must include.

The proposed repeal of §558.527, Post-Survey Procedures, deletes the rule as no longer necessary, because the content of the rule has been added to proposed new §558.529 and will allow for the proposed new §558.527, Plan of Removal.

Proposed new §558.529, Post-Survey Procedures, relocates the rule from proposed repealed subsection of §558.527 with non-substantive editorial changes. The rule informs agencies on the post-survey procedures including protocols for the exit conference, identification of violations following the exit conference, plan of correction by the agency and requesting an informal dispute resolution.

Subchapter F, Enforcement

The proposed amendment to §558.601, Enforcement Actions, adds requirements an agency must follow upon dissolution. The amendment updates references and makes non-substantive editorial changes.

The proposed amendment to §558.602, Administrative Penalties, updates the Severity Level A and B Violations chart figures by revising the rule citations and subject matter based on the amendments, repeals, and new rules in this proposal. The amendment also updates references.

The proposed amendment to §558.604, Surrender or Expiration of a License, adds provisions clarifying the actions HHSC will take if the agency either surrenders its license or allows its license to expire in lieu of paying the administrative penalty.

Subchapter G, Home Health Aides

The proposed amendment to §558.701, Home Health Aides, updates language to include a pseudo-person for use during an aide's performance evaluation and adds that agency training may be conducted virtually so long as the registered nurse or licensed vocational nurse ensures competencies are demonstrated and evaluated in person.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 1, Hospice General Provisions

The proposed amendment to §558.801, Subchapter H Applicability, requires a statement be in the client's record to specify that the start of hospice care begins on the effective date.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 2, Initial and Comprehensive Assessment of a Hospice

The proposed amendment to §558.812, Update of the Hospice Comprehensive Assessment, provides that the hospice interdisciplinary team may meet in-person or virtually if virtual meetings are effective for the purpose of the discussion.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 3, Hospice Interdisciplinary Team, Care Planning, and Coordination of Services

The proposed amendment to §558.823, Coordination of Services by the Hospice, updates the rule to incorporate communication and integration via teleservices, which supports modernization.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 4, Hospice Core Services

The proposed amendment to §558.834, Hospice Counseling Services, makes a non-substantive edit.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 5, Hospice Non-Core Services

The proposed amendment to §558.843, Hospice Aide Qualifications, adds the option for a hospice aide to be evaluated by a registered nurse using a pseudo-person or person in addition to a client to maintain consistency with the rules.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 6, Hospice Organization and Administration of Services

The proposed amendment to §558.857, Hospice Staff Training, adds provisions clarifying what a hospice must include in its staff orientation training.

The proposed amendment to §558.859, Hospice Discharge or Transfer of Care, adds language to include "practitioner" to maintain consistency within the rules.

The proposed amendment to §558.861, Management of Drugs and Biologicals and Disposal of Controlled Substance Prescription Drugs in a Client's Home or Community Setting, adds language to include "practitioner" instead of physician to maintain consistency within the rules. "Physician assistant" and "prescribing practitioner" were also added to expand authority.

The proposed amendment to §558.862, Management of Drugs and Biologicals and Disposal of Controlled Substance Prescription Drugs in an Inpatient Hospice Unit, adds language to include "practitioner" instead of physician to maintain consistency within the rules and makes minor editing changes.

The proposed amendment to §558.863, Hospice Short-term Inpatient Care, updates references.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 7, Hospice Inpatient Units

The title of Division 7 is updated to "Inpatient Units."

The proposed amendment to §558.870, Staffing in a Hospice Inpatient Unit, includes non-substantive edits.

The proposed repeal of §558.871, Physical Environment in a Hospice Inpatient Unit, deletes the rule as no longer necessary because the content of the rule has been added to proposed new Division 9 under subchapter H.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 8, Hospices that Provide Hospice Care to Residents of a Skilled Nursing Facility, Nursing Facility, or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions

The proposed amendment to §558.880, Providing Hospice Care to a Resident of a Skilled Nursing Facility, Nursing Facility, or Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions, includes non-substantive editorial changes.

Subchapter H, Standards Specific to Agencies Licensed to Provide Hospice Services

Division 9, Physical Environment in a Hospice Inpatient Unit

Proposed new §558.914, Safety Management, moves the repealed safety management language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section outlines the responsibility of the inpatient unit to identify possible dangers to the health and safety of clients, and to ensure the creation of a written disaster preparedness plan that includes procedures for designating the staff responsible for carrying out evacuation or sheltering in place protocols that are outlined in the section.

Proposed new §558.916, Physical Plant and Equipment, moves the repealed safety management language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section provides regulations regarding the disposal of trash and medical waste, light, temperature, ventilation, gas and water supply and scheduled and emergency maintenance for equipment.

Proposed new §558.918, Fire Protection, moves the repealed fire protection language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must meet the applicable requirements of the health care occupancy chapters in National Fire Protection Association, 101 and reflects updated National Fire Protection Association, Life Safety Code, 2012 edition (NFPA 101).

Proposed new §558.928, Client Areas, moves the repealed client areas language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must provide a home-like atmosphere and what that entails.

Proposed new §558.930, Client Rooms, moves the repealed client rooms language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must ensure that each client room is designed and equipped to support nursing care and to maintain the dignity, comfort, and privacy of each client when possible and what that entails.

Proposed new §558.932, Plumbing Facilities, moves the repealed plumbing facilities language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs inpatient unit that the inpatient unit must maintain a continuous supply of hot water and install plumbing fixtures equipped with control valves designed to automatically regulate hot water temperatures for client use.

Proposed new §558.936, Infection Control, moves the repealed infection control language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs inpatient unit that the inpatient unit must have an infection control program designed to prevent and control infections and communicable diseases.

Proposed new §558.940, Sanitary Environment, moves the repealed sanitary environment language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must maintain a sanitary environment by following accepted standards of practice and prevent sources and transmission of infections and communicable diseases.

Proposed new §558.942, Linen, moves the repealed linen language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must maintain a sufficient supply of clean linen for client use at all times and that they must handle, transport, and store linens in a way that prevents the spread of contaminants.

Proposed new §558.944, Meal Service and Menu Planning, moves the repealed meal service and menu planning language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must provide meals for clients and outlines requirements for those meals.

Proposed new §558.946, Use of Restraint or Seclusion, moves the repealed use of restraint or seclusion language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that clients have the right to be free from restraint or seclusion and provides requirements for when and how restraint and seclusion may be used.

Proposed new §558.948, Restraint or Seclusion Staff Training Requirements, moves the repealed restraint or seclusion staff training requirements language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must ensure that client care staff are trained and able to demonstrate competency in the application of restraints and implementation of seclusions and what competencies they must demonstrate.

Proposed new §558.950, Death Reporting Requirements Associated with the Seclusion or Restraint in a Hospice Inpatient, moves the repealed death reporting requirements associated with the seclusion or restraint in a hospice inpatient language from §558.871 into this section. This is based on an HHSC initiative to structure the physical environment requirements for hospice inpatient by section for easy reference instead of listing all the requirements in one section as they were previously. This section informs the inpatient unit that the inpatient unit must report deaths associated with the use of restraint or seclusion and the protocols they must follow to do so.

FISCAL NOTE

Victoria Grady, Deputy Chief, Finance, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules there will be an estimated increase in revenue to state government as a result of enforcing and administering the rules as proposed. Enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of local government.

There is an expected increase in revenue for state government due to the additional fees HHSC may collect from HCSSAs for security violations. The new security violations could result in a fee between $100 - $1000 per violation. However, HHSC is unable to determine the exact increase in revenue because it is unknown how many security violations will be assessed on HCSSAs and the range in fee amount varies based on the level of security violation.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of HHSC employee positions;

(3) implementation of the proposed rules results in no assumed change in future legislative appropriations;

(4) the proposed rules will affect fees paid to HHSC;

(5) the proposed rules will create a new regulation;

(6) the proposed rules will expand and repeal existing regulations;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) HHSC has insufficient information to determine the proposed rules' effect on the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Victoria Grady has also determined that there could be an adverse economic effect on a HCSSA that is a small business, micro-business, or rural community. A HCSSA may incur a cost if the agency suspends an agency staff person while due process takes place for being reported to the SEMARC. A HCSSA may need to hire additional staff on a temporary basis while the staff person is on suspension. In addition, HCSSAs may incur additional fees for new security violations implemented as a result of the proposed rules.

HHSC lacks sufficient information to estimate the number of HCSSAs that are small businesses, micro-businesses, or rural communities.

HHSC determined that alternative methods to achieve the purpose of proposed rules for small businesses, micro-businesses, or rural communities would not be consistent with ensuring the health and safety of persons receiving services from a HCSSA and because the content of the rule is necessary to implement HB 1009.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules are necessary to protect the health, safety, and welfare of the residents of Texas and implement legislation that does not specifically state that §2001.0045 applies to the rules.

PUBLIC BENEFIT AND COSTS

David Kostroun, Chief Regulatory Services Officer, has determined that for each year of the first five years the rules are in effect, the public benefit will be the clear and efficient process for applying for a HCSSA license, clarification of regulations related to teleservices and electronic records, and use of updated citations to reflect current industry practices.

Victoria Grady has also determined that for the first five years the rules are in effect, persons who are required to comply with the proposed rules may incur economic costs because suspending an agency staff person while the person goes through due process may require a HCSSA to hire additional staff on a temporary basis while the staff person is on suspension. In addition, HCSSAs may incur additional fees for new security violations implemented as a result of the proposed rules.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does 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, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal, including information related to the cost, benefit, or effect of the proposed rule, as well as any applicable data, research, or analysis, may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 4601 West Guadalupe Street, Austin, TX 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 22R045" in the subject line.

SUBCHAPTER A. GENERAL PROVISIONS

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Health and Safety Code §142.0011(b) and §142.012(a) which authorize the executive commissioner of HHSC to adopt rules relating to the quality of care and life of agency clients and that are necessary to implement Texas Health and Safety Code Chapter 142; and Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, that require HHSC to adopt rules governing the investigations of ANE.

The amendments affect Texas Government Code §524.0151; Texas Health and Safety Code Chapter 142; Texas Human Resources Code Chapter 48, Subchapter F; and Texas Family Code §261.404.

§558.1. Purpose and Scope.

(a) Purpose.

(1) The purpose of this chapter is to implement:

(A) [implement] Texas Health and Safety Code[,] Chapter 142, which requires the Texas Health and Human Services Commission (HHSC) to adopt minimum standards that a person must meet in order to be licensed as a home and community support services agency (HCSSA) and also to qualify to provide certified home health services; these[. The] requirements serve as a basis for licensure and survey activities.

(2) Except as provided by Texas Health and Safety Code §142.003 [(relating to Exemptions from Licensing Requirement)], a person, including a health care facility licensed under the Texas Health and Safety Code, may not engage in the business of providing home health, hospice, or personal assistance services (PAS), or represent to the public that the person is a provider of home health, hospice, or PAS for pay without a HCSSA license authorizing the person to perform those services issued by HHSC for each place of business from which home health, hospice, or PAS is directed. A certified HCSSA must have a license to provide certified home health services.

(b) Scope. This chapter establishes the minimum standards for acceptable quality of care. A violation of a minimum standard established by Texas Health and Safety Code Chapter 142, or by a rule adopted under that chapter, is a violation of law. The rules in this chapter are adopted to protect clients of HCSSAs by establishing minimum standards relating to quality of care and quality of life.

(c) Limitations. Requirements established by private or public funding sources such as health maintenance organizations or other private third-party insurance, Medicaid (42 United States Code (U.S.C.) [(USC)] Chapter 7, Subchapter XIX), Medicare (42 U.S.C [USC] Chapter 7, Subchapter XVIII), or state-sponsored funding programs are separate and apart from the requirements in this chapter for agencies. No matter what funding sources or requirements apply to an agency, the agency must still comply with the applicable provisions in the statute [Statute] and this chapter. The agency is responsible for researching availability of any funding source to cover a service provided by the agency.

§558.2. Definitions.

The following [words and] terms[, when used] in this chapter[,] have the following meanings, unless the context clearly indicates otherwise.

(2) [(1)] Accessible and flexible services--Services that are delivered in the least intrusive manner possible and are provided in all settings where individuals live, work, and recreate.

(4) [(2)] Accreditation organization--An accrediting entity approved by HHSC that shows its accreditation standards meet or are higher than the rule requirements for licensing under Texas Health and Safety Code Chapter 142 and this chapter. The entity reviews a HCSSA to ensure the HCSSA follows the accreditation organization's standards for the HCSSA's licensed service category. [The Joint Commission, Community Health Accreditation Partner, Accreditation Commission for Health Care, Inc., or another accrediting entity approved by HHSC that demonstrates it meets or exceeds applicable rule requirements of this chapter. The entity reviews HCSSAs for compliance with standards for accreditation by the organization that apply to a HCSSA's licensed category of service.]

(5) [(3)] Administration of medication--The direct application of any medication by injection, inhalation, ingestion, or any other means to the body of a client. The preparation of medication is part of the administration of medication and is the act or process of making ready a medication for administration, including:

(A) the calculation of a client's medication dosage;

(B) altering the form of the medication by crushing, dissolving, or any other method;

(C) reconstitution of an injectable medication;

(D) drawing an injectable medication into a syringe;

(E) preparing an intravenous admixture; or

(F) any other act required to render the medication ready for administration.

(6) [(4)] Administrative support site--A facility or site (also referred to as a drop site) where an agency performs administrative and other support functions but does not provide direct home health, hospice, or personal assistance services. This site does not require an agency license.

(7) [(5)] Administrator--The person who is responsible for implementing and supervising the administrative policies [polices] and operations of a home and community support services agency and for administratively supervising the provision of all services to agency clients on a day-to-day basis.

(8) [(6)] ADS--Alternate delivery site. A facility or site, including a residential unit or an inpatient unit:

(A) that is owned or operated by an agency providing hospice services;

(B) that is not the hospice's parent agency;

(C) that is located in the geographical area served by the hospice; and

(D) from which the hospice provides hospice services.

(9) [(7)] Advanced practice nurse--An advanced practice registered nurse.

(10) [(8)] Advanced practice registered nurse--A person licensed by the Texas Board of Nursing as an advanced practice registered nurse. The term is synonymous with "advanced practice nurse."

(11) [(9)] Advisory committee--A committee, board, commission, council, conference, panel, task force, or other similar group, or any subcommittee or other subgroup, established for the purpose of obtaining advice or recommendations on issues or policies that are within the scope of a person's responsibility.

(12) [(10)] Affiliate--With respect to an applicant or license holder that is:

(A) a corporation--[means each officer, director, and stockholder with direct ownership of at least 5.0 percent, subsidiary, and parent company;]

(B) a limited liability company--[means] each officer, member, and parent company;

(C) an individual--[means:]

(i) the individual's spouse;

(ii) each partnership and each partner thereof of which the individual or any affiliate of the individual is a partner; and

(iii) each corporation in which the individual is an officer, director, or stockholder with a direct ownership or disclosable interest of at least 5.0 percent;[.]

