TITLE 26. HEALTH AND HUMAN SERVICES
PART 1. HEALTH AND HUMAN SERVICES COMMISSION
CHAPTER 559. DAY ACTIVITY AND HEALTH SERVICES REQUIREMENTS
SUBCHAPTER
H.
The executive commissioner of the Texas Health and Human Services Commission (HHSC) adopts amendments to §§559.201, 559.203, 559.205, 559.215, 559.225, 559.227, 559.241, and 559.243; new §§559.226, 559.228, 559.253, 559.255, and 559.257; and the repeal of §559.239.
Sections 559.205, 559.225, 559.226, 559.227, 559.228, and 559.253 are adopted with changes to the proposed text as published in the July 25, 2025, issue of the Texas Register (50 TexReg 4225). These rules will be republished.
Sections 559.201, 559.203, 559.215, 559.239, 559.241, 559.243, 559.255, and 559.257 are adopted without changes to the proposed text as published in the July 25, 2025, issue of the Texas Register (50 TexReg 4225). These rules will not be republished.
BACKGROUND AND JUSTIFICATION
The adopted rules integrate heightened health and safety standards while minimizing unnecessary administrative and financial burdens on providers of Individualized Skills and Socialization (ISS). Specifically, the rules address environmental safety concerns, bolster the rights of individuals receiving individualized skills and socialization services, and implement Texas Health and Safety Code §253.0025 as established by House Bill 1009, 88th Regular Session, 2023, regarding suspension of employees during due process for reportable conduct. The adopted rules also establish alternative pathways to address infractions through administrative penalties, thereby offering providers remedial options beyond license revocation.
The adopted rules clarify existing requirements governing the prevention and investigation of abuse, neglect, or exploitation, and delineate provider requirements and criteria for license issuance or renewal. Additionally, non-substantive grammatical revisions enhance clarity and coherence within the regulatory framework.
COMMENTS
The 31-day comment period ended August 25, 2025.
During this period, HHSC received 65 comments regarding the proposed rules from six commenters including the Texas Council of Community Centers, Advantage Care Services, and Mission Road Developmental Center, and combined comments from Private Provider's Association of Texas and Provider's Alliance for Community Services of Texas. A summary of comments regarding the Individualized Skills and Socialization licensure rules and HHSC's responses follows.
Comment: Several commenters made remarks about §559.201, questioning HHSC's authority to establish licensure for Individualized Skills and Socialization providers under Day Activity and Health Services (DAHS) framework.
Response: HHSC disagrees and declines to revise the rule in response to this comment. HHSC has authority to regulate and license providers of Individualized Skills and Socialization services under Texas Human Resources Code, Chapter 103; Texas Government Code Chapter 532; and Human Resources Code, Chapter 32. The Office of the Attorney General, in Attorney General Opinion No. KP-0497, recognized HHSC's authority to establish the scope of DAHS under Chapter 103 and to create a subcategory of DAHS licensure for Individualized Skills and Socialization providers pursuant thereto.
Comment: Several commenters remarked that §559.203(1), defining "abuse" to include "negligent acts," creates confusion with the definition of "neglect," since neglect is currently defined as a failure to act resulting in harm.
Response: HHSC disagrees and declines to revise the rule in response to this comment. The proposed definitions clearly distinguish abuse, which involves acts causing harm, from neglect, which involves a failure to act.
Comment: Several commenters requested HHSC remove the term "emotional harm" from the definition of "actual harm" in §559.203(2) or provide a clearer threshold, as it may overlap with mental harm.
Response: HHSC disagrees and declines to revise the rule in response to these comments. HHSC retains "emotional harm" because it is distinct from "mental harm" and is used consistently in the Texas Administrative Code (e.g., Day Activity and Health Services (DAHS) Requirements 26 TAC §559.3 relating to Definitions). Emotional harm generally refers to injury affecting a person's emotional state, such as distress, fear, or humiliation, even if no diagnosable mental impairment occurs. Mental harm refers to injury affecting an individual's psychological or cognitive functioning.
Comment: Several commenters requested the deletion of "cause to believe" under §559.203(4), as they believe the definition is unclear, unnecessary, and does not reduce confusion in practice.
Response: HHSC disagrees and declines to revise the rule in response to these comments. "Cause to believe" means when a provider knows of, suspects, or receives an allegation regarding abuse, neglect, or exploitation, ensuring timely reporting and protection of individuals receiving services.
Comment: Several commenters stated that the definition of "complaint" in §559.203(8) is confusing because it has historically been used to refer to allegations of abuse, neglect, or exploitation (ANE), and to refer to programmatic grievances posted under §559.225(d)(2) for other services. Commenters recommended clarifying the definition to reflect both uses or provide additional guidance on the intended context.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The definition of "complaint" applies specifically to allegations of abuse, neglect, or exploitation, and any violations of Texas Human Resources Code, Chapter 103, or a rule, standard, or order adopted under Chapter 103. Any allegation, whether of abuse, neglect, and exploitation, or otherwise, reported to Complaint and Incident Intake (CII) from anyone who is not considered the provider, is considered a complaint.
Comment: Several commenters stated of §559.203(15) that the term "incident" is used inconsistently, sometimes referring to ANE and other times to non-routine occurrences affecting care. One commenter recommended either deleting the definition and addressing it only in reporting requirements or expanding the definition to capture both uses.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The definition of "incident" focuses on non-routine occurrences that impact care, supervision, or treatment, consistent with HHSC guidance. "Incident" is a broad term and instances of abuse, neglect, and exploitation are considered a specific type of incident.
