TITLE 22. EXAMINING BOARDS

PART 11. TEXAS BOARD OF NURSING

CHAPTER 213. PRACTICE AND PROCEDURE

The Texas Board of Nursing (Board) proposes amendments to §213.13, relating to Complaint Investigation and Disposition. The amendments are being proposed under the authority of the Occupations Code §301.151.

BACKGROUND. The Board's Enforcement Department underwent an internal audit, with the final report issued on May 21, 2025. The audit found that portions of Board Rule 213.13 are outdated and do not align with current enforcement practices and procedures. The proposed amendments address the complaint submission requirements, as the audit identified that some of the information currently required may not be available to complainants, resulting in procedures that conflict with the rule. The amendments also revise the complaint priority system, as the agency has determined that enforcement personnel will no longer use priority level four when designating complaints, necessitating a rule change. Finally, the amendments clarify the timeline notification requirements to ensure consistency with current standards, as recommended in the audit report.

SECTION-BY-SECTION SUMMARY OVERVIEW. Proposed amendments to §213.13 are primarily intended to modernize and clarify existing language to reflect current agency processes for receiving and investigating complaints.

In subsection (a), the Board proposes to amend the rule to specify that complaints may be submitted in writing or by the agency's online complaint portal, reflecting the current means by which most complaints are received. The subsection also updates language identifying additional data to be collected to initiate or conduct an investigation, including the nurse's license number, contact information, patient identifiers, witness information, and the date and time of the incident. These additions clarify the type of information necessary for staff to begin investigative work and ensure that the rule reflects current operational practice. Proposed subsection (a) consolidates the requirements of current subsections (a) and (b). The proposed amendments remove language requiring additional information that may be unnecessary to undertake an investigation.

In proposed subsection (b), the language is updated with three defined levels of complaint priority based on the seriousness of the conduct and potential risk to clients or the public. Priority 4 is removed from the language as that priority is not currently being used by the agency.

The Board proposes to divide current subsection (d) into proposed subsections (c), (d), and (e) for clarity and to better reflect the structure of Texas Occupations Code §301.457. The Board proposes to amend subsection (c) to specify that, within 30 days after receipt of a complaint, staff will complete a preliminary investigation to determine the identity of the person named or described in the complaint, if not known, and process the complaint to determine priority scheduling, which establishes a schedule for case completion. This addition incorporates a step already followed in practice and improves clarity regarding early-stage complaint processing.

The Board proposes amendments to subsection (d) to ensure consistency with Texas Occupations Code §301.457. It provides that parties to the complaint will be notified of the expected timeline of the investigation as soon as practicable and that any change to the timeline will be documented in the case file and communicated to all parties. This addition promotes transparency and aligns the rule with statutory notice requirements.

These proposed amendments remove the language of current subsection (e), which requires background checks on the party identified in the complaint. While the background checks are conducted as part of agency procedure, they are not conducted at this stage in the investigatory process.

Proposed subsections (e) and (f) substantively retain their existing structure with only minor revisions to remove obsolete text. These provisions define when an investigation is considered complete and require staff to provide summary data to the executive director for cases extending beyond expected timelines.

Overall, the proposed amendments remove outdated language, incorporate modern complaint submission and investigation practices, and ensure compliance with current statutory requirements governing notification and investigative procedures.

FISCAL NOTE. Dr. Kristin Benton, RN, DNP, Executive Director, has determined that for each year of the first five years the proposed new sections will be in effect, there will be no anticipated change in the revenue to state government as a result of the enforcement or administration of the proposal.

PUBLIC BENEFIT/COST NOTE. Dr. Benton has also determined that for each year of the first five years that the proposed rules are in effect, the anticipated public benefit will be the adoption of rules that notice licensees and the public of the Board's investigative processes.

There are no new anticipated costs of compliance associated with the proposal. The proposed amendments do not impose any requirement or condition on board regulated entities. The Board does not anticipate any new costs of compliance resulting from the proposal. Further, the Board is not required to comply with the requirements of Tex. Gov't Code. §2001.0045(b) because the proposed amendments are not anticipated to result in new costs of compliance and are necessary to protect the health, safety, and welfare of the residents of this state.