(D) a partnership--[means] each partner and any parent company; and

(E) a group of co-owners under any other business arrangement--[means] each officer, director, or the equivalent under the specific business arrangement and each parent company.

(13) [(11)] Agency--A HCSSA.

(14) [(12)] Applicant--The owner of an agency that is applying for a license under the statute [Statute]. This is the person in whose name the license will be issued.

(16) [(14)] Association--A partnership, limited liability company, or other business entity that is not a corporation.

(18) [(15)] Audiologist--A person who is currently licensed under the Texas Occupations Code[,] Chapter 401, as an audiologist.

(19) [(16)] Bereavement--The process by which a survivor of a deceased person mourns and experiences grief.

(20) [(17)] Bereavement services--Emotional, psychosocial, and spiritual support [Support] services offered to a family before and up to one year after the client's death [during bereavement]. Services may be provided to persons other than family members, including residents of a skilled nursing facility, nursing facility, or intermediate care facility for individuals with an intellectual disability or related conditions, assisted living facility, or inpatient unit, when appropriate and identified in a bereavement plan of care.

(21) [(18)] Biologicals--A medicinal preparation made from living organisms and [their] products of living organisms, including serums, vaccines, antigens, and antitoxins.

(22) [(19)] Boarding home facility--An establishment defined in Texas Health and Safety Code §260.001(2).

(23) [(20)] Branch office--A facility or site in the service area of a parent agency from which home health or personal assistance services are delivered or where active client records are maintained. This does not include inactive records that are stored at an unlicensed site.

(24) [(21)] Care plan--

(A) A [a] written plan prepared by the appropriate health care professional for a client of the home and community support services agency; or

(B) for home dialysis designation, a written plan developed by the physician, registered nurse, dietitian, and qualified social worker to personalize the care for the client and enable long- and short-term goals to be met.

(25) [(22)] Case conference--A meeting [conference] among personnel furnishing services to the client to ensure that the [their] efforts are coordinated effectively and support the objectives outlined in the plan of care or care plan.

(26) [(23)] Certified agency--A home and community support services agency, or portion of the agency, that:

(A) provides a home health service or hospice service; and

(B) is certified by an official of the U.S. Department of Health and Human Services as in compliance with Medicare conditions of participation in 42 United States Code (U.S.C.) [USC] Chapter 7, Subchapter XVIII.

(27) [(24)] Certified home health services--Home health services that are provided by a certified agency.

(28) [(25)] CFR--Code of Federal Regulations. The regulations and rules promulgated by agencies of the Federal government that address a broad range of subjects, including hospice care and home health services.

(29) [(26)] Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of an agency. The substitution of a personal representative for a deceased license holder is not a change of ownership.

(30) [(27)] Chief financial officer--An individual who is responsible for supervising and managing all financial activities for a HCSSA [home and community support services agency].

(31) [(28)] Client--An individual receiving home health, hospice, or personal assistance services from a licensed HCSSA [home and community support services agency]. This term includes each member of the primary client's family if the member is receiving ongoing services. This term does not include the spouse, significant other, or other family member living with the client who receives a one-time service (for example, vaccination) if the spouse, significant other, or other family member receives the service in connection with the care of a client.

(32) [(29)] Clinical note--A dated and signed written notation by agency personnel of a contact with a client containing a description of signs and symptoms; treatment and medication given; the client's reaction; other health services provided; and any changes in physical and emotional condition.

(33) [(30)] CMS--Centers for Medicare & Medicaid Services. The federal agency that administers the Medicare program and works in partnership with the states to administer Medicaid.

(34) [(32)] Community disaster resources--A local, statewide, or nationwide emergency system that provides information and resources during a disaster, including weather information, transportation, evacuation, and shelter information, disaster assistance and recovery efforts, evacuee and disaster victim resources, and resources for locating evacuated friends and relatives.

(36) [(33)] Controlled substance--As defined [Has the meaning assigned] in Texas Health and Safety Code Chapter 481, Subchapter A.

(37) [(34)] Controlling person--A person with the ability, acting alone or with others, to directly or indirectly influence, direct, or cause the direction of the management, expenditure of money, or policies of an agency or other person.

(A) A controlling person includes:

(i) a management company or other business entity that operates or contracts with others for the operation of an agency;

(ii) a person who is a controlling person of a management company or other business entity that operates an agency or that contracts with another person for the operation of an agency; and

(iii) any other individual who, because of a personal, familial, or other relationship with the owner, manager, or provider of an agency, is in a position of actual control or authority with respect to the agency, without regard to whether the individual is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the agency.

(B) A controlling person, as described by subparagraph (A)(iii) of this paragraph, does not include an employee, lender, secured creditor, or other person who does not exercise formal or actual influence or control over the operation of an agency.

(38) [(35)] Conviction--An adjudication of guilt based on a finding of guilt, a plea of guilty, or a plea of nolo contendere.

(39) [(36)] Counselor--An individual qualified under Medicare standards to provide counseling services, including bereavement, dietary, spiritual, and other counseling services to both the client and the family.

(41) [(37)] Day--A [Any reference to a day means a] calendar day, unless otherwise specified in the text. A calendar day includes weekends and holidays.

(42) [(38)] Deficiency--A finding of noncompliance with federal requirements resulting from a survey.

(43) [(39)] Designated survey office--An HHSC HCSSA program [Program] office located in an agency's geographic region.

(44) [(40)] Dialysis treatment record--For home dialysis designation, a dated and signed written notation by the person providing dialysis treatment, which contains a description of signs and symptoms, machine parameters and pressure settings, type of dialyzer and dialysate, actual pre- and post-treatment weight, medications administered as part of the treatment, and the client's response to treatment.

(45) [(41)] Dietitian--A person who is currently licensed under the laws of the State of Texas to use the title of licensed dietitian or provisional licensed dietitian, or who is a registered dietitian.

(46) [(42)] Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.

(47) [(43)] Disaster--The occurrence or imminent threat of widespread or severe damage, injury, or loss of life or property resulting from a natural or man-made cause, such as fire, flood, earthquake, wind, storm, wave action, oil spill or other water contamination, epidemic, air contamination, infestation, explosion, riot, hostile military or paramilitary action, or energy emergency. In a hospice inpatient unit, a disaster also includes failure of the heating or cooling system, power outage, explosion, and bomb threat.

(48) [(44)] Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.

(52) [(45)] ESRD--End stage renal disease. For home dialysis designation, the stage of renal impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplantation to maintain life.

(55) [(46)] Functional need--Needs of the individual that require services without regard to diagnosis or label.

(56) [(47)] Habilitation--Services [Habilitation services], as defined by Texas Government Code §542.0001 [§534.001], provided by an agency licensed under this chapter.

(57) [(48)] HCSSA--Home and community support services agency. A person who provides home health, hospice, or personal assistance services for pay or other consideration in a client's residence, an independent living environment, or another appropriate location.

(58) [(49)] Health assessment--A determination of a client's physical and mental status through inventory of systems.

(63) [(51)] Home health aide--An individual working for an agency who meets at least one of the requirements for home health aides as described in §558.701 of this chapter (relating to Home Health Aides).

(64) [(52)] Home health medication aide--An unlicensed person issued a permit by HHSC to administer medication to a client under Texas Health and Safety Code Chapter 142, Subchapter B.

(65) [(53)] Home health service--The provision of one or more of the following health services required by an individual in a residence or independent living environment:

(A) nursing, including blood pressure monitoring and diabetes treatment;

(B) physical, occupational, speech, or respiratory therapy;

(C) medical social service;

(D) intravenous therapy;

(E) dialysis;

(F) service provided by unlicensed personnel under the delegation or supervision of a licensed health professional;

(G) the furnishing of medical equipment and supplies, excluding drugs and medicines; or

(H) nutritional counseling.

(66) [(54)] Hospice--A person licensed under this chapter to provide hospice services, including a person who owns or operates a residential unit or an inpatient unit.

(67) [(55)] Hospice aide--A person working for an agency licensed to provide hospice services who meets the qualifications for a hospice aide, regardless of license or certification held by the individual, as described in §558.843 of this chapter (relating to Hospice Aide Qualifications).

(68) [(56)] Hospice homemaker--A person working for an agency licensed to provide hospice services who meets the qualifications described in §558.845 of this chapter (relating to Hospice Homemaker Qualifications).

(69) [(57)] Hospice services--Services, including services provided by employees without a license but under the supervision of a registered nurse or physical therapist, provided to a client or a client's family as part of a coordinated program that follows the rules in this chapter. [unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to a client or a client's family as part of a coordinated program consistent with the standards and rules adopted under this chapter.] These services include physical care and support services to optimize quality of life for terminally ill clients and the terminally ill client's [their] families that:

(A) are available 24 hours a day, seven days a week, during the last stages of illness, death, and bereavement;

(B) are provided by a medically directed interdisciplinary team; and

(C) may be provided in a home, nursing facility, residential unit, inpatient unit, or other residence according to need. These services do not include inpatient care normally provided in a licensed hospital to a terminally ill person who has not elected to be a hospice client.

(70) [(58)] IDR--Informal dispute resolution. An informal process that allows an agency to refute a violation or condition-level deficiency cited during a survey.

(73) [(59)] Independent living environment--A client's residence, which may include a group home, foster home, or boarding home facility, or other settings where a client participates in activities, including school, work, or church.

(74) [(60)] Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder.

(75) [(61)] Individual and family choice and control--Individuals and families who express preferences and make choices about how their support service needs are met.

(76) [(62)] Individualized service plan--A written plan prepared by the appropriate healthcare [health care] personnel or healthcare professional for a client of a HCSSA [home and community support services agency] licensed to provide personal assistance services.

(78) [(63)] Inpatient unit--A facility, also referred to as a hospice freestanding inpatient facility, that provides a continuum of medical or nursing care and other hospice services to clients admitted into the unit and that is in compliance with:

(A) the Medicare conditions of participation for inpatient units adopted under 42 U.S.C. [USC] Chapter 7, Subchapter XVIII; and

(B) standards adopted under this chapter.

(79) [(64)] Joint training--Training provided by HHSC at least semi-annually to HCSSAs [for home and community support services agencies] and HHSC representatives [surveyors] on subjects that address the 10 most commonly cited violations of federal or state law by HCSSAs [home and community support services agencies] as published in HHSC annual reports.

(80) [(65)] LAR--Legally authorized representative. A person authorized by law to act on behalf of a client regarding a matter described in this chapter, and may include:

(E) a surrogate decision-maker under Texas Health and Safety Code §313.004. [a parent of a minor, guardian of an adult or minor, managing conservator of a minor, agent under a medical power of attorney, or surrogate decision-maker under Texas Health and Safety Code §313.004.]

(81) [(66)] License holder--A person that holds a license to operate an agency.

(82) [(67)] Life Safety Code (also referred to as NFPA 101)--The Code for Safety to Life from Fire in Buildings and Structures, Standard 101, of the National Fire Protection Association (NFPA).

(83) [(68)] Local emergency management agencies--The local emergency management coordinator, fire, police, and emergency medical services.

(84) [(69)] Local emergency management coordinator--The person identified as the emergency management coordinator by the mayor or county judge in an agency's service area.

(85) [(70)] LVN--Licensed vocational nurse. A person who is currently licensed under Texas Occupations Code Chapter 301[,] as a licensed vocational nurse.

(86) [(71)] Manager--An employee or independent contractor responsible for providing management services to a HCSSA [home and community support services agency] for the overall operation of a HCSSA, [home and community support services agency] including administration, staffing, or delivery of services. Examples of contracts for services that will not be considered contracts for management services include contracts solely for maintenance, laundry, or food services.

(87) [(72)] Medication administration record--A record used to document the administration of a client's medications.

(88) [(73)] Medication list--A list that includes all prescription and over-the-counter medication that a client is currently taking, including the dosage, the frequency, and the method of administration.

(89) [(74)] Mitigation--An action taken to eliminate or reduce the probability of a disaster or reduce a disaster's severity or consequences.

(90) [(75)] Multiple location--A Medicare-approved ADS that meets the definition in 42 CFR §418.3.

(92) [(76)] Notarized copy--A sworn affidavit stating that attached copies are true and correct copies of the original documents.

(93) [(77)] Nursing facility--An institution licensed as a nursing home under Texas Health and Safety Code[,] Chapter 242.

(94) [(78)] Nutritional counseling--Advising and assisting individuals or families on appropriate nutritional intake by integrating information from the nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention, and nutrition education. Nutritional counseling may include the following:

(A) dialogue with the client to discuss current eating habits, exercise habits, food budget, and problems with food preparation;

(B) discussion of dietary needs to help the client understand why certain foods should be included or excluded from the client's diet and to help with adjustment to the new or revised or existing diet plan;

(C) a personalized written diet plan as ordered by the client's physician or practitioner, to include instructions for implementation;

(D) providing the client with motivation to help the client understand and appreciate the importance of the diet plan in getting and staying healthy; or

(E) working with the client or the client's family members by recommending ideas for meal planning, food budget planning, and appropriate food gifts.

(95) [(79)] Occupational therapist--A person who is currently licensed under the Texas Occupations Code Chapter 454[,] as an occupational therapist.

(96) [(80)] Online portal--A secure portal provided on the HHSC website for licensure activities, including for a HCSSA applicant to submit licensure applications and information.

(97) [(81)] Operating hours--The days of the week and the hours of day an agency's place of business is open as identified in an agency's written policy as required by §558.210 of this chapter (relating to Agency Place of Business and Operating Hours).

(98) [(82)] Original active client record--A record composed first-hand for a client currently receiving services.

(99) [(83)] Palliation [Palliative]--Ameliorating the symptoms associated with serious illness without the primary goal of curing an underlying condition.

(100) [(84)] Parent agency--An agency's principal place of business; the location where an agency develops and maintains administrative controls and provides supervision of branch offices and ADSs.

(101) [(85)] Parent company--A person, other than an individual, who has a direct 100 percent ownership interest in the owner of an agency.

(102) [(86)] Person--An individual, corporation, or association.

(103) [(87)] Personal assistance services--Routine ongoing care or services required by an individual in a residence or independent living environment that enable the individual to engage in the activities of daily living or to perform the physical functions required for independent living, including respite services. The term includes:

(A) personal care;

(B) health-related services performed under circumstances that are defined as not constituting the practice of professional nursing by the Texas Board of Nursing; and

(C) health-related tasks provided by unlicensed personnel under the delegation of a registered nurse or that a registered nurse determines do not require delegation.

(104) [(88)] Personal care--The provision of one or more of the following services required by an individual in a residence or independent living environment:

(A) bathing;

(B) dressing;

(C) grooming;

(D) feeding;

(E) exercising;

(F) toileting;

(G) positioning;

(H) assisting with self-administered medications;

(I) routine hair and skin care; and

(J) transfer or ambulation.