Comment: A commenter recommended revising the statutory or Texas Administrative Code (TAC) reference found under §559.203(29), as the definition of "pattern" and other references to Texas Human Resources Code, Chapters 103 and 104, are inappropriate because these statutes govern the DAHS program rather than Individualized Skills and Socialization. The commenter recommended using more appropriate statutory or TAC references.
Response: HHSC disagrees and declines to revise the rule in response to this comment. HHSC has authority to regulate and license providers of Individualized Skills and Socialization services under Texas Human Resources Code, Chapter 103; Texas Government Code Chapter 532; and Human Resources Code, Chapter 32. The legislature expressly conferred upon HHSC authority to establish the scope of DAHS under Chapter 103, and HHSC created a subcategory of DAHS licensure for Individualized Skills and Socialization providers pursuant thereto. The licensure rules for Individualized Skills and Socialization do not include reference to Texas Human Resources Code, Chapter 104.
Comment: A commenter recommended revising the definition of "substantial violation" as found under §559.203(33), to "critical violation" and align it with the TAC definitions used in rules relating to administrative penalties for Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver programs.
Response: HHSC disagrees and declines to revise the rule in response to this comment. "Substantial violation" is defined in the rule to reflect the licensure framework for DAHS-Individualized Skills and Socialization providers. The terminology and definition are tailored to licensure requirements under TAC for this license type and do not conflict with waiver program terminology, which applies in a separate regulatory context. Maintaining distinct terminology avoids conflating licensure standards with Medicaid program requirements.
Comment: A commenter recommended including alternatives to the phrase "HHSC will refer the application for enforcement" as found under §559.205(h).
Response: HHSC disagrees and declines to revise the rule in response to this comment. The phrase "HHSC will refer the application for enforcement" reflects existing rule language and was not revised as part of this rule project. This phrase is consistent with terminology used across HHSC rules to describe the process by which possible non-compliance with requirements for licensure is evaluated for enforcement purposes including denial of a license.
Comment: A commenter requested HHSC provide clarification in rule regarding the requirement that a provider must not serve more individuals than indicated on its license, as found under §559.205(l). A commenter stated that it is unclear whether this refers to daily capacity or total enrollment.
Response: HHSC agrees with the commenters and incorporated clarifying language under §559.205(e)(7) of the rule regarding capacity requirements. The changes clarify that licensed capacity refers to the maximum number of individuals, regardless of funding source, who can receive services at or from this location, as determined by the provider and informed by building occupancy requirements, staff availability, and Medicaid program requirements governing on-site and off-site staff-to-clients ratios. Neither daily capacity (or attendance) nor total enrollment should exceed licensed capacity.
Comment: Several commenters stated that the individual information document required under §559.225(e) appears duplicative of the list of individuals required under §559.231(f)(3). Commenters requested HHSC offer training or guidance on the individual information document, and recommended HHSC incorporate flexibility into this requirement, so providers can include this information in one document.
Response: HHSC agrees with the commenters and revised the rule to incorporate language clarifying the start date and that the information required under §559.225(e) and §559.231(f) may be combined into a single document. HHSC intends to provide training and guidance to support providers in implementing requirements outlined in new and revised rules as needed, after rule adoption.
Comment: Several commenters made remarks about standards found in §559.226(a). Commenters stated requiring facilities to meet these standards is overly prescriptive and unrealistic since providers may not be able to prevent all occurrences despite reasonable measures. Commenters recommended revising the rule to focus on requiring reasonable efforts to prevent and remediate all potential concerns related to these standards, rather than prohibiting their occurrence outright.
Response: HHSC agrees with the commenters and revised the rule to include language under §559.226(b) indicating that, when determining whether a violation of the standards outlined in §559.226(a)(2) or (3) has occurred, HHSC considers actions taken by the provider to meet the requirements of these standards.
Comment: Several commenters stated that the requirement for major appliances under §559.226(a)(8) is unclear and overly broad. Commenters recommended that only refrigerators necessary for medication storage should be required, as other appliances (such as dishwashers, ovens, and washing machines) are not essential for the safe delivery of Individualized Skills and Socialization services.
Response: HHSC agrees with the commenters and revised the rule to include language clarifying that the requirement for major appliances applies to those that are necessary for meeting individual health and safety needs based on the population served by the provider.
Comment: Several commenters remarked that §559.226(a)(10)(A), which requires that cleaning chemicals be stored in their original containers, is impractical and inconsistent with common, safe practices such as diluting or transferring products into clearly labeled secondary containers. Commenters recommended allowing either original containers or properly labeled secondary containers consistent with Occupational Safety and Health Administration (OSHA) requirements.
Response: HHSC agrees with the commenters and revised the rule to include flexibility in labeling, such as requiring the label to include, at least, warnings, chemical names, and handling precautions. This will ensure the rules relating to cleaning chemical storage maintain clear, enforceable expectations that align with longstanding practices for other licensed long-term care providers as necessary for ensuring health and safety.