ECONOMIC IMPACT STATEMENT AND REGULATORY FLEXIBILITY ANALYSIS FOR SMALL AND MICRO BUSINESSES AND RURAL COMMUNITIES. The Government Code §2006.002(c) and (f) require, that if a proposed rule may have an economic impact on small businesses or micro businesses or rural communities, state agencies must prepare, as part of the rulemaking process, an economic impact statement that assesses the potential impact of the proposed rule on these businesses and communities and a regulatory flexibility analysis that considers alternative methods of achieving the purpose of the rule. Section 2006.002(c-1) requires that the regulatory analysis "consider, if consistent with the health, safety, and environmental and economic welfare of the state, using regulatory methods that will accomplish the objectives of applicable rules while minimizing adverse impacts on small businesses" are feasible. Therefore, an agency is not required to consider alternatives that, while possibly minimizing adverse impacts on small and micro businesses, would not be protective of the health, safety, and environmental and economic welfare of the state.

The Government Code §2006.001(1) defines a micro business as a legal entity, including a corporation, partnership, or sole proprietorship that: (i) is formed for the purpose of making a profit; (ii) is independently owned and operated; and (iii) has not more than 20 employees. The Government Code §2006.001(2) defines a small business as a legal entity, including a corporation, partnership, or sole proprietorship, that: (i) is formed for the purpose of making a profit; (ii) is independently owned and operated; and (iii) has fewer than 100 employees or less than $6 million in annual gross receipts. Each of the elements in §2006.001(1) and §2006.001(2) must be met for an entity to qualify as a micro business or small business. The Government Code §2006.001(1-a) defines a rural community as a municipality with a population of less than 25,000.

These proposed rules cannot reasonably be expected to result in any costs of compliance for small businesses, micro businesses, or rural communities. As such, the Board is not required to prepare an economic impact statement and regulatory flexibility analysis.

GOVERNMENT GROWTH IMPACT STATEMENT. The Board is required, pursuant to Tex. Gov't Code §2001.0221 and 34 Texas Administrative Code §11.1, to prepare a government growth impact statement. The Board has determined for each year of the first five years the proposed amendments will be in effect: (i) the proposal does not create or eliminate a government program; (ii) implementation of the proposal does not require the creation of new employee positions or the elimination of existing employee positions, as the proposal is not expected to have an effect on existing agency positions; (iii) implementation of the proposal does not require an increase or decrease in future legislative appropriations to the Board, as the proposal is not as the Board intends to shift necessary resources to comply with the statutory mandate; (iv) the proposal does not require an increase or decrease in fees paid to the Board; (v) the proposal references new statutory requirements for the Board to follow in investigations but does not add additional requirements for licensees; (vi) the proposal does not expand or repeal an existing regulation; (vii) the proposed rule does not increase or decrease the number of individuals subject to the rule's applicability; and (viii) the proposal does not have an effect on the state's economy.

TAKINGS IMPACT STATEMENT. The Board has determined that no private real property interests are affected by this proposal and that this proposal does not restrict or limit an owner's right to property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking or require a takings impact assessment under the Government Code §2007.043.

REQUEST FOR PUBLIC COMMENT. Comments on this proposal may be submitted to James W. Johnston, General Counsel, Texas Board of Nursing, 1801 Congress Avenue, Suite 10-200, Austin, Texas 78701, or by e-mail to dusty.johnston@bon.texas.gov, or faxed to (512) 305-8101. Comments must be received no later than thirty (30) days from the date of publication of this proposal. If a hearing is held, written and oral comments presented at the hearing will be considered.

STATUTORY AUTHORITY. These rule sections are proposed under the authority of Texas Occupations Code §301.151.

CROSS REFERENCE TO STATUTE. The following statutes are affected by this proposal: Texas Occupations Code §§301.151, 301.457.

§213.13. Complaint Investigation and Disposition.