(105) [(89)] Pharmacist--A person who is licensed to practice pharmacy under Texas Occupations Code Chapter 558.

(106) [(90)] Pharmacy--A facility defined in Texas Occupations Code §551.003(31), at which a prescription drug or medication order is received, processed, or dispensed, and which holds a pharmacy license issued under Texas Occupations Code Title 3, Subtitle J.

(108) [(91)] Physical therapist--A person who is currently licensed under Texas Occupations Code Chapter 453[,] as a physical therapist.

(109) [(92)] Physician--This term includes a person who is:

(A) licensed in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code Chapter 155;

(B) licensed in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of a client and orders home health or hospice services for the client, in accordance with Texas Occupations Code §151.056(b)(4); or

(C) a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service, if the person is not engaged in private practice, in accordance with the Texas Occupations Code §151.052(a)(8).

(110) [(93)] Physician assistant--A person who is licensed under Texas Occupations Code Chapter 204[,] as a physician assistant.

(111) [(94)] Physician-delegated task--A task performed in accordance with Texas Occupations Code Chapter 157, including orders signed by a physician that specify the delegated task, individual to whom the task is delegated, and client's name.

(112) [(95)] Place of business--An office that is a physical location for maintaining client records and directing home health, hospice, or personal assistance services. This term includes a parent agency, branch office, inpatient unit, and ADS. This term does not include an administrative support site. [An office of a home and community support services agency that maintains client records or directs home health, hospice, or personal assistance services. This term includes a parent agency, a branch office, and an ADS. The term does not include an administrative support site.]

(113) [(96)] Plan of care--The written orders of a practitioner for a client who requires skilled services.

(114) [(97)] Practitioner--A person who is currently licensed in a state in which the person practices as a physician, dentist, podiatrist, or a physician assistant, or a person who is an RN registered with the Texas Board of Nursing as an advanced practice nurse.

(115) [(98)] Preparedness--Actions taken in anticipation of a disaster.

(118) [(99)] Presurvey training--A computer-based training provided by HHSC for the applicant or the applicant's representatives to review licensure standards and survey documents, and to provide information regarding the survey process.

(120) [(100)] Progress note--A dated and signed written notation by agency personnel summarizing facts about care and the client's response during a given period of time.

(122) [(101)] Psychoactive treatment--The provision of a skilled nursing visit to a client with a psychiatric diagnosis under the direction of a physician that includes one or more of the following:

(A) assessment of alterations in mental status or evidence of suicide ideation or tendencies;

(B) teaching coping mechanisms or skills;

(C) counseling activities; or

(D) evaluation of the plan of care.

(123) [(102)] Recovery--Activities implemented during and after a disaster response designed to return an agency to its normal operations as quickly as possible.

(124) [(103)] Registered nurse delegation--The delegation of nursing tasks to an unlicensed professional [Delegation by a registered nurse] in accordance with:

(A) 22 TAC Chapter 224 (relating to [concerning] Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments); and

(B) 22 TAC Chapter 225 [(relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions)].

(126) [(104)] Residence--A place where a person resides within the State of Texas, including a home, [a] nursing facility, [a] convalescent home, [or a] residential unit, homeless or emergency evacuation shelter, or tent encampment.

(127) [(105)] Residential unit--A facility that provides living quarters and hospice services to clients admitted into the unit and that is in compliance with standards adopted under Texas Health and Safety Code Chapter 142.

(128) [(106)] Respiratory therapist--A person who is currently licensed under Texas Occupations Code Chapter 604[,] as a respiratory care practitioner.

(129) [(107)] Respite services--Support options that are provided temporarily for the purpose of relief for a primary caregiver in providing care to individuals of all ages with disabilities or at risk of abuse or neglect.

(130) [(108)] Response--Actions taken immediately before an impending disaster or during and after a disaster to address the immediate and short-term effects of the disaster.

(131) [(109)] Restraint--A restraint is:

(A) a manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a client in an [a hospice] inpatient unit to move the client's [his or her] arms, legs, body, or head freely, but does not include a device, such as an orthopedically prescribed device, a surgical dressing or bandage, a protective helmet, or other method that involves the physical holding of the client for the purpose of:

(i) conducting a routine physical examination or test;

(ii) protecting the client from falling out of bed; or

(iii) permitting the client to participate in activities without the risk of physical harm, not including a physical escort; or

(B) a drug or medication when used as a restriction to manage a client's behavior or restrict the client's freedom of movement in an [a hospice] inpatient unit, but not as a standard treatment or medication dosage for the client's condition.

(132) [(110)] RN--Registered nurse. A person who is currently licensed under the Nursing Practice Act, Texas Occupations Code Chapter 301, as a registered nurse.

(133) [(111)] Seclusion--The involuntary confinement of a client alone in a room or an area in an [a hospice] inpatient unit from which the client is physically prevented from leaving.

(134) [(112)] Section--A reference to a specific rule in this chapter.

(135) [(113)] Service area--A geographic area established by an agency in which all or some of the agency's services are available.

(137) [(114)] Skilled services--Servicesprovided in accordance with a plan of care that require the skills of:

(A) an RN;

(B) an LVN;

(C) a physical therapist;

(D) an occupational therapist;

(E) a respiratory therapist;

(F) a speech-language pathologist;

(G) an audiologist;

(H) a social worker; or

(I) a dietitian.

(138) [(115)] Social worker--A person who is currently licensed as a social worker under Texas Occupations Code Chapter 505.

(139) [(116)] Speech-language pathologist--A person who is currently licensed as a speech-language pathologist under Texas Occupations Code Chapter 401.

(140) [(117)] Statute--Texas Health and Safety Code Chapter 142.

(142) [(119)] Supervised practical training--Hospice aide training that is conducted in a laboratory or other setting in which the trainee demonstrates knowledge while performing tasks on an individual. The training is supervised by an RN or by an LVN who works under the direction of an RN. [a registered nurse.]

(143) [(120)] Supervising nurse--The person responsible for supervising skilled services provided by an agency and who has the qualifications described in §558.244(c) of this chapter (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications). This person may also be known as the director of nursing or similar title.

(144) [(121)] Supervision--Authoritative procedural guidance by a qualified person for the accomplishment of a function or activity with initial direction and periodic inspection of the actual act of accomplishing the function or activity.

(145) [(122)] Supportive palliative care--Physician-directed interdisciplinary client [patient] and family-centered care provided to a client [patient] with a serious illness without regard to the client's [patient's] age or terminal prognosis that:

(A) may be provided concurrently with methods of treatment or therapies that seek to cure or minimize the effects of the client's [patient's] illness; and

(B) seek to optimize the quality of life for a client's [patient] with a life-threatening or life-limiting illness and the client's [patient's] family through various methods, including methods that seek to:

(i) anticipate, prevent, and treat the client's [patient's] total suffering related to the client's [patient's] physical, emotional, social, and spiritual condition;

(ii) address the physical, intellectual, emotional, cultural, social, and spiritual needs of the client [patient]; and

(iii) facilitate for the client [patient], regarding treatment options, education, informed consent, and expression of desires.

(146) [(123)] Support services--Social, spiritual, and emotional care provided to a client and a client's family by a hospice.

(147) [(124)] Survey--An [on-site] inspection or complaint investigation conducted by an HHSC representative to determine if an agency is in compliance with the statute [Statute] and this chapter or in compliance with applicable federal requirements or both.

(148) [(125)] TAC--Texas Administrative Code.

(154) [(126)] Terminal illness--An illness for which there is a limited prognosis if the illness runs its usual course.

(155) [(127)] Unlicensed person--A person not licensed as a healthcare [health care] provider. The term includes home health aides, hospice aides, hospice homemakers, medication aides permitted by HHSC, and other unlicensed individuals providing personal care or assistance in health services.

(156) [(128)] Unsatisfied judgments--A failure to fully carry out the terms or meet the obligation of a court's final disposition on the matters before it in a suit regarding the operation of an agency.

(159) [(129)] Violation--A finding of noncompliance with this chapter or the statute [Statute] resulting from a survey.

(160) [(130)] Volunteer--An individual who provides assistance to a HCSSA [home and community support services agency] without compensation other than reimbursement for actual expenses.

(162) [(131)] Working day--Any day except Saturday, Sunday, a state holiday, or a federal holiday.

§558.3. License Fees.

(a) The schedule of fees for licensure of an agency authorized to provide one or more services is as follows:

(1) initial (includes change of ownership) license fee--$2,625;

(2) renewal license fee for a three-year license--$2,625;

(3) [(4)] initial (includes change of ownership) branch office license fee--$2,625;

(4) [(5)] renewal branch office license fee for a three-year license--$2,625;

(5) [(7)] initial (includes change of ownership) ADS license fee-- $1,500; and [$1,000;]

(6) [(8)] renewal ADS license fee for a three-year license--$900.[; and]

(b) Separate fees for branch office and ADS licenses and renewals are required for each physical address. To renew a branch office or ADS license, the license holder [licensee] must submit the renewal application and payment in full through the online portal, of all applicable licensing fees, for each branch office and ADS sought to be renewed, at the same time as the parent agency submission for renewal.

(c) A late fee assessed under Subchapter B of this chapter (relating to Criteria and Eligibility, Application Procedures, and Issuance of a License) is one-half the amount of the required renewal license fee established in subsection (a) of this section. If HHSC assesses a late fee described in this subsection, the applicant must pay the applicable renewal application fee in full plus the late fee described in this section. HHSC may assess a separate late fee for each parent agency, branch office, and ADS renewal application.

(d) If an applicant for an initial license based on a change of ownership submits a late application for a license to HHSC, as described in §558.25 of this chapter (relating to Requirements for Change of Ownership), the applicant must pay the required initial license fee, as set out in subsection (a) of this section, plus a late fee of $250.

(e) HHSC does not review an application until the applicant submits the application through the online portal and the online portal reflects a status of payment received.

(f) A license fee paid to HHSC is not refundable but may be reimbursed under the circumstances and conditions described in §558.31 of this chapter (relating to Time Frames for Processing and Issuing a License).

(g) HHSC accepts payment of required fees made in accordance with options made available through the online portal.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603802

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3161

SUBCHAPTER B. CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Health and Safety Code §142.0011(b) and §142.012(a) which authorize the executive commissioner of HHSC to adopt rules relating to the quality of care and life of agency clients and that are necessary to implement Texas Health and Safety Code Chapter 142; and Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, that require HHSC to adopt rules governing the investigations of ANE.

The amendments affect Texas Government Code §524.0151; Texas Health and Safety Code Chapter 142; Texas Human Resources Code Chapter 48, Subchapter F; and Texas Family Code §261.404.

§558.11. Criteria and Eligibility for Licensing.

(a) An applicant for a license must not admit a client or initiate services until the applicant completes the application process and receives an initial license.

(b) A first-time application for a license is an application for an initial license.

(c) An application for a license when there is a change of ownership is an application for an initial license.

(d) A separate license is required for each place of business as defined in §558.2 of this chapter (relating to Definitions).

(e) An agency's place of business must be located in and have a physical [an] address in Texas. An agency located in another state must receive a license as a parent agency in Texas to operate as an agency in Texas.

(f) An applicant must be at least 18 years of age.

(g) Before issuing a license, HHSC considers the background of:

(1) the applicant;

(2) a controlling person of the applicant;

(3) a person with a disclosable interest;

(4) an affiliate of the applicant; and

(5) the chief financial officer.

(h) Before issuing a license, HHSC considers the background and qualifications of the administrator and alternate administrator in accordance with §558.244 of this chapter (relating Administrator Qualifications and Conditions and Supervising Nurse Qualifications).

(i) HHSC may deny an application for an initial license or for renewal of a license if a person described in subsection (g) or (h) of this section:

(1) on the date of the application:

(A) is subject to denial or refusal as described in Chapter 560 of this title (relating to Denial or Refusal of License) during the time frames described in that chapter;

(B) has an unsatisfied final judgment in any state or other jurisdiction; or

(C) is delinquent on child support obligations (Texas Family Code Chapter 232);

(2) for two years preceding the date of the application, has a history in any state or other jurisdiction of any of the following:

(A) an unresolved federal or state tax lien;

(B) an eviction involving any property or space used as an inpatient hospice agency; [or]

(C) an unresolved final Medicare or Medicaid audit exception; or

(3) for 12 months preceding the date of the application, has a history in any state or other jurisdiction of any of the following:

(A) denial, suspension, or revocation of an agency license or a license for a health care facility;

(B) [(C)] a Medicaid or Medicare sanction or penalty relating to the operation of an agency or a healthcare [health care] facility;

(D) operating an agency that has been decertified in any state under Medicare or Medicaid; or

(E) debarment, exclusion, or involuntary contract cancellation in any state from Medicare or Medicaid.

§558.13. Obtaining an Initial License.

(a) The following staff must complete the Presurvey Training before submitting an application for a license:

(1) the administrator and alternate administrator; and

(2) the supervising nurse and alternate supervising nurse of an agency that provides licensed home health services with or without home dialysis designation, licensed and certified home health services with or without home dialysis designation, or hospice services.

(b) An applicant may request to be licensed in one or more, in any combination, of the following categories:

(1) licensed and certified home health services;

(2) licensed and certified home health services with home dialysis designation;

(3) licensed home health services;

(4) licensed home health services with home dialysis designation;

(5) hospice services; or

(6) personal assistance services.

(c) HHSC does not require an agency to be licensed in more than one category if the category for which the agency is licensed includes the services the agency provides.

(d) An applicant who has requested the category of licensed and certified home health services on the initial license application must also apply to CMS for certification as a Medicare-certified agency under the 42 United States Code Chapter 7, Subchapter XVIII.

(1) While the applicant is waiting for CMS to certify the agency [it] as [a] Medicare-certified [agency]:

(A) HHSC issues an initial license reflecting the category of licensed home health services if the applicant meets the criteria for the license; and

(B) the applicant must comply with the Medicare conditions of participation for home health agencies in 42 CFR Part 484, as if the applicant were dually certified.

(2) If CMS certifies an agency to participate in the Medicare program during the initial license period, HHSC sends a notice to the agency that the category of licensed and certified home health services has been added to the license. If the agency wants to remove the licensed home health services category from the agency's license after the category of licensed and certified home health services has been added, the agency must submit to HHSC an application through the online portal to remove that category from the agency's license.

(3) If CMS denies certification to an agency or an agency withdraws the application for participation in the Medicare program, the agency may retain the category of licensed home health services on its license.

(e) An applicant for an initial license must comply with §558.30 of this subchapter (relating to Operation of a Hospice [an] Inpatient Unit at a Parent Agency) to operate an inpatient unit at the applicant's parent agency.

§558.15. Issuance of an Initial License.

(a) HHSC issues an initial license when HHSC determines:

(1) the application, including supporting documents, submitted are complete and accurate;

(2) HHSC has received funds constituting full payment of all applicable license fees, including late fees; and

(3) an applicant meets the criteria for a license as described in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing) and §558.13 of this subchapter (relating to Obtaining an Initial License).