Comment: Several commenters supported the requirement in §559.226(b)(1) for a functioning heating and cooling system but objected to the additional requirement for an alternate method of supplying heating and cooling. Commenters stated the requirement is burdensome and unnecessary, suggesting that instead, HHSC requires providers to arrange alternate service locations if the system fails and the environment becomes unsafe.
Response: HHSC disagrees and declines to amend the rule as recommended by commenters. However, HHSC has amended the rule to clarify that, in the event of heating and cooling system failure, the provider must ensure temporary alternate methods of heating and cooling are available to individuals, including methods such as using back-up generators or fans that meet state, local, and federal guidelines in the event the system does not work or is in repair, and if alternate methods are not available, the provider must ensure alternate arrangements of service provision or methods of heating and cooling are provided in accordance with the provider's emergency plan, as outlined in §559.229 of this division (relating to Environment and Emergency Response Plan).
Comment: Several commenters recommended that, under §559.227(b)(1) regarding admission and discharge requirements, HHSC require licensed DAHS-Individualized Skills and Socialization providers to follow the same admission and discharge standards as HCS program providers.
Response: HHSC disagrees and declines to amend the rule as recommended by commenters. This requires a DAHS-Individualized Skills and Socialization provider to admit or discharge individuals based on the provider's demonstrated capacity to meet the needs of individuals safely and appropriately. However, HHSC has amended the rule to further clarify the providers' obligation to make reasonable efforts to retain an individual and to admit an individual when appropriate and feasible.
Comment: Several commenters suggested that, under §559.227(c)(2)(D), HHSC revise the rule to replace "individuals" with "all individuals" for clarity, noting that the current singular wording could be confusing.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The use of the term "individual" is intentional in this context and refers to each individual receiving services. The term "individual" aligns with the person-centered focus of the rule and avoids ambiguity.
Comment: Concerning §559.227(e), several commenters stated that the rule requiring the service location to be owned or leased by the DAHS-Individualized Skills and Socialization provider is too restrictive and limits the use of community-based spaces made available through formal agreements with non-profits, faith-based, or community organizations. Commenters recommended revising the rule to allow for such arrangements.
Response: HHSC disagrees and declines to revise the rule at this time. Location requirements for the provision of on-site and off-site Individualized Skills and Socialization services are governed by Medicaid program rules and settings requirements for home and community-based services (HCBS) under 26 TAC §263.2005. On-site, but not off-site, services must be provided in a location owned or leased by the provider. HHSC will gather the appropriate parties to discuss future rule projects related to this recommendation.
Comment: Several commenters stated that the requirement under §559.227(i) to document non-participation could be interpreted to require documentation of every individual activity choice (e.g., bowling vs. park), which would create an unnecessary administrative burden. Commenters recommended limiting intent to documenting when an individual or Legally Authorized Representative (LAR) declines participation in a scheduled service period, not activity preferences within it.
Response: HHSC agrees to make changes and revised the rule to clarify that documentation is not required if an individual or LAR chooses one activity over another during the scheduled on-site or off-site individualized skills and socialization activity.
Comment: A commenter agreed that DAHS-Individualized Skills and Socialization providers should be able to communicate observed needs, as outlined in §559.227(j), but stated that making assessments is outside the provider's scope and falls within the responsibility of licensed professionals.
Response: HHSC appreciates the commenters feedback but declines to revise the rule in response to this comment. The proposed rule under §559.227(j) does not imply that the DAHS-Individualized Skills and Socialization provider is required to assess individuals. This requirement outlines the DAHS-Individualized Skills and Socialization provider's responsibility to communicate when the provider becomes aware of a modification or restriction needed based on an already assessed need. This ensures health and safety needs are addressed while maintaining the defined scope of the DAHS-Individualized Skills and Socialization provider's responsibilities.
Comment: A commenter recommended replacing the term "person centered plan" with Person-directed Plan or Implementation Plan (whichever was intended) in §559.227(j).
Response: HHSC disagrees and declines to revise the rule in response to this comment. This subsection defines the term "person-centered plan," which includes the individual's person-directed plan (PDP) for HCS and TxHmL waiver program participants, or individual program plan (IPP) for Deaf Blind with Multiple Disabilities (DBMD) waiver program participants.
Comment: Several commenters recommended revising the cross-reference in §559.227(j)(3) from §559.225(f) to §559.225(e).
Response: HHSC agrees with the commenters and revised the cross-reference found under §559.227(j)(3) from §559.225(f) to §559.225(e).
Comment: A commenter stated the requirement outlined in §557.227(j)(4) is outside the scope of the DAHS-Individualized Skills and Socialization provider's responsibility, as DAHS-Individualized Skills and Socialization providers do not participate in creating or updating the PDP or person-centered service plans. Commenter stated that such updates are the responsibility of the service coordinator and the individual, or the LAR, and DAHS-Individualized Skills and Socialization providers would not have the capacity to update the plan.
Response: HHSC disagrees and declines to revise the rule in response to this comment. The intent of this requirement is not to imply that a DAHS-Individualized Skills and Socialization provider would be responsible for updating an individual's PDP or person-centered service plan; this requirement indicates that providers must inform service providers, which are defined in §559.203 of rule concerning Definitions, as employees, contractors, or volunteers who directly provide Individualized Skills and Socialization services, of modifications or restrictions to an individual's plan. This requirement aligns with existing rule requirements and ensures health and safety needs are met while maintaining the provider's defined responsibilities.