(a) Complaints shall be submitted to the Board in writing or by the agency's online complaint portal and should contain at least the following information: Nurse/Respondent Name, [~~License Number, Social Security Number, Date of Birth, Employer, Dates of Occurrence(s),~~] Description of Facts or Conduct, Location of Incident, and [~~Witnesses, Outcome,~~] Complainant Identification (Name, Mailing Address, Email Address, and Telephone Number). Additional data to be collected in order to initiate or conduct an investigation includes Nurse/Respondent License Number, Nurse/Respondent Contact Information, Patient(s) Identifier(s), Witness Information, and Date and Time of Incident. [~~, and Written Instructions For Providing Information to the Board. Complaints may be made on the agency's complaint form.~~]

~~[(b) A preliminary investigation shall be conducted to determine the identity of the person named or described in the complaint.]~~

(b) [~~(c)~~] Complaints shall be assigned a priority status:

(1) Priority 1--those indicating that credible evidence exists showing a guilty plea, with or without an adjudication of guilt, or conviction of a serious crime involving moral turpitude; a violation of the NPA involving actual deception, fraud, or injury to clients or the public or a high probability of immediate deception, fraud or injury to clients or the public;

(2) Priority 2--those indicating that credible evidence exists showing a violation of the NPA involving a high probability of potential deception, fraud, or injury to clients or the public; and

(3) Priority 3--those indicating that credible evidence exists showing a violation of the NPA. [~~involving a potential for deception, fraud, or injury to clients or the public; and~~]

~~[(4) Priority 4--all other complaints.]~~

(c) [~~(d)~~] Not later than the 30th day after a complaint is received, the staff shall complete a preliminary investigation to determine the identity of the person named or described in the complaint, if not known, and process the complaint to determine priority scheduling, which establishes a schedule for case completion. [~~place a time line for completion, not to exceed one year, in the investigative file and notify all parties to the complaint.~~]

(d) In compliance with Texas Occupations Code §301.457, parties to the complaint will be notified of the expected timeline of the investigation as soon as practicable. Any change in timeline [~~time line~~] must be noted in the file and all parties notified of the change not later than seven days after the change was made.

(e) For purposes of this rule, completion of an investigation in a disciplinary matter occurs when:

(1) staff determines insufficient evidence exists to substantiate the allegation of a violation of the NPA or [,] Board's rules [~~, or a Board order~~]; or

(2) staff determines sufficient evidence exists to demonstrate a violation of the NPA or [,] Board's rules [~~, or a Board order~~] and files [~~drafts proposed~~] formal charges.

~~[(e) Staff shall conduct a criminal background search of the party described in the complaint.]~~

(f) The staff shall provide summary data of complaints extending beyond the complaint timeline [~~time line~~] to the executive director.

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 December 5, 2025.

TRD-202504433

James W. Johnston

General Counsel

Texas Board of Nursing

Earliest possible date of adoption: January 18, 2026

For further information, please call: (512) 305-6879

CHAPTER 217. LICENSURE, PEER ASSISTANCE AND PRACTICE

22 TAC §217.24

The Texas Board of Nursing (Board) proposes amendments to §217.24, relating Telemedicine Medical Service Prescriptions. The amendments are being proposed under the authority of the Occupations Code §301.151.

BACKGROUND. The proposed amendments to §217.24 reflect changes required by House Bill 1700, which amended Texas Occupations Code §111.004. Specifically, the bill specifies the informed consent documentation that is required when licensees perform telehealth service or telemedicine medical service. The proposed amendments ensure that a written record is maintained of informed consent when nursing services are provided by video or telephone.

SECTION-BY-SECTION SUMMARY OVERVIEW. Proposed amendments to §217.24 are primarily intended to comply with the requirements of new legislation.

In Subsection (a), the Board defines "telehealth service" and "telemedicine medical service" based on the relevant sections of Texas Occupations Code §111.001.

In proposed Subsection (b), the Board specifies that standards of care are the same regardless of the format of telehealth or telemedicine medical service, as required by HB 1700.

Subsection (c) specifies the requirements for documentation of informed consent prior to telehealth or telemedicine medical service. These requirements include signature by the patient, parent, or legal guardian, disclosure of complications, risks, hazards for treatment methods, nursing license numbers, and practice location. A nurse is also required to confirm the identity of the patient taking part in telehealth or telemedicine medical service, verify their health history, and inform the patient regarding risks of electronic and digital communications in the provision of care.

Subsection (d) required telehealth and telemedicine medical service records regarding informed consent must be retained for seven years.