(b) An initial license is valid for three years from the date of issuance.

(c) HHSC may deny an application to renew an initial license, or revoke or suspend an initial license, if an agency fails to:

(1) meet the requirements for an initial survey as specified in Subchapter E of this chapter (relating to Licensure Surveys and Investigations of Abuse, Neglect, and Exploitation); or

(2) maintain compliance with the statute [Statute] and this chapter for the services authorized under the license.

(d) HHSC may deny an application for an initial license for any of the reasons specified in §558.21 of this subchapter [chapter] (relating to Denial of an Application or a License).

(e) A license designates an agency's place of business from which services are to be provided and designates an agency's authorized category or categories of service.

§558.17. Application Procedures for a Renewal License.

(a) To renew its license, an agency must submit a renewal application through the online portal.

(b) An agency must submit its renewal application in accordance with §558.12 of this subchapter (relating to General Application) when submitting a renewal application through the online portal.

(c) For each license period, an agency must provide services to at least one client to be eligible to renew its license.

(d) HHSC does not require an agency to admit a client under each category of service authorized under the license to be eligible to renew its license.

(e) With each renewal application, an agency accredited by an accreditation organization referenced in §558.503 of this chapter (relating to Accreditation Process and Exemption from a Survey) must submit to HHSC through the online portal a copy of the accreditation documentation that the agency receives from the accreditation organization.

(f) At least 120 days before the expiration date of a license, HHSC makes the renewal application and instructions available through the online portal. HHSC notifies the agency with electronic notice that the application and instructions to renew the license are made available through the online portal.

(1) If the renewal application is not made available by HHSC in accordance with this subsection, the agency must, at least 90 days before the expiration date of a license, notify HHSC in writing that the agency [it] has not received notice of expiration and request that HHSC make a renewal application available.

(2) To avoid a late fee, an agency must submit to HHSC a complete and accurate renewal application, as described in §558.12(c) of this subchapter, with full payment of all required license fees as specified in §558.3 of this chapter (relating to License Fees), no later than the 45th day before the expiration date of the license.

(3) If an agency submits a renewal application after the 45th day before the expiration date of a license, but before the expiration date of the license, HHSC assesses the late fee set out in §558.3(c) of this chapter for failure to comply with paragraph (2) of this subsection.

(g) If an agency submits a renewal application to HHSC after the expiration date of the license, HHSC denies the renewal application and does not refund the renewal license fee. The agency is not eligible to renew the license and must cease operation on the date the license expires. An agency whose license expires must apply for an initial license in accordance with §558.13 of this subchapter (relating to Obtaining an Initial License).

(h) If an agency submits a renewal application before the expiration date of the license in accordance with this subsection, the license does not expire until HHSC has made a final determination on the application.

(1) If an enforcement action is pending at the time the renewal applicant submits a renewal application, the agency's license does not expire and the agency may continue to operate until HHSC had made a final determination on the application, concurrent with the agency's opportunity for a formal hearing as described in §558.601 of this chapter (relating to Enforcement Actions).

(2) A license expires if the license holder fails to submit a renewal application in accordance with the subsection before the expiration date.

(i) If a license holder fails to submit a renewal application in accordance with subsection (h) of this section because the license holder is or was on active duty with the armed forces of the United States of America outside the State of Texas, the license holder may renew the license pursuant to this subsection.

(1) An individual having power of attorney from the license holder or other authority to act on behalf of the license holder may request renewal of the license. The renewal application must include a current address and telephone number for the individual requesting the renewal.

(2) An agency may submit a request for a renewal application through the online portal before or after the expiration of the license.

(3) A copy of the official orders or other official military documentation showing that the license holder is or was on active military duty serving outside the State of Texas must be submitted to HHSC with the renewal application.

(4) A copy of the power of attorney from the license holder or other authority to act on behalf of the license holder must be submitted to HHSC with the renewal application.

(5) A license holder applying to renew a license under this subsection must pay the required renewal fee in full.

(6) A license holder may not operate the agency for which the license was obtained after the expiration of the license unless and until HHSC renews the license.

(7) This subsection applies to a license holder who is an individual or a partnership comprised of individuals, all of whom are or were on active duty with the armed forces of the United States of America serving outside the State of Texas.

(j) An applicant for a renewal license must comply with §558.30 of this subchapter (relating to Operation of a Hospice [an] Inpatient Unit at a Parent Agency) to operate an inpatient unit at the applicant's parent agency.

§558.19. Issuance of a Renewal License.

(a) A license issued under this chapter expires three years after the date HHSC issues the license [it, except as provided in subsections (e)(1) and (f)(1) of this section].

(b) Except as specified in §558.503 of this chapter (relating to Accreditation Process and Exemption from [From] a Survey), HHSC may not renew an initial license unless HHSC conducts an initial survey of the agency. For renewal of an initial license, an agency must:

(1) meet the requirements for an initial survey as specified in Subchapter E of this chapter (relating to Licensure Surveys and Investigations of Abuse, Neglect, and Exploitation);

(2) have had [demonstrate substantial compliance with the Statute and this chapter for the services authorized under the license as confirmed by] an initial survey; and

(3) apply for renewal of the license in accordance with §558.17 of this subchapter (relating to Application Procedures for a Renewal License).

(c) For renewal of a license other than an initial license, an agency must[:]

[(2)] apply for renewal of the license in accordance with §558.17 of this subchapter.

(d) If HHSC grants the renewal application, it issues a renewal license effective on the day after the previous license expires.

(e) [(g)] HHSC may deny a renewal application:

(1) if an agency fails to meet the eligibility criteria in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing);

(2) if the agency fails to meet the requirements for renewal of a license as specified in this subchapter; or

(3) for any of the reasons specified in §558.21 of this subchapter (relating to Denial of an Application or a License).

(f) [(h)] A renewal license designates an agency's place of business from which services are to be provided or directed and designates an agency's authorized category or categories of service.

§ 558.21. Denial of an Application or a License.

(a) HHSC may deny an application for a license on any ground described in this chapter, or if any person described in §558.11(g) or (h) of this subchapter (relating to Criteria and Eligibility for Licensing):

(1) fails to comply with the statute [Statute];

(2) fails to comply with this chapter;

(3) knowingly aids, abets, or permits another person to violate the statute [Statute] or this chapter;

(4) fails to meet the criteria for a license established in §558.11 of this subchapter; or

(5) violates Texas Occupations Code §102.001.

(c) [(b)] If HHSC denies an application for a license, the applicant or agency may request an administrative hearing in accordance with §558.601 of this chapter (relating to Enforcement Actions).

§ 558.23. Change of Ownership.

(a) A license holder may not transfer its license. If there is a change of ownership, the license holder's license becomes invalid on the date of the licensure change of ownership. The prospective license holder must apply for a license in accordance with §558.12 of this subchapter (relating to General Application) and §558.13 of this subchapter (relating to Obtaining an Initial License).

(b) If HHSC approves an [grants the] application for an initial change of ownership license and allows an initial change of ownership application to occur without a gap in the agency's licensed status, the license holder at the time of the application must maintain an active and valid license until HHSC grants and issues an initial license to the change of ownership applicant. Between the date when ownership changes and the date when HHSC issues the change of ownership license, the current license holder remains responsible under the current license; however, the applicant may operate the agency on behalf of the current license holder during such time.

(c) A change of ownership for a parent agency is a change of ownership for the parent agency's branch office or ADS and requires the submittal of an application and license fee for each branch office and ADS at the same time as the parent agency application and fee.

(d) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a license as a result of a change of ownership. HHSC may conduct a desk review instead of an on-site health inspection after issuing a license as a result of a change of ownership if:

(1) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or

(2) every owner with a disclosable interest in the new license holder had a disclosable interest in the former license holder.

(e) For an agency licensed to provide licensed and certified home health services or certified, as well as licensed, to provide hospice services, applicable federal laws and regulations relating to change of ownership or control apply in addition to the requirements of this section.

§558.25. Requirements for Change of Ownership.

(1) The change of ownership applicant must submit the complete and accurate initial application with full payment of required license fees at least 30 days before the anticipated date of sale or other transfer of ownership and before the expiration date of the current license holder's license.

(A) HHSC may accept a change of ownership application less than 30 days before the effective date.

(B) HHSC may assess a late fee set out in §558.3(d) of this chapter (relating to License Fees).

(3) [(2)] The change of ownership applicant must apply for an [the] initial license by submitting a change of ownership application through the online portal in accordance with §558.23(a) of this subchapter (relating to Change of Ownership) and meet the criteria for a license as described in §558.11 of this subchapter (relating to Criteria and Eligibility for Licensing) and §558.13 of this subchapter (relating to Obtaining an Initial License).

(4) [(3)] If an applicant submits a complete and accurate application through the online portal, has met all the criteria for a license, and HHSC has received funds constituting full payment of all required license fees, [fee] HHSC issues the change of ownership applicant an initial license. The effective date of the license constitutes the licensure change of ownership date.

(5) [(4)] The initial license issued to the new owner through a change of ownership is valid for three years from the date of issuance.

§558.27. Application and Issuance of an Initial Branch Office License.

(a) An agency with a current license to provide licensed home health services, licensed and certified home health services, or personal assistance services may qualify for a branch office license, if the parent agency:

(1) [(2)] has no enforcement action pending against the license; and

(2) [(3)] meets its initial survey requirements before HHSC approves a branch office license.

(b) To apply for a branch office license, an agency must submit an application for the license to HHSC through the online portal, in accordance with §558.12 of this subchapter (relating to General Application).

(c) A designated survey office conducts a review of an agency's request to establish a branch office. The survey office makes a recommendation to approve or disapprove the branch office request.

(d) HHSC HCSSA Licensing Unit approves or proposes to deny [denies] the application for a branch office license after considering the designated survey office's recommendation. If HHSC HCSSA Licensing Unit proposes to deny the application [denies the application], HHSC Regulatory Enforcement Division sends the agency a written notice:

(1) of its decision; and

(2) the agency's opportunity to appeal its decision through a formal hearing process as described in §558.601 of this chapter (relating to Enforcement Actions).

(e) CMS approves or denies the branch location if an agency is licensed to provide licensed and certified home health services.

(f) A branch office license expires on the same expiration date as the parent agency's license. To renew a branch office license, the license holder must submit, to HHSC through the online portal, a complete and accurate renewal application and all required fees for the branch office license application, and the agency must [may] renew the branch office license [it] with the parent agency's license.

(g) If HHSC grants a branch office license, it provides the branch office license to the license holder for the parent agency and branch office. The branch office must post the license in a conspicuous place on the licensed branch office premises.

(h) A branch office must comply with §558.321 of this chapter [title] (relating to Standards for Branch Offices) and the additional standards that relate to the agency's authorized categories under the license.

(i) Unless an agency is exempt from the survey, as specified in §558.503 of this chapter (relating to Accreditation Process and Exemption from [From] a Survey), HHSC does not renew a branch office license if HHSC [it] has not conducted a health survey of a branch office after issuance of the license to verify compliance with the statute [Statute] and this chapter.

§558.29. Application and Issuance of an Alternate Delivery Site License.

(a) An agency with a license to provide hospice services may qualify for an ADS license if the parent agency[:]

[(2)] has no enforcement action pending against its license.

(b) To apply for an ADS license, an agency must submit an ADS application to HHSC through the online portal, in accordance with §558.12 of this subchapter (relating to General Application).

(1) In the application, an agency may request to operate an inpatient unit at the ADS location.

(2) To add an inpatient unit to a licensed ADS, an agency must submit a change of service category application through the online portal according to the instructions for requesting HHSC approval, and otherwise comply with requirements of this section.

(c) After an agency submits an application for an ADS with an inpatient unit, the agency must upload a notification of readiness for Life Safety Code survey to the online portal. HHSC coordinates with [contact] the HHSC Architectural Unit and regional office to request a Life Safety Code survey. [Before HHSC considers whether the application is complete, HHSC determines an agency's compliance with the Life Safety Code requirements §558.871 of this chapter (relating to Physical Environment in a Hospice Inpatient Unit).]

(e) [(d)] A designated survey office reviews an agency's application for an ADS license and makes a recommendation to the HHSC HCSSA Licensing Unit [licensing unit] whether to approve or deny the application. The HHSC HCSSA Licensing Unit [licensing unit] approves or proposes to deny [denies] the agency's application.

(f) [(e)] After receiving the proposal to deny the agency's application from the HHSC HCSSA Licensing Unit, HHSC Regulatory Enforcement Division [If HHSC denies an agency's application, HHSC] sends the agency a written notice:

(1) informing the agency of its decision; and

(2) providing the agency with an opportunity to appeal its decision through a formal hearing process as described in §558.601 of this chapter (relating to Enforcement Actions).

(g) [(f)] Except as provided in subsection (h) [(g)] of this section, after HHSC issues a license for an ADS for a hospice [with an] inpatient unit:[,]

(1) the agency must, after providing inpatient services to a client, submit the Notification of Readiness for a Health Survey [of a Hospice Inpatient Unit] (HHSC Form 2020 [Form 2020-A]), to the designated survey office; and[.]

(2) HHSC conducts an initial licensure health survey to review the requirements [in §558.871 of this chapter] specified in Subchapter H, Division 7 of this chapter (relating to [Hospice] Inpatient Units) that an HHSC Life Safety Code surveyor did not review during the initial Life Safety Code survey.

(h) [(g)] An agency is not required to request an initial licensure health survey of an ADS for a hospice [with an] inpatient unit if the agency is exempt from the health survey as specified in §558.503 of this chapter (relating to Accreditation Process and Exemption from [From] a Survey). [To demonstrate that it is exempt, the agency must send the accreditation documentation from the accreditation organization to the HHSC designated survey office within seven days after the agency receives the accreditation documentation.]

(i) A Medicare-certified hospice agency must also submit a request to CMS for approval of an ADS, including an ADS for a hospice [with an] inpatient unit. CMS approves or denies the request. An agency must not admit Medicare beneficiaries for reimbursement before receiving CMS approval.

(j) An ADS license expires on the same date the parent agency's license expires. To renew an ADS license, the license holder must submit to HHSC through the online portal a renewal application and all required fees for the ADS license when submitting a renewal application for the parent agency's license.

(k) If HHSC grants an ADS license, it will provide the license to the parent agency. The agency must post the ADS license in a conspicuous place on the licensed ADS premises.

(l) An ADS must comply with the statute [Statute] and this chapter, including the applicable additional standards for hospice agencies in Subchapter H of this chapter (relating to Standards Specific to Agencies Licensed to Provide Hospice Services) and §558.322 of this chapter (relating to Standards for Alternate Delivery Sites). A Medicare-certified hospice agency's ADS must also comply with the applicable federal rules and regulations for hospice agencies in 42 CFR Part 418.

§558.30. Operation of a Hospice [an] Inpatient Unit at a Parent Agency.