Comment: Several commenters made remarks about §559.227(l). Commenters stated trainings are required too frequently and recommended extending the period of time allowed between trainings. Commenters recommended changing the current rule regarding the ongoing training requirement for Cardiopulmonary Resuscitation (CPR) in §559.227(l)(1)(B)(i) from "ensure service providers maintain current CPR certification" to "maintain current documentation of course completion or current certification in CPR."
Response: HHSC agrees with the commenters and revised the timeframe between required training. While initial and ongoing training requirements will remain consistent with existing requirements, HHSC will incorporate language into the rules to extend retraining requirements to every two years (biannually). For the population served, retraining will be required whenever there is an update to an individual's plan.
Comment: With respect to §559.227(m)(1)(C)(i) and (ii), several commenters recommended refining medication documentation requirements to align with standard medical and pharmacy practices, including verification through the pharmacy label or updated healthcare provider order, and allowing temporary use of a prescriber's order until a new pharmacy label is available. Commenters stated that requiring providers to verify prescription orders with the pharmacy or healthcare provider, or the requirement to document certain details, such as pharmacist instructions, generic substitutions, administration times, doses received, and administration specifics could be confusing and burdensome.
Response: HHSC agrees with the commenters and revised rule language to indicate that medication documentation must reflect information on the prescription label. The requirement to document this information in the medication record is essential to ensure that medications are properly accounted for and accurately administered. Omitting this information creates potential risk to the individual's health and safety and increases the likelihood of medication discrepancies or drug diversion. These requirements align with federal and state pharmacy labeling requirements and ensure safe, accurate medication administration.
Comment: Several commenters stated of §559.227(m)(3)(E) that requiring Schedule II medications to be stored in a locked, permanently attached cabinet, box, or drawer is impractical for off-site, community-based services. Commenters expressed concern that individuals needing these medications could potentially be excluded from off-site activities or face care disruptions. One commenter recommended allowing secure, portable storage under authorized staff control for off-site services.
Response: HHSC agrees with the commenters and revised rule language to incorporate provisions pertaining to off-site storage of Schedule II medications under §559.227(m)(3)(iii).
Comment: Several commenters made remarks about §559.228(e), recommending that HHSC revise rule language to require DAHS-Individualized Skills and Socialization providers to support individuals in addressing concerns that apply only to the provision of Individualized Skills and Socialization services and not to unrelated waiver services.
Response: HHSC agrees with the commenters and revised rule language to clarify that this requirement applies to individualized skills and socialization providers addressing concerns with the program provider regarding the individual plan of care (IPC), IPP, PDP, or implementation plan when the individual dislikes or disagrees with the services being rendered by the individualized skills and socialization provider.
Comment: Several commenters recommended that, under §559.229(f)(2)(C), providers be permitted to use provider-developed documentation systems for forms such as the Fire Drill Report Form (4719), the individual information document (as outlined in §559.225(e) and §559.231(f)(3)), or an individual's Electronic Health Record (EHR), whether paper or electronic, so long as all HHSC-required elements are included.
Response: HHSC agrees with the commenters and revised rule language to incorporate this flexibility into rule under §559.225(g). This allows for flexibility regarding certain forms, documents, and records required under the Individualized Skills and Socialization Licensure Rules, such as the HHSC Fire Drill Report Form (4719) referenced under §559.229(f)(2)(C) of this subchapter, the individual information document referenced under §559.225(e), the list of individuals referenced under §559.231(f), and Electronic Health Records (EHRs). These documents may be completed and maintained electronically, either on the HHSC-prescribed form or on a provider-developed form or template that includes, at a minimum, the information required by HHSC. After rule adoption, HHSC will issue communication to providers about this flexibility. Rule language found under §559.229(f)(2)(C) referencing the HHSC Fire Drill Report Form will be amended to include this clarification in a future rule project, as changes to this rule section were not included as part of this rulemaking.
Comment: Several commenters stated that requirements under §559.241(d) eliminate the ability for providers to use their own forms or electronic systems for provider investigation reports. Commenters further stated that many providers use internal tools that capture all required elements, and requiring providers to use specific HHSC forms could create duplicative documentation, increase costs, and reduce efficiency without improving protections for individuals.
Response: HHSC disagrees and declines to revise the rule in response to these comments. HHSC Form 3613-A, Provider Investigation Report, is the standard form used by licensed long-term care providers when submitting written investigation reports to HHSC in accordance with regulatory requirements. This requirement to send a written investigation report on Form 3613-A, Provider Investigation Report, is necessary to avoid delays in processing submissions and ensure investigations are undertaken consistently among providers.
Comment: Several commenters stated that the term "complaint" in §559.243 is confusing because it has been historically used in two ways: to refer to allegations of ANE, and to refer to programmatic grievances posted under §559.225(d)(2) for other services. Commenters recommend clarifying the definition under §559.203(8) concerning Definitions, to reflect both uses or provide additional guidance on the intended context.
Response: HHSC disagrees and declines to revise the rule in response to these comments. "Complaint," as defined in §559.203(8) concerning Definitions, applies specifically to allegations of abuse, neglect, or exploitation, and any violations of Texas Human Resources Code, Chapter 103, or a rule, standard, or order adopted under Chapter 103. Any allegation, whether of abuse, neglect, and exploitation, or otherwise, reported to Complaint and Incident Intake (CII) from anyone who is not considered the provider, is considered a complaint. Use of the term in this subsection is consistent with the definition found under §559.203(8).