Subsection (e) was not amended except for adding a title to clarify the content relates to issuance of prescriptions. Subsections (f), (g), (h) and (i) substantively retain their existing structure, except for amendments to Texas Medical Board rules citations, which were recently recodified by the agency.

PUBLIC BENEFIT/COST NOTE. Dr. Benton has also determined that for each year of the first five years that the proposed rules are in effect, the anticipated public benefit will be ensuring the public, participating in telehealth service or telemedicine medical service is appropriately informed of the potential risks of participating in said service.

There may be costs to licensees and/or their employers in drafting and/or implementing informed consent procedures for telehealth service or telemedicine medical service. However, the Board is not required to comply with the requirements of Tex. Gov't Code. §2001.0045(b) because the proposed amendments are necessary to implement legislation and to protect the health, safety, and welfare of the residents of this state.

The Board does not anticipate that any rural communities will be affected by the proposal. The Board anticipates few, if any, individual licensees will qualify as a small or micro business under §2006.001 and, therefore, be affected by the proposal. However, for those that may, the Board has determined that the proposal is necessary to protect the health, safety, and economic welfare of the state.

The purpose of the proposal is to implement the statutory requirements of Texas Occupations Code §111.004. In particular, the provisions of the proposal that may result in the cost of compliance are based upon the statutory mandates that require the same. The legislature has already determined that these requirements and associated costs are necessary to ensure that individuals participating in telehealth service or telemedicine medical service have documentation of appropriate informed consent on file. The proposal does not impose any additional costs other than those already imposed by the legislature. As a result, the Board has determined that there are no additional regulatory alternatives to the proposed new requirements that will sufficiently protect the health, safety, and economic interests of Texas consumers and the welfare of the state.

GOVERNMENT GROWTH IMPACT STATEMENT. The Board is required, pursuant to Tex. Gov't Code §2001.0221 and 34 Texas Administrative Code §11.1, to prepare a government growth impact statement. The Board has determined for each year of the first five years the proposed amendments will be in effect: (i) the proposal does not create or eliminate a government program; (ii) implementation of the proposal does not require the creation of new employee positions or the elimination of existing employee positions, as the proposal is not expected to have an effect on existing agency positions; (iii) implementation of the proposal does not require an increase or decrease in future legislative appropriations to the Board; (iv) the proposal does not require an increase or decrease in fees paid to the Board; (v) the proposal references new statutory requirements for licensees to follow when performing telehealth or telemedicine medical service; (vi) the proposal does not expand or repeal an existing regulation; (vii) the proposed rule does not increase or decrease the number of individuals subject to the rule's applicability; and (viii) the proposal does not have an effect on the state's economy.

STATUTORY AUTHORITY. These rule sections are proposed under the authority of Texas Occupations Code §111.004(c) and §301.151.

CROSS REFERENCE TO STATUTE. The following statutes are affected by this proposal: Texas Occupations Code §§111.001, 301.151.

§217.24. Telehealth Service and Telemedicine Medical Service in Nursing [~~Telemedicine Medical Service Prescriptions~~].

(a) Definitions.

(1) "Telehealth service" shall have the meaning defined by Texas Occupations Code §111.001(3).

(2) "Telemedicine medical service" shall have the meaning defined by Texas Occupations Code §111.001(4).

(b) The same standards discussed in this rule are applicable to telehealth service and telemedicine medical service regardless of whether the patient interaction occurs in a video format or an audio-only format.

(c) Informed consent for either telehealth service or telemedicine medical service requires the nurse to ensure a written record is maintained of informed consent signed by the patient, or a parent or legal guardian of the patient, if the patient is a minor, or the patient has been adjudicated incompetent to manage the patient's personal affairs. A signed, written informed consent is required for all treatment plans and procedures where a reasonable possibility of complications from the treatment planned or a procedure exists, or the treatment plans and procedures involve risks or hazards that could influence a reasonable person in deciding to give or withhold consent. Such consent must disclose any and all complications, risks and hazards and include the following:

(1) the name and Texas nursing license number(s) and/or license number with multistate licensure privilege, contact information, and practice location involved in the patient's telehealth service and/or telemedicine medical service. This information must be kept current, accessible and provided in writing to the patient, parent, or legal guardian;