(a) To operate a hospice [an] inpatient unit at a parent agency, the license holder for the parent agency or an applicant for an initial license to provide hospice services must:

(1) submit an initial parent application through the online portal according to applicable instructions for requesting HHSC approval to operate a hospice [an] inpatient unit at the parent agency;

(2) send written notice to HHSC that the agency [it] is ready for a Life Safety Code inspection through the online portal and

(3) allow HHSC to conduct an on-site Life Safety Code inspection to determine if the inpatient unit is in compliance with Subchapter H, Division 9 [ §558.871 ] of this chapter (relating to Physical Environment in an [a Hospice] Inpatient Unit).[;]

(c) After HHSC issues a license authorizing the hospice inpatient unit, the agency must:

(d) [(b)] If the applicant is currently licensed at the time an agency submits an application through the online portal to [notifies] HHSC in accordance with subsection (a)(1) of this section, the agency must not have enforcement action pending against the license, as specified in §558.601 of this chapter (relating to Enforcement Actions), under which the agency would operate the inpatient unit.

(e) [(c)] An agency that provides hospice services is not required to submit the Notification of Readiness for a Health Survey [of a Hospice Inpatient Unit] (HHSC Form 2020 [Form 2020-A]) in accordance with subsection (c)(2) [(a)(6)(A)] of this section if the agency demonstrates that it is exempt from a health survey, as described in §558.503 of this chapter (relating to Accreditation Process and Exemption from [From] a Survey). [The agency may demonstrate that it is exempt from the initial health survey described in §558.521 of this chapter (relating to Requirements for an Initial Survey) by submitting the accreditation documentation from an approved accreditation organization referenced in §558.503 of this chapter to the designated HHSC survey office within seven days after the agency receives the accreditation documentation.]

(f) [(d)] If HHSC grants an application for an initial [parent agency] license for a hospice [with an] inpatient unit or to add a hospice [an] inpatient unit to a [licensed] parent agency's license [agency], the licensed agency and the license holder must comply with the statute [Statute] and this chapter[, including Subchapter H of this chapter].

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603803

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3161

SUBCHAPTER C. MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES

SUBCHAPTER D. ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Health and Safety Code §142.0011(b) and §142.012(a) which authorize the executive commissioner of HHSC to adopt rules relating to the quality of care and life of agency clients and that are necessary to implement Texas Health and Safety Code Chapter 142; and Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, that require HHSC to adopt rules governing the investigations of ANE.

The amendments affect Texas Government Code §524.0151; Texas Health and Safety Code Chapter 142; Texas Human Resources Code Chapter 48, Subchapter F; and Texas Family Code §261.404.

§558.401. Standards Specific to Licensed Home Health Services.

(a) In addition to the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency providing licensed home health services must also meet the standards of this section.

(b) The agency's admission of a client must be based on an initial health assessment, performed in the client's residence in-person or via teleservices by an appropriate healthcare professional, prior to any home health services being initiated, to ensure the agency can meet the [The agency must accept a client for home health services based on a reasonable expectation that the] client's medical, nursing, and social needs [can be met adequately in the client's residence].

(c) The [An] agency must reasonably expect [has made a reasonable expectation] that it can meet a client's needs if, at the time of the agency's admittance [acceptance] of the client, the client and the agency have agreed as to what needs the agency would meet; for instance, the agency and the client could agree that some needs would be met but not necessarily all needs.

(d) [(1)] The agency must start providing licensed home health services to a client based on the orders of the primary care physician or practitioner [within a reasonable time] after admittance [acceptance] of the client and according to the agency's policy. The initiation of licensed home health services must be based on the client's health service needs.

(e) [(A)] The agency must ensure the appropriate healthcare professional prepares a care plan when a primary care physician or [If] a practitioner has not ordered skilled care for a client[, then the appropriate health care professional must prepare a care plan]. The care plan must be developed after consultation with the client, [and] the client's family, the LAR if applicable, and agency staff. The care plan [and] must include:

(1) the services to be provided by the agency; [rendered,]

(3) the frequency of visits or hours of service to be provided by the agency;[,]

(5) the identified problems;[,]

(6) the methods [method] of intervention;[,] and

(7) the projected date of resolution. [The care plan must be reviewed and updated by all appropriate staff members involved in client care at least annually, or more often as necessary to meet the needs of the client.]

(f) [(B)] The agency must ensure the appropriate healthcare professional prepares a plan of care when [If] a primary care physician or practitioner orders skilled care and services [treatment, then the appropriate health care professional must prepare a plan of care].

(1) The primary care physician or practitioner must sign and approve the plan of care within 60 days after the date of the initial assessment [The plan of care must be signed and approved by a practitioner in a timely manner].

(2) The primary care physician or practitioner must work together with the client, the client's family, the LAR if applicable, and agency staff to develop the plan of care. The plan of care must list all important diagnoses and include the following information about the client: [The plan of care must be developed in conjunction with agency staff and must cover all pertinent diagnoses, including]

(A) mental status;[,]

(B) types of services and equipment required;[,]

(C) frequency of visits at the time of admission;[,]

(D) prognoses;[,]

(E) functional limitations;[,]

(F) activities permitted;[,]

(G) nutritional requirements;[,]

(H) medications and treatments;[,]

(I) any safety measures to protect against injury;[,]

(K) [and] any other appropriate items.

(3) The appropriate healthcare [health care] personnel must perform services as specified in the plan of care. [The plan of care must be revised as necessary, but it must be reviewed and updated at least every six months.]

(g) [(c)] Agency staff must provide at least one home health service.

(i) [(d)] Licensed personnel must provide and supervise all services. The appropriate licensed healthcare professional must be available to supervise services as needed whenever services are provided. If medical social service is provided, the social worker must hold a license in the Texas to provide social work services. [All services must be provided and supervised by qualified personnel. The appropriate licensed health care professional must be available to supervise as needed, when services are provided. If medical social service is provided, the social worker must be licensed in the State of Texas to provide social work services.]

(j) [(e)] All staff providing services, delegation, and supervision must be employed by or be under contract with the agency.

(k) [(f)] An agency is not required to employ home health aides. If an agency employs home health aides or uses certified nurse aides to meet home health aide requirements, the agency must comply with §558.701 of this chapter (relating to Home Health Aides).

(l) [(g)] Unlicensed personnel employed by an agency to provide licensed home health services must:

(1) have demonstrated competency in the task assigned when competency cannot be determined through education and experience; [and]

(2) be at least 18 years of age or, if under 18 years of age, be a high school graduate or work as part of course completion while enrolled in a vocational education program; and[.]

§558.404. Standards Specific to Agencies Licensed to Provide Personal Assistance Services.

(a) In addition to meeting the standards in Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies), an agency holding a license with the category of personal assistance services must meet the standards of this section.

(b) A person who is not licensed to provide personal assistance services under this chapter may not indicate or imply that the person is licensed to provide personal assistance services by using the words "personal assistance services" or in any other manner.

(c) Personal assistance services, as defined in §558.2 of this chapter (relating to Definitions), may be performed by an unlicensed person who is at least 18 years of age and has demonstrated competency, when competency cannot be determined through education and experience, to perform the tasks assigned by the supervisor. An unlicensed person who is under 18 years of age must be[, is] a high school graduate or working as part of course completion while [is] enrolled in a vocational educational program[,] and must have [has] demonstrated competency to perform the tasks assigned by the supervisor in order to[, may] perform personal assistance services.

(h) [(d)] The following tasks may be performed under the [a] personal assistance services category:

(1) personal care as defined in §558.2 of this chapter;

(2) health-related tasks provided by unlicensed personnel that an RN determines through an in-person assessment may be delegated [by an RN, or that an RN determines do not require delegation,] in accordance with the agency's written policy adopted, implemented, and enforced to ensure compliance with the rules adopted [by the Texas Board of Nursing] in 22 TAC Chapter 225 [(relating to RN Delegation to Unlicensed Personnel and Tasks Not Requiring Delegation in Independent Living Environments for Clients with Stable and Predictable Conditions)];

(4) [(3)] health-related tasks that are not the practice of professional nursing under the memorandum of understanding between HHSC and the Texas Board of Nursing.[; and]

(k) [(e)] The agency must ensure that when developing its operational policies, the policies are considerate of principles of individual and family choice and control, functional need, and accessible and flexible services.

(n) [(f)] In addition to the client record requirements in §558.301(a)(9) of this chapter (relating to Client Records), the client file must include the following:

(1) documentation of determination of services based on an on-site visit by the supervisor where services will be primarily delivered and records of supervisory visits, if applicable;

(2) individualized service plan developed, agreed upon, and signed by the client or family and the agency, that includes [The individualized service plan must include]:

(A) types of services, supplies, and equipment to be provided;

(B) locations of services;

(C) frequency and duration of services;

(D) planned date of service initiation;

(E) charges for services rendered if the charges will be paid in full or in part by the client or significant other [other(s)], or on request; and

(F) plan of supervision; and

(3) documentation that the services have been provided according to the individualized service plan.

(o) [(g)] In addition to the written policies required by §558.245 of this chapter (relating to Staffing Policies), the agency must adopt and enforce a written policy addressing the supervision of personnel with input from the client or family on the frequency of supervision.

(1) Supervision of personnel must be in accordance with the agency's policies and applicable state [State] laws and rules, including rules adopted by the Texas Board of Nursing in 22 TAC Chapter 225.

(2) A supervisor must be:

(A) a licensed nurse;

(B) an individual who has [or have] completed two years of full-time study at an accredited college or university; or[.]

(C) an [An] individual with a high school diploma or general equivalence diploma (GED), with each [may substitute one] year of full-time employment in a supervisory capacity in a healthcare [health care] facility, agency, or community-based agency substituting for each required year of college.

(3) The client in a client managed attendant care program funded by HHSC that allows the client to hire staff and supervise the client's own care [or the Department of Assistive and Rehabilitative Services] is not required to meet the standard in paragraph (2) of this subsection.

(p) [(h)] Tube feedings and medication administration through a permanently placed g-tube [gastrostomy tube (g-tube)] in accordance with subsection (g) [(d)(3)] of this section may be performed by an unlicensed person only after successful completion of the training and competency program and procedures described in paragraphs (1) - (5) of this subsection.

(1) The training and competency program for the performance of g-tube feedings by an unlicensed person must be taught by an RN, a practitioner, [physician, physician assistant (PA),] or a qualified trainer. A qualified trainer must:

(A) have successfully completed the training and competency program described in paragraphs (2) and (3) of this subsection taught by an RN or practitioner [, physician, or PA];

(B) have demonstrated upon return demonstration to an RN, practitioner, [physician,] or PA the performance of the task and the ability to teach the task; and

(C) have been deemed competent by an RN, practitioner [physician], or PA, to train unlicensed personnel in these procedures. Documentation of competency to perform, train, and teach must be maintained in the employee's or contractor's file. Competency must be evaluated and documented annually by an RN, practitioner, [physician,] or PA.

(2) The minimum training program must include:

(A) a description of the g-tube placement, including its purpose;

(B) infection control procedures and universal precautions to be used when performing g-tube feedings or medication administration through a g-tube;

(C) a description of conditions that must be reported to the client or the primary caregiver, or in the absence of the primary caregiver, to the agency administrator, supervisor, or the client's practitioner, including [physician. The description of conditions must include] a plan to be effected if the g-tube comes out or is not positioned correctly to ensure medical attention is provided within one hour;

(D) review of a written procedure for g-tube feeding or medication administration through a g-tube that is[. The written procedure must be] equivalent to current acceptable nursing standards of practice, including addressing the crushing of medications;

(E) conditions under which g-tube feeding or medication administration must not be performed; and

(F) demonstration of a g-tube feeding and medication administration to a client; if[. If] the trainee becomes [will become] a qualified trainer, the demonstration must be done by the RN[, PA,] or practitioner [physician]. If the trainee does [will] not become a qualified trainer, the demonstration may be done by an RN, practitioner [PA, physician], or qualified trainer.

(3) The minimum competency evaluation must be documented and maintained in the employee's file and must include:

(A) a score of 100 percent on a written multiple-choice test that consists of situational questions to include the criteria in paragraph (2)(A) - (F) [(2)(A) - (E)] of this subsection and an evaluation of the trainee's judgment and understanding of the essential skills, risks, and possible complications of a g-tube feeding or medication administration through a g-tube;

(B) a skills checklist demonstrating that the trainee has successfully completed the necessary skills for a g-tube feeding and medication administration via g-tube, and if the trainee will become a qualified trainer, the skills checklist must also demonstrate the ability to teach another person to perform the task; the[. The] skills checklist must be completed by an RN, practitioner [physician], [or PA,] if the trainee will become a qualified trainer; the[. The] skills checklist for a trainee who will not become a qualified trainer may be completed by an RN, physician, [PA,] or qualified trainer; and

(C) documentation of an accurate demonstration of the g-tube feeding and medication administration performed by the trainee as required by paragraph (2)(F) of this subsection. If the trainee will become a qualified trainer, documentation of competency to teach this task must be maintained in the file of the qualified trainer. The person responsible for the training of the trainee must document the successful demonstration of the g-tube feeding and medication administration via g-tube by the trainee and the trainee's competency to perform this task in the trainee's file.

(4) The client or primary caregiver must provide information on the client's g-tube feeding or medication administration to the agency supervisor. If the client is not capable of directing his or her own care, the client's primary caregiver must be present to instruct and orient the supervisor regarding the client's g-tube feeding and medication regime. A copy of the current regime including unique conditions specific to the client must be placed in the client's file by the agency supervisor and provided to the respite caregiver. The respite caregiver must be oriented by the client, the client's primary caregiver, or the agency supervisor. The supervisor of the delivery of these services must have successfully completed a training and competency program outlined in paragraphs (2) and (3) of this subsection or be a qualified trainer.

(5) Legend medications that are to be administered must be in a legally labeled container from a pharmacy that contains the name of the client. Instructions for dosages according to weight or age for over-the-counter drugs commonly given the client must be furnished by the primary caregiver to the respite caregiver performing the tube feeding or medication administration.

§558.405. Standards Specific to Agencies Licensed to Provide Home Dialysis Services.

(a) License designation. An agency may not provide peritoneal dialysis or hemodialysis services in a client's residence, independent living environment, or other appropriate location unless the agency holds a license to provide licensed home health or licensed and certified home health services and designated to provide home dialysis services. In order to receive a home dialysis designation, the agency must meet the licensing standards specified in this section and the standards for home health services in accordance with Subchapter C of this chapter (relating to Minimum Standards for All Home and Community Support Services Agencies) and §558.401 of this subchapter (relating to Standards Specific to Licensed Home Health Services), except for §558.401(e) and (f) [§558.401(b)(2)(A) and (B)] of this subchapter. If there is a conflict between the standards specified in this section and those specified in Subchapter C of this chapter and §558.401 of this subchapter, the standards specified in this section will apply to the home dialysis services.