Comment: Several commenters made remarks about §559.253, stating that HHSC cannot reasonably impose costly new obligations without addressing rate adequacy, or services will continue to destabilize.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The cost to providers regarding administrative penalties will depend on each provider's compliance with regulatory requirements. Rates are not within the scope of this rulemaking.
Comment: A commenter recommended that HHSC insert the phrase "against the individualized skills and socialization provider" in §559.253(a) to increase clarity.
Response: HHSC disagrees and declines to revise the rule in response to this comment. The Individualized Skills and Socialization licensure rules apply specifically to licensed DAHS-Individualized Skills and Socialization providers.
Comment: Several commenters made remarks about §559.253(b) regarding administrative penalty amounts. Commenters stated that penalties should not exceed $500 per violation, and recommended HHSC change rule language to align Individualized Skills and Socialization penalties with DAHS penalty standards and Texas Human Resources Code §103.012(b).
Response: HHSC agrees with the commenters and revised administrative penalty amounts, as shown under Figure §559.253(b) in rule. Penalty amounts have been revised to align with Texas Human Resources Code §103.012(b).
Comment: Several commenters recommended revising §559.253(f)(1) so that the penalty period begins on the date the provider is formally notified of the violation, not on the date HHSC internally "identifies" it.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The penalty period should begin when the violation began. The beginning of the violation corresponds better with when HHSC identifies the violation to protect the health and safety of individuals than when HHSC provides formal notice of it.
Comment: Several commenters recommended aligning §559.253(g) with DAHS administrative penalty rules regarding the date of correction, which presume the date of correction identified in the provider's written plan of correction to be the actual date of correction unless HHSC later determines the correction was not made or was unsatisfactory.
Response: HHSC disagrees and declines to revise the rule in response to these comments. The plan of correction gives a presumed date of correction. Because actual correction is determined by follow-up visit, HHSC will not amend the proposed rule.
Comment: Several commenters requested that HHSC consider, under §559.253 regarding implementation of administrative penalties for DAHS-Individualized Skills and Socialization providers, an effective date for implementation of administrative penalties that is at least six months from the effective date of the new administrative penalty rules.
Response: HHSC disagrees and declines to revise the rule in response to these comments. As the Individualized Skills and Socialization Licensure rules are an extension of the DAHS rules generally, providers were aware of administrative penalties as a possible remedy in the Individualized Skills and Socialization rules.
Comment: Several commenters recommended including information about the Informal Dispute Resolution (IDR) process under §559.255(g)(3)(B).
Response: HHSC disagrees and declines to revise the rule in response to these comments. The IDR process for DAHS-Individualized Skills and Socialization providers is outlined under §559.233(g) of existing licensure rules for Individualized Skills and Socialization, and no changes to §559.233(g) were proposed as part of this rulemaking.
Comment: Several commenters recommended matching DAHS penalty rule language regarding the date of correction under §559.255(l).
Response: HHSC disagrees and declines to revise the rule in response to these comments. The language under §559.255(l) is consistent with the current DAHS rule language regarding the date of correction located at §559.107(c).
HHSC made changes to rule language independent of the formal comment process and as a result of internal and external stakeholder meeting feedback.
HHSC received several comments that fell outside the scope of this project. Comments included that HHSC provide adequate reimbursement rates to cover operational costs; include language in the Individualized Skills and Socialization licensure rules that prohibits providers from charging individuals and their LARs additional fees; and outline HHSC's internal processes for licensure surveys.
HHSC did not make changes as a result of the comments noted above, as they were outside the scope of this rulemaking.
DIVISION 1. INTRODUCTION
26 TAC §559.201, §559.203STATUTORY AUTHORITY
The amendments are adopted under 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 §532.0051, which provides HHSC with the authority to administer federal funds and plan and direct the Medicaid program in each agency that operates a portion of the Medicaid program; and Texas Human Resources Code §32.021, which provides that HHSC adopt rules necessary for the proper and efficient operation of the Medicaid program, and §103.004, which requires the executive commissioner of HHSC to adopt rules and set standards implementing Chapter 103.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600192
Karen Ray
Chief Counsel
Health and Human Services Commission
Effective date: February 9, 2026
Proposal publication date: July 25, 2025
For further information, please call: (512) 438-3161
DIVISION 2. LICENSING
26 TAC §559.205, §559.215STATUTORY AUTHORITY
The amendments are adopted under 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 §532.0051, which provides HHSC with the authority to administer federal funds and plan and direct the Medicaid program in each agency that operates a portion of the Medicaid program; and Texas Human Resources Code §32.021, which provides that HHSC adopt rules necessary for the proper and efficient operation of the Medicaid program, and §103.004, which requires the executive commissioner of HHSC to adopt rules and set standards implementing Chapter 103.
§559.205.
(a) An entity may not establish or provide individualized skills and socialization services in Texas without a license issued by the Texas Health and Human Services Commission (HHSC) in accordance with Texas Human Resources Code, Chapter 103, and this subchapter.
(b) An individualized skills and socialization provider must be listed on the HHSC Day Activity and Health Services (DAHS) directory as an individualized skills and socialization provider to provide individualized skills and socialization services.
(c) An applicant for a license must follow the application instructions and submit a completed application form, required documentation, and required license fee to HHSC through the online licensure portal.