(2) an advanced practice registered nurse (APRN) who completes a telemedicine medical service must ensure that the informed consent of the patient includes disclosure to the patient of:

(A) the name of the delegating physician;

(B) the physician's Texas medical license number;

(d) When engaging in telehealth or telemedicine medical services, a licensee must:

(1) confirm the identity of the patient;

(2) verify and authenticate the patient's health history;

(3) obtain informed consent from the patient after disclosures have been made regarding the delivery models and treatment methods and limitations, to include any special informed consent regarding the use of telehealth service or telemedicine medical service. At a minimum, the informed consent must inform the patient and document acknowledgment of the risk and limitations of:

(A) the collection and use of electronic and digital communications in the provision of care;

(B) the potential for breach of confidentiality, or inadvertent access, of protected health information using electronic and digital communication in the provision of care; and

(C) the potential disruption of electronic and digital communication in the use of telehealth service or telemedicine medical service;

(4) inform the patient that it is the role of the licensee to determine whether the treatment is appropriate for a telehealth service or telemedicine medical service encounter; and

(5) state the requirement for explicit patient consent to forward patient identifiable information to a third party.

(d) Informed consent records must be retained at least seven years from the date of last treatment by a nurse or longer if required by other federal or state law. If a patient is under 18 years old, informed consent records must be retained until the patient reaches 21 years old, or seven years from the date of last treatment, whichever is longer.

(e) Issuance of Prescriptions. [~~(a)~~] The validity of a prescription issued as a result of a telemedicine medical service is determined by the same standards that would apply to the issuance of the prescription in an in-person setting.

(f) [~~(b)~~] This rule does not limit the professional judgment, discretion or decision-making authority of a licensed practitioner. A licensed practitioner is expected to meet the standard of care and demonstrate professional practice standards and judgment, consistent with all applicable statutes and rules when issuing, dispensing, delivering, or administering a prescription medication as a result of a telemedicine medical service.

(g) [~~(c)~~] A valid prescription must be:

(1) issued for a legitimate medical purpose by a practitioner as part of patient-practitioner relationship as set out in §111.005, Texas Occupations Code; and

(2) meet all other applicable laws before prescribing, dispensing, delivering, or administering a dangerous drug or controlled substance.

(h) [~~(d)~~] Any prescription drug orders issued as the result of telemedicine medical service, are subject to all regulations, limitations, and prohibitions set out in the federal and Texas Controlled Substances Act, Texas Dangerous Drug Act and any other applicable federal and state law.

(i) [~~(e)~~] Limitation on Treatment of Chronic Pain.

(1) For purposes of this rule, chronic pain has the same definition as used in 22 Texas Administrative Code §172.1(2) [~~§170.2(4)~~] (relating to Definitions).

(A) Telemedicine medical service [~~services~~] used for the treatment of chronic pain with scheduled drugs by any means other than via audio and video two-way communication is prohibited, unless a patient:

(i) is an established patient of the APRN being treated for chronic pain;

(ii) is receiving a prescription that is identical to a prescription issued at the previous visit; and

(iii) has been seen by the prescribing APRN, physician, or other health professional as defined in Tex. Occ. Code §111.001(1) in the last 90 days, either:

(I) in-person; or

(II) via telemedicine medical service using audio and video two-way communication.

(B) An APRN, when determining whether to utilize telemedicine medical service [~~services~~] for the treatment of chronic pain with controlled substances as permitted by paragraph (1)(A) of this subsection, shall give due consideration to factors that include, at a minimum, the date of the patient's last in-person visit, patient co-morbidities, and occupational related COVID risks. These are not the sole, exclusive, or exhaustive factors an APRN should consider under this rule.

(C) If a patient is treated for chronic pain with scheduled drugs through the use of telemedicine medical service [~~services~~] as permitted by paragraph (1)(A) of this subsection, the medical records must document the exception and the reason that a telemedicine medical service visit was conducted instead of an in-person visit.

(2) For purposes of this rule, acute pain has the same definition as used in 22 Texas Administrative Code §172.1(1) [~~§170.2(2)~~]. Telemedicine medical service [~~services~~] may be used for the treatment of acute pain with scheduled drugs, unless otherwise prohibited under federal and state law.