(b) Governing body. An agency must have a governing body. The governing body must appoint a medical director and the physicians who are on the agency's medical staff. The governing body must annually approve the medical staff policies and procedures. The governing body on a biannual basis must review and consider for approval continuing privileges of the agency's medical staff. The minutes from the governing body of the agency must be on file in the agency office.

(c) Qualifications and responsibilities of the medical director.

(1) Qualifications. The medical director must be a physician licensed in the State of Texas who:

(A) is eligible for certification or is certified in nephrology or pediatric nephrology by a professional board; or

(B) during the five-year period prior to September 1, 1996, served at least 12 months as director of a dialysis facility or program.

(2) Responsibilities. The medical director must:

(A) participate in the selection of a suitable treatment modality for all clients;

(B) ensure [assure] adequate training of nurses in dialysis techniques;

(C) ensure [assure] adequate monitoring of the client and the dialysis process; and

(D) ensure [assure] the development and availability of a client care policy and procedures manual and its implementation.

(d) Personnel files. An agency must have individual personnel files on all physicians, including the medical director. The file must include the following:

(1) a curriculum vitae which documents undergraduate, medical school, and all pertinent post graduate training; and

(2) evidence of current licensure, and evidence of current United States Drug Enforcement Administration certification, Texas Department of Public Safety registration, and the board eligibility or certification, or the experience or training described in subsection (c)(1) of this section.

(e) Provision of services. An agency that provides home staff-assisted dialysis must, at a minimum, provide nursing services, nutritional counseling, and medical social service. These services must be provided as necessary and as appropriate at the client's home, by telephone, or by a client's visit to a licensed ESRD facility in accordance with this subsection. The use of dialysis technicians in home dialysis is prohibited.

(1) Nursing services.

(A) An RN, licensed by the State of Texas, who has at least 18 months experience in hemodialysis obtained within the last 24 months and has successfully completed the orientation and skills education described in subsection (f) of this section, must be available whenever dialysis treatments are in progress in a client's home. The agency administrator must designate a qualified alternate to this RN.

(B) Dialysis services must be supervised by an RN who meets the qualifications for a supervising nurse as set out in §558.244(c)(2) of this chapter (relating to Administrator Qualifications and Conditions and Supervising Nurse Qualifications).

(C) Dialysis services must be provided by a qualified licensed nurse who:

(i) is licensed as an RN or LVN by the State of Texas;

(ii) has at least 18 months experience in hemodialysis obtained within the last 24 months; and

(iii) has successfully completed the orientation and skills education described in subsection (f) of this section.

(2) Nutritional counseling. A dietitian who meets the qualifications of this paragraph must be employed by or under contract with the agency to provide services. A qualified dietitian must meet the definition of dietitian in §558.2 of this chapter (relating to Definitions) and have at least one year of experience in clinical nutrition after obtaining eligibility for registration by the American Dietetic Association, Commission on Dietetic Registration.

(3) Medical social services. A social worker who meets the qualifications established in this paragraph must be employed by or be under contract with the agency to provide services. A qualified social worker is a person who:

(A) is currently licensed under the laws of the State of Texas as a social worker and has a master's degree in social work from a graduate school of social work accredited by the Council on Social Work Education; or

(B) has served for at least two years as a social worker, one year of which was in a dialysis facility or program prior to September 1, 1976, and has established a consultative relationship with a licensed master social worker.

(f) Orientation, skills education, and evaluation.

(1) All personnel providing dialysis in the home must receive orientation and skills education and demonstrate knowledge of the following:

(A) anatomy and physiology of the normal kidney;

(B) fluid, electrolyte, and acid-base balance;

(C) pathophysiology of renal disease;

(D) acceptable laboratory values for the client with renal disease;

(E) theoretical aspects of dialysis;

(F) vascular access and maintenance of blood flow;

(G) technical aspects of dialysis;

(H) peritoneal dialysis catheter, testing for peritoneal membrane equilibration, and peritoneal dialysis adequacy clearance, if applicable;

(I) the monitoring of clients during treatment, beginning with treatment initiation through termination;

(J) the recognition of dialysis complications, emergency conditions, and institution of the appropriate corrective action, including[. This includes] training agency personnel in emergency procedures and how to use emergency equipment;

(K) psychological, social, financial, and physical complications of chronic dialysis;

(L) care of the client with chronic renal failure;

(M) dietary modifications and medications for the uremic client;

(N) alternative forms of treatment for ESRD;

(O) the role of renal health team members (physician, nurse, social worker, and dietitian);

(P) performance of laboratory tests (hematocrit and blood glucose);

(Q) the theory of blood products and blood administration; and

(R) water treatment to include:

(i) standards for treatment of water used for dialysis as described in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standard, Hemodialysis Systems, March 1992 Edition, published by the Association for the Advancement of Medical Instrumentation (AAMI), 3330 Washington Boulevard, Suite 500, Arlington, Virginia 22201[. Copies of the standards are indexed and filed in the Texas Health and Human Services Commission, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours];

(ii) systems and devices;

(iii) monitoring; and

(iv) risks to clients of unsafe water.

(2) The requirements for the orientation and skills education period for licensed nurses are as follows.

(A) The agency must develop an 80-hour written orientation program that includes classroom theory and direct observation of the licensed nurse performing procedures on a client in the home.

(i) The orientation program must be provided by an RN qualified under subsection (e)(1) of this section to supervise the provision of dialysis services by a licensed nurse.

(ii) The licensed nurse must pass a written skills examination or competency evaluation at the conclusion of the orientation program and prior to the time the licensed nurse delivers independent client care.

(B) The licensed nurse must complete the required classroom component as described in paragraph (1)(A) - (E), (K) - (O), (Q) and (R) of this subsection and satisfactorily demonstrate the skills described in paragraph (1)(F) - (J) and (P) of this subsection. The orientation program may be waived by successful completion of the written examination as described in subparagraph (A)(ii) of this paragraph.

(C) The supervising nurse or qualified designee must complete an orientation competency skills checklist for each licensed nurse to reflect the progression of learned skills, as described in paragraph (1) [subsection (f)(1)] of this subsection [section].

(D) Prior to the delivery of independent client care, the supervising nurse or qualified designee must directly supervise the licensed nurse for a minimum of three dialysis treatments and ensure satisfactory performance. Dependent upon the trainee's experience and accomplishments on the skills checklist, additional supervised dialysis treatments may be required.

(E) Continuing education for employees must be provided quarterly.

(F) Performance evaluations must be done annually.

(G) The supervising nurse or qualified designee must provide direct supervision to the licensed nurse providing dialysis services monthly, or more often if necessary. Direct supervision means that the supervising nurse is on the premises but not necessarily immediately present where dialysis services are being provided.

(g) Hospital transfer procedure. An agency must establish an effective procedure for the immediate transfer to a local Medicare-certified hospital for clients requiring emergency medical care. The agency must have a written transfer agreement with such a hospital, or all physician members of the agency's medical staff must have admitting privileges at such a hospital.

(h) Backup dialysis services. An agency that supplies home staff-assisted dialysis must have an agreement with a licensed ESRD facility to provide backup outpatient dialysis services.

(i) Coordination of medical and other information. An agency must provide for the exchange of medical and other information necessary or useful in the care and treatment of clients transferred between treating facilities. This provision must also include the transfer of the client care plan, hepatitis B status, and long-term program.

(j) Transplant recipient registry program. An agency must ensure that the names of clients awaiting cadaveric donor transplantation are entered in a recipient registry program.

(k) Testing for hepatitis B. An agency must conduct routine testing of home dialysis clients and agency employees to ensure detection of hepatitis B in employees and clients.

(1) An agency must offer hepatitis B vaccination to previously unvaccinated, susceptible new staff members in accordance with 29 CFR §1910.1030(f)(1) - (2) [(Bloodborne Pathogens)].

(A) Staff vaccination records must be maintained in each staff member's personnel file.

(B) New staff members providing home dialysis care must be screened for hepatitis B surface antigen (HBsAg) and the results reviewed prior to the staff providing client care, unless the new staff member provides the agency documentation of positive serologic response to hepatitis B vaccine.

(C) An agency must establish, implement, and enforce a policy for repeated serologic screening of staff. The repeated serologic screening must be based on each staff member's HBsAg/antibody to HBsAg (anti-HBs) and must be congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Disease in the United States, 1993, published by the United States Department of Health and Human Services (USDHHS).

(2) With the advice and consent of a client's nephrologist or primary care [attending] physician, an agency must make the hepatitis B vaccine available to a client who is susceptible to hepatitis B, provided that the client has coverage or is willing to pay for vaccination.

(A) An agency must make available to clients literature that explains [describing] the risks and benefits of the hepatitis B vaccination.

(B) Candidates for home dialysis must be screened for HBsAg within one month before or at the time of admission to the agency.

(C) Repeated serologic screening must be based on the antigen or antibody status of the client.

(D) Monthly screening for HBsAg is required for clients whose previous test results are negative for HBsAg.

(E) Screening for HBsAg-positive or anti-HBsAg-positive clients may be performed less often if the agency policy matches the most current survey of the National Surveillance of Dialysis Associated Diseases in the United States. [Screening of HbsAg-positive or anti-HbsAg-positive clients may be performed on a less frequent basis, provided that the agency's policy on this subject remains congruent with Appendices i and ii of the National Surveillance of Dialysis Associated Diseases in the United States, 1993, published by the USDHHS.]

(l) CPR certification. All direct client care employees must have current CPR certification.

(m) Initial admission assessment. Assessment of the client's residence must be made to ensure a safe physical environment for the performance of dialysis. The initial admission assessment must be performed by a qualified RN who meets the qualifications under subsection (e)(1)(A) of this section.

(n) Client long-term program. The agency must develop a long-term program for each client admitted to home dialysis. Criteria must be defined in writing and must provide guidance to the agency in the selection of clients suitable for home staff-assisted dialysis and in noting changes in a client's condition that would require discharge from the program. For the purposes of this subsection, Long-term program means the written documentation of the selection of a suitable treatment modality and dialysis setting, which has been selected by the client and the interdisciplinary team.

(o) Client history and physical. The agency must ensure that the history and physical is conducted upon the client's admission, or no more than six months prior to the date of admission, then annually after the date of admission.

(p) Practitioner's [Physician] orders. If home staff-assisted dialysis is selected, the practitioner [physician] must prepare orders outlining specifics of prescribed treatment.

(1) If these practitioner's [physician's] orders are received verbally, the orders [they] must be confirmed in writing within a reasonable time frame. An agency must adopt and enforce a policy on the time frame for the countersignature of a practitioner's [physician's] verbal orders. Medical orders for home staff-assisted dialysis must be revised as necessary but reviewed and updated at least every six months.

(2) The initial orders for home staff-assisted dialysis must be received prior to the first treatment and must cover all pertinent diagnoses, including mental status, prognosis, functional limitations, activities permitted, nutritional requirements, medications and treatments, and any safety measures to protect against injury. Orders for home staff-assisted dialysis must include frequency and length of treatment, target weight, type of dialyzer, dialysate, dialysate flow rate, heparin dosage, and blood flow rate, and must specify the level of preparation required for the caregiver, such as an LVN or RN.

(q) Client care plan. The client care plan must be developed after consultation with the client and the client's family by the interdisciplinary team. The interdisciplinary team must include the practitioner [physician], the RN, the dietitian, and the qualified social worker responsible for planning the care delivered to the home staff-assisted dialysis patient.

(1) The initial client care plan must be completed by the interdisciplinary team within 10 [calendar] days after the first home dialysis treatment.

(2) The client care plan must implement the medical orders and must include services to be rendered, such as the identification of problems, methods of intervention, and the assignment of healthcare [health care] personnel.

(3) The client care plan must be in writing, be personalized for the individual, and reflect the ongoing medical, psychological, social, nutritional, and functional needs of the client, including treatment goals.

(4) The client care plan must include written evidence of coordination with other service providers, such as dialysis facilities or transportation providers, as needed to assure the provision of safe care.

(5) The client care plan must include written evidence of the client's or client's legal representative's input and participation, unless the client or client's legal representative [they] refuse to participate. At a minimum, the client care plan must demonstrate that the content was shared with the client or the client's legal representative.

(6) For non-stabilized clients, where there is a change in modality, unacceptable laboratory work, uncontrolled weight changes, infections, or a change in family status, the client care plan must be reviewed at least monthly by the interdisciplinary team. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when progress toward stabilization or the goals are not achieved, must be documented and included in the client record.

(7) For a stable client, the client care plan must be reviewed and updated as indicated by any change in the client's medical, nutritional, or psychosocial condition or at least every six months. The long-term program must be revised as needed and reviewed annually. Evidence of the review of the client care plan with the client and the interdisciplinary team to evaluate the client's progress or lack of progress toward the goals of the care plan, and interventions taken when the goals are not achieved, must be documented and included in the client record.

(r) Medication administration. Medications must be administered only by licensed personnel.

(s) Client records. In addition to the applicable information described in §558.301(a)(9) of this chapter (relating to Client Records), records of home staff assisted dialysis clients must include the following:

(1) a medical history and physical;

(2) clinical progress notes by the practitioner [physician], qualified licensed nurse, qualified dietitian, and qualified social worker;

(3) dialysis treatment records;

(4) laboratory reports;

(5) a client care plan;

(6) a long-term program; and

(7) documentation of supervisory visits.

(t) Water treatment.

(1) Water used for dialysis purposes must be analyzed for chemical contaminants every six months. Additional chemical analysis must be conducted if test results exceed the maximum levels of chemical contaminants listed in §3.2.2 (Maximum Level of Chemical Contaminants) of the American National Standards for Hemodialysis Systems, March 1992 Edition, published by the AAMI. [Copies of the standards are indexed and filed in the Texas Health and Human Services Commission, 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.]

(2) Water used for dialysis must be treated as necessary to maintain a continuous water supply that is biologically and chemically compatible with acceptable dialysis techniques.

(3) Water used to prepare dialysate must meet the requirements set forth in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum Level of Chemical Contaminants), March 1992 Edition, published by the AAMI. [Copies of the standards are indexed and filed in the Texas Health and Human Services Commission 701 W. 51st Street, Austin, Texas 78751, and are available for public inspection during regular working hours.]

(4) Records of test results and equipment maintenance must be maintained at the agency.

(u) Equipment testing. An agency must adopt and enforce a policy to describe how the nurse will check the machine for conductivity, temperature, and pH prior to treatment, and describe the equipment required for these tests. The equipment must be available for use prior to each treatment. This policy must reflect current standards.

(v) Preventive maintenance for equipment. An agency must develop and enforce a written preventive maintenance program to ensure client care related equipment receives electrical safety inspections, if appropriate, and maintenance at least annually or more frequently if recommended by the manufacturer. The preventive maintenance may be provided by agency or contract staff qualified by training or experience in the maintenance of dialysis equipment.

(1) All equipment used by a client in home dialysis must be maintained free of defects, which could be a potential hazard to clients, the client's family, or agency personnel.