(d) An applicant for a license must complete HHSC required training to become an individualized skills and socialization provider and provide documentation that required training is complete through the application in the online licensure portal.
(e) An applicant for a license must submit to HHSC as part of the application the:
(1) name of the business entity to be licensed;
(2) tax identification number;
(3) name of the chief executive officer (CEO) or equivalent person;
(4) ownership information;
(5) address of the on-site individualized skills and socialization location or, for providers of off-site individualized skills and socialization services only, the designated place of business where records are kept;
(6) name of program providers using this entity for individualized skills and socialization services, if any;
(7) maximum number of individuals, regardless of funding source, who can receive services at or from this location, as determined by the provider and informed by building occupancy requirements, staff availability, and Medicaid program requirements, which will become the licensed capacity when approved;
(8) effective date the entity will be available to provide individualized skills and socialization services;
(9) attestation that the applicant has created and implemented a community engagement plan, including:
(A) a description of how the organization will meet the requirement to make off-site individualized skills and socialization available to individuals;
(B) a description of how the organization will work with contracted program providers to obtain information from the individuals' person-directed plans (PDP) and implementation plan, and use that information to inform on-site and off-site activities that are aligned with an individual's PDP; and
(C) a description of how staff will respond to an emergency or other unexpected circumstance that may occur during the provision of on-site and off-site individualized skills and socialization services to ensure the health and safety of all individuals; and
(10) any other information required by the online application instructions.
(f) HHSC may deny an application that remains incomplete after 120 days.
(g) Before issuing a license, HHSC considers the background and qualifications of:
(1) the applicant or license holder;
(2) a person with a disclosable interest;
(3) an affiliate of the applicant or license holder;
(4) an administrator;
(5) a manager; and
(6) any other person disclosed on the submitted application as defined by the application instructions.
(h) If the location where an applicant intends to provide on-site or off-site individualized skills and socialization services is located within, on the grounds of, or physically adjacent to a prohibited setting as set forth in the rules governing the Home and Community-based Services (HCBS) waiver programs, as described in §263.2005(d) of this title (relating to Description of On-Site and Off-Site Individualized Skills and Socialization), and the applicant has not been approved through heightened scrutiny process as described in §263.2005(e) of this title, HHSC will refer the application for enforcement.
(i) HHSC issues a license if it finds that the applicant or license holder, and all persons described in subsection (g) of this section, affirmatively demonstrate compliance with all applicable requirements of this subchapter, based on an on-site survey.
(j) For DAHS Individualized Skills and Socialization Only licensure applications, HHSC may:
(1) at its sole discretion, issue a temporary initial license effective for 180 days, which may be extended until such time as an applicant demonstrates that it meets the requirements for operation based on an on-site survey; and
(2) issue a three-year license to applicants described under this subsection.
(k) For DAHS with Individualized Skills and Socialization licensure applications, HHSC will follow the criteria for licensure as described in §559.11 of this chapter (related to Criteria for Licensing).
(l) An individualized skills and socialization provider must not provide services to more individuals than the number of individuals specified on its license.
(m) An individualized skills and socialization provider must prominently and conspicuously post its license for display in a public area of the on-site individualized skills and socialization location that is readily accessible to individuals, employees, and visitors. For an off-site only individualized skills and socialization provider, the license must be displayed in a conspicuous place in the designated place of business.
(n) If any information submitted through the application process changes following licensure, the license holder must submit an application through the online licensure portal to make the changes.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600193
Karen Ray
Chief Counsel
Health and Human Services Commission
Effective date: February 9, 2026
Proposal publication date: July 25, 2025
For further information, please call: (512) 438-3161
DIVISION 3. PROVIDER REQUIREMENTS
26 TAC §§559.225 - 559.228STATUTORY AUTHORITY
The amendments and new sections are adopted under 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 §532.0051, which provides HHSC with the authority to administer federal funds and plan and direct the Medicaid program in each agency that operates a portion of the Medicaid program; and Texas Human Resources Code §32.021, which provides that HHSC adopt rules necessary for the proper and efficient operation of the Medicaid program, and §103.004, which requires the executive commissioner of HHSC to adopt rules and set standards implementing Chapter 103.
§559.225.
(a) An individualized skills and socialization provider must:
(1) comply with the provisions of Texas Health and Safety Code (HSC), Chapter 250 (relating to Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities Serving the Elderly, Persons with Disabilities, or Persons with Terminal Illnesses);
(2) before offering employment to any person, search the following registries to determine if the person is eligible for employment:
(A) the employee misconduct registry (EMR) established under HSC §253.007;
(B) the Texas Health and Human Services Commission (HHSC) nurse aide registry (NAR) and medication aide registry (MAR);
(C) the List of Excluded Individuals and Entities (USLEIE) maintained by the United States Department of Health and Human Services; and
(D) the List of Excluded Individuals and Entities (LEIE) maintained by HHSC Office of Inspector General;
(3) not employ a person who is listed on the:
(A) HHSC employee misconduct registry as unemployable; or
(B) HHSC nurse or medication aide registries as revoked or suspended; and
(4) provide information about the EMR to an employee in accordance with §561.3 of this title (relating to Employment and Registry Information).
(b) In addition to the initial search of the EMR, LEIE, NAR, MAR, and USLEIE, an individualized skills and socialization provider must:
(1) conduct a search of the NAR, MAR, and EMR to determine if the employee is designated in those registries as unemployable at least every 12 months;
(2) keep a copy of the results of the initial and annual searches of the NAR, MAR, and EMR in the employee's personnel file and make it available to HHSC upon request; and
(3) comply with all relevant federal and state standards.
(c) An individualized skills and socialization provider must:
(1) report abuse, neglect, and exploitation in accordance with §559.241 of this subchapter (relating to Reporting Abuse, Neglect, or Exploitation to HHSC);
(2) suspend a service provider who HHSC finds has engaged in reportable conduct while the service provider exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, pending a final decision by an administrative law judge, and may not reinstate the service provider during any applicable appeals process;
(3) develop and enforce policies and procedures for creating and maintaining incident reports; and
(4) ensure the confidentiality of individual records and other information related to individuals.
(d) An individualized skills and socialization provider must prominently and conspicuously post for display in a public area of the on-site individualized skills and socialization location, or designated place of business for off-site only individualized skills and socialization, that is readily available to individuals, employees, and visitors:
(1) the license issued under this chapter;
(2) a sign prescribed by HHSC that describes complaint procedures and specifies how complaints may be filed with HHSC;
(3) a notice in the form prescribed by HHSC stating that survey and related reports are available at the on-site individualized skills and socialization location for public survey and providing the HHSC toll-free telephone number that may be used to obtain information concerning the individualized skills and socialization provider;
(4) a copy of the most recent survey report relating to the individualized skills and socialization provider;
(5) a brochure, letter, or website that outlines the individualized skills and socialization provider's hours of operation, holidays, and a description of activities offered; and
(6) emergency telephone numbers, including the abuse hotline telephone number.
(e) In addition to the list of individuals served as described in §559.231(f)(3) of this subchapter (relating to Surveys and Visits), an individualized skills and socialization provider must also maintain an individual information document that includes:
(1) information on the individualized skills and socialization provider's service delivery method for each individual, such as on-site and off-site, or off-site only;
(2) the individual's name, identification, or clinical record number; and
(3) the date the individual began receiving on-site and off-site, or off-site only individualized skills and socialization services from the provider.
(f) An individualized skills and socialization provider may combine the list of individuals served and the information required for the individual information document into a single document. However, the provider must ensure the combined document meets all requirements of §559.231(f)(3) of this subchapter and subsection (e) of this section.
(g) An individualized skills and socialization provider may maintain records or forms either on the HHSC-prescribed form or on a provider-developed form or template maintained through the provider's own documentation system, whether digital or paper, including electronic health records or other documents maintained for the purpose of compliance with the licensure requirements of this subchapter, unless otherwise specified. Records maintained through the provider's own documentation system must:
(1) contain the same information as the HHSC-prescribed document or form as outlined in this subchapter;
(2) meet the confidentiality and recordkeeping requirements outlined in this subchapter; and
(3) be readily accessible and available for review by HHSC upon request, as required under §559.231(f) of this subchapter.
§559.226.
(a) An individualized skills and socialization provider must ensure the facility interior of the on-site location:
(1) has furnishings that are appropriately maintained and safe for use;
(2) is clean, sanitary, and free of odors that are considered disruptive, unpleasant, or potentially offensive;
(3) is free of infestation by bugs, rodents, and other pests;
(4) has walls, ceilings, floors, and windows that are structurally sound;
(5) is free of environmental contaminants, physical hazards, and accumulated waste or trash;
(6) has bathrooms that are accessible, functional, and safe for use;
(7) has hot water available for use by individuals receiving services that:
(A) is located at sinks in the facility that may be used by individuals receiving services; and
(B) does not exceed 120 degrees Fahrenheit;
(8) has any major appliances maintained in a safe and operational condition necessary to meet the health and safety needs of individuals served by the provider, such as refrigerators for medication storage;
(9) has a secure storage area for cleaning chemicals and supplies that is located separately from any storage area for food items;
(10) has cleaning chemicals that are used in accordance with directions and warnings on the product label and that are stored:
(A) in their original containers; or
(B) in clearly labeled secondary containers with a label that includes, at a minimum, warnings, chemical names, and handling precautions;
(11) has a location where perishable food is either refrigerated or otherwise stored safely; and
(12) has working smoke alarms in all main areas that:
(A) are maintained in accordance with the manufacturer's instructions;
(B) emit a distinguishable audible response that can be heard throughout the facility including classrooms, common areas, and hallways; and
(C) are used solely for the purpose of alerting individuals and service providers of a fire.
(b) When determining whether a violation of the standards outlined in subsection (a)(2) or (3) of this section has occurred, HHSC considers actions taken by the provider to meet the requirements of these standards.
(c) An individualized skills and socialization provider must ensure the interior of the on-site location is serviced by a functioning heating and cooling system.
(1) If the heating and cooling system fails, the provider must ensure temporary alternate methods of heating and cooling are available to individuals, including methods such as using back-up generators or fans that meet state, local, and federal guidelines in the event the system does not work or is in repair.
(2) If alternate methods are not available, the provider must ensure alternate arrangements of service provision or methods of heating and cooling are provided in accordance with the provider's emergency plan, as outlined in §559.229 of this division (relating to Environment and Emergency Response Plan).