(A) Agency staff must be able to identify malfunctioning equipment and report such equipment to the appropriate agency staff. Malfunctioning equipment must be immediately removed from use.

(B) Written evidence of all preventive maintenance and equipment repairs must be maintained.

(C) After repairs or alterations are made to any equipment, the equipment must be thoroughly tested for proper operation before returning to service.

(D) An agency must comply with the federal Food, Drug, and Cosmetic Act, 21 United States Code (U.S.C.) [(USC)] §360i(b), concerning reporting when a medical device, as defined in 21 U.S.C. [USC] §321(h), has or may have caused or contributed to the injury or death of an agency client.

(2) In the event that the water used for dialysis purposes or home dialysis equipment is found not to meet safe operating parameters, and corrections cannot be effected to ensure safe care promptly, the client must be transferred to a licensed hospital (if inpatient care is required) or licensed ESRD facility until such time as the water or equipment is found to be operating within safe parameters.

(w) Reuse or reprocessing of medical devices. Reuse or reprocessing of disposable medical devices, including but not limited to, dialyzers, end-caps, and blood lines must be in accordance with this subsection.

(1) An agency's reuse practice must comply with the American National Standard, Reuse of Hemodialyzers, 2003 [1993] Edition, published by the AAMI. An agency must adopt and enforce a policy for dialyzer reuse criteria (including any agency-set number of reuses allowed) which is included in client education materials.

(2) A transducer protector must be replaced when wetted during a dialysis treatment and must be used for one treatment only.

(3) Arterial lines may be reused only when the arterial lines are labeled to allow for reuse by the manufacturer and the manufacturer-established protocols for the specific line have been approved by the United States Food and Drug Administration.

(4) An agency must consider and address the health and safety of clients sensitive to disinfectant solution residuals.

(5) An agency must provide each client and the client's family or legal representative with information regarding the reuse practices of the agency, the opportunity to tour the reuse facility used by the agency, and the opportunity to have questions answered.

(6) An agency practicing reuse of dialyzers must:

(A) ensure that dialyzers are reprocessed via automated reprocessing equipment in a licensed ESRD facility or a centralized reprocessing facility;

(B) maintain responsibility and accountability for the entire reuse process;

(C) adopt and enforce policies to ensure that the transfer and transport of used and reprocessed dialyzers to and from the client's home does not increase contamination of the dialyzers, staff, or the environment; and

(D) ensure that HHSC staff has access to the reprocessing facility as part of an agency inspection.

(x) Laboratory services. Provision of laboratory services must be as follows.

(1) All laboratory services ordered for the client by a practitioner [physician] must be performed by a laboratory which meets the applicable requirements of 42 U.S.C. [United States Code (USC)] §263a, concerning certification and certificates of waiver of a clinical laboratory (CLIA 1988) and in accordance with a written arrangement or agreement with the agency. CLIA 1988 applies to all agencies with laboratories that examine human specimens for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of, human beings.

(2) Copies of all laboratory reports must be maintained in the client's medical record.

(3) Hematocrit and blood glucose tests may be performed at the client's home in accordance with §558.284 of this chapter (relating to Laboratory Services). Results of these tests must be recorded in the client's medical record and signed by the qualified licensed nurse providing the treatment. Maintenance, calibration, and quality control studies must be performed according to the equipment manufacturer's suggestions, and the results must be maintained at the agency.

(4) Blood and blood products must only be administered to dialysis clients in their homes by a licensed nurse or physician.

(y) Home dialysis supplies. Supplies for home dialysis must meet the following requirements.

(1) All drugs, biologicals, and legend medical devices must be obtained for each client pursuant to a physician's prescription in accordance with applicable rules of the Texas State Board of Pharmacy.

(2) In conjunction with the client's primary care [attending] physician, the agency must ensure that there are sufficient supplies maintained in the client's home to perform the scheduled dialysis treatments and to provide a reasonable number of backup items for replacements, if needed, due to breakage, contamination, or defective products. All dialysis supplies, including medications, must be delivered directly to the client's home by a vendor of such products. However, agency personnel may transport prescription items from a vendor's place of business to the client's home for the client's convenience, so long as the item is properly labeled with the client's name and direction for use. Agency personnel may transport medical devices for reuse.

(z) Emergency procedures. The agency must adopt and enforce policies and procedures for medical emergencies and emergencies resulting from a disaster.

(1) Procedures must be individualized for each client to include the appropriate evacuation from the home and emergency telephone numbers. Emergency telephone numbers must be posted at each client's home and must include 911, if available, the number of the practitioner [physician], the ambulance, the qualified RN on call for home dialysis, and any other phone number deemed as an emergency number.

(2) The agency must ensure that the client and the client's family know the agency's procedures for medical emergencies and emergencies resulting from a disaster.

(3) The agency must ensure that the client and the client's family know the procedure for disconnecting the dialysis equipment.

(4) The agency must ensure that the client and the client's family know emergency call procedures.

(5) A working telephone must be available during the dialysis procedure.

(6) Depending on the kinds of medications administered, an agency must have available emergency drugs as specified by the medical director.

(7) In the event of a medical emergency or an emergency resulting from a disaster requiring transport to a hospital for care, the agency must ensure [assure] the following:

(A) the receiving hospital is given advance notice of the client's arrival;

(B) the receiving hospital is given a description of the client's health status; and

(C) the selection of personnel, vehicle, and equipment are appropriate to effect a safe transfer.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603811

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3161

SUBCHAPTER E. LICENSURE SURVEYS AND INVESTIGATIONS OF ABUSE, NEGLECT, AND EXPLOITATION

SUBCHAPTER F. ENFORCEMENT

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Health and Safety Code §142.0011(b) and §142.012(a) which authorize the executive commissioner of HHSC to adopt rules relating to the quality of care and life of agency clients and that are necessary to implement Texas Health and Safety Code Chapter 142; and Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, that require HHSC to adopt rules governing the investigations of ANE.

The amendments affect Texas Government Code §524.0151; Texas Health and Safety Code Chapter 142; Texas Human Resources Code Chapter 48, Subchapter F; and Texas Family Code §261.404.

§558.601. Enforcement Actions.

(a) Enforcement actions. HHSC may take the following enforcement actions against an agency:

(1) license suspension;

(2) immediate license suspension;

(3) license revocation;

(4) immediate license revocation;

(5) administrative penalties; and

(6) denial of license application.

(b) Denial of license application. HHSC may deny a license application for the reasons set out in §558.21 of this chapter (relating to Denial of an Application or a License).

(c) Suspension or revocation.

(1) HHSC may suspend or revoke an agency's license if the license holder, the controlling person, the affiliate, the administrator, or the alternate administrator:

(A) fails to comply with this chapter;

(B) fails to comply with the statute [Statute]; or

(C) violates Texas Occupations Code §102.001 [(relating to Soliciting Patients; Offense)] and §102.006 [(relating to Failure to Disclose; Offense)].

(2) HHSC may suspend or revoke an agency's license to provide licensed and certified home health services if the agency fails to maintain its certification qualifying the agency as a certified agency, as referenced in Texas Health and Safety Code §142.011(c).

(d) Administrative penalties.

(1) HHSC may assess an administrative penalty against an agency in accordance with §558.602 of this subchapter (relating to Administrative Penalties).

(2) HHSC may consider the assessment of past administrative penalties when considering another enforcement action against an agency.

(e) Immediate licensure suspension or revocation. HHSC may immediately suspend or revoke an agency's license when the health and safety of persons are threatened.

(1) If HHSC issues an order for immediate suspension or revocation of the agency's license, HHSC provides immediate notice to the controlling person, administrator, or alternate administrator of the agency by fax and either by certified mail with return receipt requested or hand-delivery. The notice includes:

(A) the action taken;

(B) legal grounds for the action;

(C) the procedure governing appeal of the action; and

(D) the effective date of the order.

(2) An order for immediate suspension or revocation goes into effect immediately.

(3) An agency is entitled to a formal administrative hearing not later than seven days after the effective date of the order for immediate suspension or revocation.

(4) If an agency requests a formal administrative hearing, the hearing is held in accordance with the Texas Government Code Chapter 2001, and with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 of this title [40 TAC Chapter 91](relating to Hearings Under the Administrative Procedure Act).

(f) Opportunity to show compliance.

(1) Before revocation or suspension of an agency's license or denial of an application for the renewal of an agency's license, HHSC gives the license holder:

(A) a notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action, with a copy sent to the agency; and

(B) an opportunity to show compliance with all requirements of law for the retention of the license by sending the HHSC Regulatory Enforcement Division [Services] office a written request. The request must:

(i) be postmarked within 10 days after the date of HHSC notice and be received in HHSC Regulatory Enforcement Division [Services] office within 10 days after the date of the postmark; and

(ii) contain specific documentation refuting HHSC allegations.

(2) HHSC limits its review to the documentation submitted by the license holder and information HHSC used as the basis for its proposed action. An agency may not attend the HHSC meeting to review the opportunity to show compliance. HHSC gives a license holder a written affirmation or reversal of the proposed action.

(3) After the agency has an opportunity to show compliance, HHSC sends a license holder a written notice that:

(A) informs the license holder of the HHSC decision; and

(B) provides the agency with an opportunity to appeal the HHSC decision through a formal hearing process.

(g) Notice of denial of application for license or renewal of a license, suspension or revocation of license. HHSC sends an applicant or license holder notice by fax and either by certified mail with return receipt requested, or hand-delivery of the HHSC denial of an application for an initial license or renewal of a license, suspension of a license or revocation of a license.

(h) Formal appeal. An applicant or license holder has the right to make a formal appeal after receipt of the HHSC notice [notification] of denial of an application for an initial license or renewal of a license, [and] suspension of a license, or revocation of a license.

(1) An agency must request a formal administrative hearing within 20 days of receipt of the HHSC notice of denial of an application for an initial license or renewal of a license, suspension of a license, or revocation of a license. To make a formal appeal, the applicant or agency must comply with the formal hearing procedures in 1 TAC Chapter 357, Subchapter I and Chapter 110 of this title. [40 TAC Chapter 91.]

(2) HHSC presumes receipt of HHSC notice to occur on the 10th day after the notice is mailed to the last known address, unless another date is reflected on the return receipt.

(3) If an agency does not meet the deadline for requesting a formal hearing, the agency has lost its opportunity for a formal hearing, and HHSC enforces [takes] the proposed action.

(4) A formal administrative hearing is held in accordance with Texas Government Code[,] Chapter 2001, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I and Chapter 110 of this title. [40 TAC Chapter 91.]

(5) Except for the denial of an application for an initial license, if an agency appeals, the license remains valid until all appeals are final, unless the license expires without a timely application for renewal submitted to HHSC. The agency must continue to submit a renewal application in accordance with §558.17 of this chapter (relating to Application Procedures for a Renewal License) until the action to revoke, suspend, or deny renewal of the license is completed. However, HHSC does not renew the license until it determines the reason for the proposed action no longer exists.

(6) If an agency appeals, the enforcement action will take effect when all appeals are final, and the proposed enforcement action is upheld. If the agency wins the appeal, the proposed action does not happen.

(7) If HHSC suspends a license, the suspension remains in effect until HHSC determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC conducts a survey of the agency before making a determination to recommend cancellation of a suspension.

(8) If HHSC revokes or does not renew a license and two years have [one year has] passed following the effective date of revocation or denial of licensure renewal, a person may reapply for a license by complying with the requirements and procedures in §558.13 of this chapter (relating to Obtaining an Initial License). HHSC does not issue a license if the reason for revocation or nonrenewal continues to exist.

(i) Agency dissolution. Upon suspension, revocation, or nonrenewal of a license, the license holder must comply with the following.[:]

(1) If agency dissolution occurs and no enforcement action is in effect, the license holder must:

(A) [(1)] destroy [return] the original license [to HHSC]; [and]

(C) [(2)] implement its written plan required in §558.291 of this chapter (relating to Agency Dissolution) and §558.217 of this chapter (relating to Agency Closure Procedures and Voluntary Suspension of Operations).

§558.602. Administrative Penalties.

(a) Assessing penalties. HHSC may assess an administrative penalty against a person who violates:

(1) the statute [Statute];

(2) a provision in this chapter for which a penalty may be assessed; or

(3) Texas Occupations Code §102.001 [(relating to Soliciting Patients; Offense)] or §102.006 [(relating to Failure to Disclose; Offense)], if related to the provision of home health, hospice, or personal assistance services.

(b) Criteria for assessing penalties. HHSC assesses administrative penalties in accordance with the schedule of appropriate and graduated penalties established in this section.

(1) The schedule of appropriate and graduated penalties for each violation is based on the following criteria:

(A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation and the hazard of the violation to the health or safety of clients;

(B) the history of previous violations by a person or a controlling person with respect to that person;

(C) whether the affected agency identified the violation as part of its internal quality assurance process and made a good faith, substantial effort to correct the violation in a timely manner;

(D) the amount necessary to deter future violations;

(E) efforts made to correct the violation; and

(F) any other matters that justice may require.

(2) In determining which violation warrants a penalty, HHSC considers:

(A) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation and the hazard of the violation to the health or safety of clients; and

(B) whether the affected agency identified the violation as part of its internal quality assurance program and made a good faith, substantial effort to correct the violation in a timely manner.

(c) Opportunity to correct. Except as provided in subsections (e) and (f) of this section, HHSC provides an agency with an opportunity to correct a violation in accordance with the time frames established in §558.529(g)(2) [§558.527(g)(2)]of this chapter (relating to Post-Survey Procedures) before assessing an administrative penalty if a plan of correction has been implemented.

(d) Minor violations.

(1) HHSC may not assess an administrative penalty for a minor violation unless the violation is of a continuing nature or is not corrected in accordance with an accepted plan of correction.

(2) HHSC may assess an administrative penalty for a subsequent occurrence of a minor violation when cited within three years from the date the agency first received written notice of the violation.

(3) HHSC does not assess an administrative penalty for a subsequent occurrence of a minor violation when cited more than three years from the date the agency first received written notice of the violation.

(e) No opportunity to correct. HHSC may assess an administrative penalty without providing an agency with an opportunity to correct a violation if HHSC determines that the violation:

(1) results in serious harm to or death of a client;

(2) constitutes a serious threat to the health or safety of a client;

(3) substantially limits the agency's capacity to provide care;

(4) involves the provisions of Texas Human Resources Code Chapter 102[, Rights of the Elderly]; or

(5) is a violation in which a person:

(A) makes a false statement, that the person knows or should know is false of a material fact:

(i) on an application for issuance or renewal of a license or in an attachment to the application; or

(ii) with respect to a matter under investigation by HHSC;

(B) refuses to allow a representative of HHSC to inspect a book, record, or file required to be maintained by an agency;

(C) willfully interferes with the work of a representative of HHSC or the enforcement of this chapter;

(D) willfully interferes with a representative of HHSC preserving evidence of a violation of this chapter or a rule, standard, or order adopted, or license issued under this chapter;

(E) fails to pay a penalty assessed by HHSC under this chapter within 10 days after the date the assessment of the penalty becomes final; or

(F) fails to submit:

(i) a plan of correction within 10 days after the date the person receives a statement of licensing violations; or

(ii) an acceptable plan of correction within 30 days after the date the person receives notification from HHSC that the previously submitted plan of correction is not acceptable.

(f) Violations relating to advance directives [Advance Directives]. As provided in Texas Health and Safety Code §142.0145, HHSC assesses an administrative penalty of $500 for a violation of §558.283 of this chapter (relating to Advance Directives) without providing an agency with an opportunity to correct the violation.

(g) Penalty calculation and assessment.

(1) Each day that a violation occurs before the date on which the person receives written notice of the violation is considered one violation.

(2) Each day that a violation occurs after the date on which an agency receives written notice of the violation constitutes a separate violation.

(h) Schedule of appropriate and graduated penalties.

(1) If two or more rules listed in paragraphs (2) and (3) of this subsection relate to the same or similar matter, one administrative penalty may be assessed at the higher severity level violation.

(2) Severity Level A violations.

(A) The penalty range for a Severity Level A violation is $100 - $250 per violation.

(B) A Severity Level A violation is a violation that has or has had minor or no client health or safety significance.

(C) HHSC assesses a penalty for a Severity Level A violation only if the violation is of a continuing nature or was not corrected in accordance with an accepted plan of correction.

(D) HHSC may assess a separate Severity Level A administrative penalty for each of the rules listed in the following table.

Figure: 26 TAC §558.602(h)(2)(D) (.pdf)

[Figure: 26 TAC §558.602(h)(2)(D)]

(3) Severity Level B violations.

(A) The penalty range for a Severity Level B violation is $500-$1,000 per violation.

(B) A Severity Level B violation is a violation that:

(i) results in serious harm to or death of a client;

(ii) constitutes an actual serious threat to the health or safety of a client; or

(iii) substantially limits the agency's capacity to provide care.

(C) The penalty for a Severity Level B violation that:

(i) results in serious harm to or death of a client is $1,000;

(ii) constitutes an actual serious threat to the health or safety of a client is $500 - $1,000; and

(iii) substantially limits the agency's capacity to provide care is $500 - $750.

(D) As provided in subsection (e) of this section, a Severity Level B violation is a violation for which HHSC may assess an administrative penalty without providing an agency with an opportunity to correct the violation.

(E) HHSC may assess a separate Severity Level B administrative penalty for each of the rules listed in the following table.

Figure: 26 TAC §558.602(h)(3)(E) (.pdf)

[Figure: 26 TAC §558.602(h)(3)(E)]

(i) Violations for which HHSC may assess an administrative penalty of $500.

(1) HHSC may assess an administrative penalty of $500 for each of the violations listed in subsection (e)(4) and (5) of this section, without providing an agency with an opportunity to correct the violation.

(2) A separate penalty may be assessed for each of these violations.

(j) Proposal of administrative penalties.

(1) If HHSC assesses an administrative penalty, HHSC provides a written notice of violation letter to an agency. The notice includes:

(A) a summary of the violation;

(B) the amount of the proposed penalty; and

(C) a statement of the agency's right to a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both the occurrence of the violation and the amount of the penalty.

(2) An agency may accept an HHSC determination within 20 days after the date on which the agency receives the notice of violation letter, including the proposed penalty, or may make a written request for a formal administrative hearing on the determination.

(A) If an agency notified of a violation accepts the HHSC determination, the HHSC executive commissioner or the HHSC executive commissioner's designee issues an order approving the determination and ordering that the agency pay the proposed penalty.

(B) If an agency notified of a violation does not accept the HHSC determination, the agency must submit to HHSC [the Health and Human Services Commission] a written request for a formal administrative hearing on the determination and must not pay the proposed penalty. Remittance of the penalty to HHSC is deemed acceptance by the agency of the HHSC determination, is final, and waives the agency's right to a formal administrative hearing.

(C) If an agency notified of a violation fails to respond to the notice of violation letter within the required time frame, the HHSC executive commissioner or the HHSC executive commissioner's designee issues an order approving the determination and ordering that the agency pay the proposed penalty.

(D) If an agency requests a formal administrative hearing, the hearing is held in accordance with the statute in Texas Health and Safety Code [Statute] §142.0172 and [,] §142.0173, and the formal hearing procedures in 1 TAC Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and Chapter 110 of this title [40 TAC Chapter 91] (relating to Hearings Under the Administrative Procedure Act).

§558.604. Surrender or Expiration of a License.

(a) If an agency surrenders the agency's license or allows the agency's license to expire without seeking renewal, HHSC will deny any application for a license by the agency, the license holder, and any affiliate for two years starting from the date the license is surrendered or expires. [After a survey in which a surveyor cited deficiencies, an agency may surrender its license or allow its license to expire to avoid enforcement action by HHSC.]

(c) [(b)] For an agency's license to be considered surrendered [If an agency surrenders its license] before the expiration date, the agency must destroy [return] its original license and provide the following information to HHSC:

(2) [(1)] the effective date of closure;

(3) [(2)] the location of client records;

(4) [(3)] the name and address of the client record custodian;

(5) [(4)] a statement signed and dated by the license holder agreeing to the surrender of the license; and

(6) [(5)] the disposition of active clients at the time of closure.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603816

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3161

SUBCHAPTER G. HOME HEALTH AIDES

STATUTORY AUTHORITY

The amendment is authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; Texas Health and Safety Code §142.0011(b) and §142.012(a) which authorize the executive commissioner of HHSC to adopt rules relating to the quality of care and life of agency clients and that are necessary to implement Texas Health and Safety Code Chapter 142; and Texas Human Resources Code Chapter 48, Subchapter F, and Texas Family Code §261.404, that require HHSC to adopt rules governing the investigations of ANE.

The amendment affects Texas Government Code §524.0151; Texas Health and Safety Code Chapter 142; Texas Human Resources Code Chapter 48, Subchapter F; and Texas Family Code §261.404.

§558.701. Home Health Aides.

(a) A home health aide may be used by an agency providing licensed home health services if the aide meets one of the following requirements:

(1) a minimum of one year of full-time experience in direct client care in an institutional setting (hospital or nursing facility);

(2) one year of full-time experience within the last five years in direct client care in an agency setting;

(3) satisfactorily completed a training and competency evaluation program that complies with the requirements of this section;

(4) satisfactorily completed a competency evaluation program that complies with the requirements of this section;

(5) submitted to the agency documentation from the director of programs or the dean of a school of nursing that states that the individual is a nursing student who has demonstrated competency in providing basic nursing skills in accordance with the school's curriculum; or

(6) listed on the HHSC nurse aide registry (NAR) with no finding against the aide relating to client abuse or neglect or misappropriation of client property.

(b) A home health aide must have provided home health services within the previous 24 months to qualify under subsection (a)(3) or (4) of this section.

(c) Assignment, delegation, and supervision of services provided by home health aides must be performed in accordance with rules in this chapter governing the agency's license category.

(d) The training portion of a training and competency evaluation program for home health aides must be conducted by or under the general supervision of an RN who possesses a minimum of two years of nursing experience, at least one year of which must be in the provision of home health care. The training program may contain other aspects of learning, but must contain the following:

(1) a minimum of 75 hours as follows:

(A) an appropriate number of hours of classroom instruction; and

(B) a minimum of 16 hours of clinical experience, which will include in-home training and must be conducted in a home, hospital, nursing home, or laboratory;

(2) completion of at least 16 hours of classroom training before a home health aide begins clinical experience working directly with clients under the supervision of qualified instructors;

(3) if LVN instructors are used for the training portion of the program, the following qualifications and supervisory requirements apply:

(A) an LVN may provide the home health aide classroom training under the supervision of an RN who has two years of nursing experience, at least one year of which must be in the provision of home health care;

(B) LVNs, as well as RNs, may supervise home health aide candidates in the course of the clinical experience; and

(C) an RN must maintain overall responsibility for the training and supervision of all home health aide training students; and

(4) an assessment that the student knows how to read and write English and carry out directions.

(e) The classroom instruction and clinical experience content of the training portion of a training and competency evaluation program must include, but is not limited to:

(1) communication skills;

(2) observation, reporting, and documentation of a client's status and the care or service furnished;

(3) reading and recording temperature, pulse, and respiration;

(4) basic infection control procedures and instruction on universal precautions;

(5) basic elements of body functioning and changes in body function that must be reported to an aide's supervisor;

(6) maintenance of a clean, safe, and healthy environment;

(7) recognizing emergencies and knowledge of emergency procedures;

(8) the physical, emotional, and developmental needs of and ways to work with the populations served by the agency, including the need for respect for the client and his or her privacy and property;

(9) appropriate and safe techniques in personal hygiene and grooming that include:

(A) bed bath;

(B) sponge, tub, or shower bath;

(C) shampoo, sink, tub, or bed;

(D) nail and skin care;

(E) oral hygiene; and

(F) toileting and elimination;

(10) safe transfer techniques and ambulation;

(11) normal range of motion and positioning;

(12) adequate nutrition and fluid intake;

(13) any other task the agency may choose to have the home health aide perform in accordance with §558.298 of this chapter (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel and Tasks Not Requiring Delegation); and

(14) the rights of the elderly.

(f) This section addresses the requirements for the competency evaluation program or the competency evaluation portion of a training and competency evaluation program.

(1) The competency evaluation must be performed by an RN.

(2) The competency evaluation must address each of the subjects listed in subsection (e)(2) - (13) of this section.

(3) Each of the areas described in subsection (e)(3) and (9) - (11) of this section must be evaluated by observation of the home health aide's performance of the task with a client, pseudo-person, or person.

(4) Each of the areas described in subsection (e)(2), (4) - (8), (12), and (13) of this section may be evaluated through written examination, oral examination, or by observation of a home health aide with a client, pseudo-person, or person.

(5) A home health aide is not considered to have successfully completed a competency evaluation if the aide has an unsatisfactory rating in more than one of the areas described in subsection (e)(2) - (13) of this section.

(6) If an aide receives an unsatisfactory rating, the aide must not perform that task without direct supervision by an RN or LVN, until the aide receives training in the task for which he or she was evaluated as unsatisfactory and successfully completes a subsequent competency evaluation with a satisfactory rating on the task.

(7) If an individual fails to complete the competency evaluation satisfactorily, the individual must be advised of the areas in which he or she is inadequate.

(h) [(g)] If a person, organization, or healthcare entity that [who] is not an agency licensed under this section[,] desires to implement a home health aide training and competency evaluation program or a competency evaluation program, the person, organization, or healthcare entity that must meet the requirements of this section in the same manner as set forth for an agency.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603817

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3161

SUBCHAPTER H. STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES

CHAPTER 926. STATE FACILITY REQUIREMENTS TO ENHANCE THE SAFETY OF INDIVIDUALS RECEIVING SERVICES

SUBCHAPTER E. INPATIENT COMPETENCY RESTORATION

The executive commissioner of the Texas Health and Human Services Commission (HHSC) proposes new §926.201, concerning Purpose; §926.203, concerning Application; §926.205, concerning Definitions; §926.207, concerning Standardized Competency Restoration Curriculum, §926.209, concerning Memorandum of Understanding, and §926.211, concerning Report to the Texas Health and Human Services Commission.

BACKGROUND AND PURPOSE

The proposal implements Senate Bill 528, 89th Legislature, Regular Session, 2025, which added Texas Health and Safety Code (HSC) Chapter 580, Inpatient Competency Restoration Services.

HSC Chapter 580 requires HHSC to establish rules requiring each facility that contracts with HHSC to provide inpatient competency restoration services to enter into a memorandum of understanding (MOU) to outline the powers and duties of competency restoration services. The MOU is between the facility, the county and municipality where the facility is located, and each local mental health authority or local behavioral health authority that operate in the county or municipality.

The proposal implements HSC §580.004 which requires each facility to report data to HHSC regarding individuals receiving inpatient competency restoration services.

In addition to the changes that implement HSC Chapter 580, the proposal also requires an HHSC contractor to use the Texas State Hospitals standardized competency restoration curriculum. Additionally, the contractor must require the subcontractor to use the Texas State Hospitals standardized competency restoration curriculum in providing inpatient competency restoration services.

SECTION-BY-SECTION SUMMARY

Proposed new §926.201 describes that the purpose of the subchapter is to set standards for inpatient competency restoration services.

Proposed new §926.203 states that the rules apply to a contractor with HHSC to provide inpatient competency restoration services to an individual.

Proposed new §926.205 defines terms used in the subchapter.

Proposed new §926.207 requires a contractor and their subcontractors to use the Texas State Hospitals standardized competency restoration curriculum. It also informs a contractor and a subcontractor how to access the curriculum.

Proposed new §926.209 identifies with whom a facility must enter into an MOU about inpatient competency restoration services. It also identifies the topics the MOU must include.

Proposed new §926.211 requires each facility to collect and submit specific data in the format and timeframe set by HHSC regarding individuals who received inpatient competency restoration services at the facility. It also requires that the facility report data separately for individuals charged with a misdemeanor offense and for individuals charged with a felony offense.

FISCAL NOTE

Victoria Grady, Deputy Chief, Finance, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules do not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of HHSC employee positions;

(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) the proposed rules will not affect fees paid to HHSC;

(5) the proposed rules will create new regulations;

(6) the proposed rules will not expand, limit, or repeal existing regulations;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) the proposed rules will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Victoria Grady has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities because the rules do not apply to small businesses, micro-businesses, or rural communities.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules: are necessary to protect the health, safety, and welfare of the residents of Texas; do not impose a cost on regulated persons; and are necessary to implement legislation that does not specifically state that §2001.0045 applies to the rules.

PUBLIC BENEFIT AND COSTS

Kristy Carr, Associate Commissioner of State Hospitals, has determined that for each year of the first five years the rules are in effect, the public benefit will be increased public safety; improved communication between emergency services, law enforcement, and mental health providers; and improved outcomes for individuals in inpatient competency restoration programs.

Victoria Grady has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules because there are no new fees or costs imposed on those required to comply.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal, including information related to the cost, benefit, or effect of the proposed rule, as well as any applicable data, research, or analysis, may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 4601 West Guadalupe Street, Austin, Texas 78751; or emailed to HHSRulesCoordinationOffice@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 26R039" in the subject line.

STATUTORY AUTHORITY

The new sections are authorized by Texas Government Code §524.0151, which provides that the executive commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services system, and Texas Health and Safety Code §580.003 and §580.004, which requires the executive commissioner of HHSC to promulgate rules related to the MOU and requires submission of inpatient competency restoration data to HHSC.

The new sections affect Texas Government Code §524.0151 and Texas Health and Safety Code Chapter 580.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on September 2, 2026.

TRD-202603812

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: October 18, 2026

For further information, please call: (512) 438-3049