(3) The provider must ensure that heating and cooling temperature settings for its system, or any alternate method, are appropriate for maintaining a safe environment for individuals and consider the specific health and safety needs of individuals when determining the appropriate heating and cooling temperature settings.
(d) An individualized skills and socialization provider must ensure the facility exterior of the on-site location:
(1) is free of hazards and the accumulation of waste and trash;
(2) is accessible to individuals receiving services;
(3) does not compromise the health or safety of individuals; and
(4) if applicable, has exterior furnishings that are maintained appropriately and safe for use.
§559.227.
(a) Staff qualifications.
(1) An individualized skills and socialization provider must:
(A) employ an administrator;
(B) ensure the administrator meets the requirements outlined in paragraph (2) of this subsection; and
(C) have a policy regarding the delegation of responsibility in the administrator's absence.
(2) A service provider of individualized skills and socialization must be at least 18 years of age and:
(A) have a high school diploma or a certificate recognized by a state as the equivalent of a high school diploma; or
(B) have documentation of a proficiency evaluation of experience and competence to perform the job tasks that includes:
(i) a written competency-based assessment of the ability to document service delivery and observations of the individuals receiving services; and
(ii) at least three written personal references from persons not related by blood that indicate the ability to provide a safe, healthy environment for the individuals receiving services.
(3) A service provider of individualized skills and socialization who provides transportation must:
(A) have a valid driver's license; and
(B) transport individuals in a vehicle that:
(i) is insured in accordance with state law; and
(ii) meets all state registration and safety requirements.
(b) Admission and retention of individuals; staffing. An individualized skills and socialization provider must ensure the following.
(1) An individualized skills and socialization provider must not admit an individual whose needs the provider cannot meet. The determination that the provider cannot meet the individual's needs must be based on:
(A) information provided by the program provider regarding the individual's health and safety needs, as documented in the individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), and implementation plan, as applicable; and
(B) the provider's availability of trained staff to meet the individual's needs.
(2) An individualized skills and socialization provider must not retain an individual whose needs the provider can no longer meet. The determination that the provider can no longer meet the individual's needs must be based on:
(A) documented reasonable efforts by the individualized skills and socialization provider to meet the individual's needs and discussion with the individual, the individual's LAR, and the program provider, as applicable, regarding the provider's efforts and any identified areas of concern; and
(B) notification to the individual, the individual's LAR, and the program provider, as applicable, prior to discharge, that the individualized skills and socialization provider can no longer meet the individual's needs.
(3) An individualized skills and socialization provider must maintain a ratio of service providers to individuals in accordance with §260.507 of this title (relating to Staffing Ratios), §262.917 of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), and §263.2017 of this title (relating to Staffing Ratios for Off-Site Individualized Skills and Socialization), during the provision of off-site individualized skills and socialization, including during transportation.
(4) An individualized skills and socialization provider must ensure adequate numbers of appropriately trained staff are on duty at all times during the provision of on-site individualized skills and socialization to ensure:
(A) the health and safety of the individuals;
(B) the needs and behaviors of the individuals are managed;
(C) supervision is provided in accordance with the needs of an individual; and
(D) individualized skills and socialization services or similar services are provided in accordance with an individual's individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), and implementation plan, as applicable.
(c) Staff responsibilities.
(1) The administrator:
(A) manages the individualized skills and socialization services and the on-site individualized skills and socialization location;
(B) ensures staff are trained;
(C) supervises staff; and
(D) maintains all records.
(2) A service provider:
(A) delivers individualized skills and socialization services;
(B) assists with recreational activities;
(C) provides protective supervision through observation and monitoring; and
(D) is trained on the needs of the individual.
(d) An individualized skills and socialization provider must make both on-site and off-site individualized skills and socialization services available to an individual who receives Home and Community-based Services (HCS), Texas Home Living (TxHmL), or Deaf Blind with Multiple Disabilities (DBMD) services, unless the individualized skills and socialization provider provides off-site individualized skills and socialization services only.
(e) An individualized skills and socialization provider must ensure that on-site individualized skills and socialization services:
(1) are provided in a building or a portion of a building that is owned or leased by an individualized skills and socialization provider;
(2) promote an individual's development of skills and behavior that support the individual's independence and personal choice; and
(3) are not provided in:
(A) a prohibited setting for an individual, as set forth in the rules governing Home and Community-based Services (HCBS) waiver programs; or
(B) the residence of an individual or another person.
(f) An individualized skills and socialization provider must ensure that off-site individualized skills and socialization services:
(1) include activities that:
(A) integrate the individual into the community; and
(B) promote the individual's development of skills and behavior that support the individual's independence and personal choice;
(2) are provided in a community setting chosen by the individual from among available community setting options;
(3) include transportation necessary for the individual's participation in off-site individualized skills and socialization; and
(4) are not provided in:
(A) a building in which on-site individualized skills and socialization are provided;
(B) a prohibited setting for an individual, as set forth in the rules governing Home and Community-based Services (HCBS) waiver programs, unless:
(i) provided in an event open to the public; or
(ii) the activity is a volunteer activity performed by an individual in such a setting; or
(C) the residence of an individual or another person, unless the activity is a volunteer activity performed by an individual in the residence.
(g) An individualized skills and socialization provider must:
(1) provide services:
(A) that promote autonomy and positive social interaction;
(B) in accordance with:
(i) the individuals IPC, IPP, PDP, or implementation plan as applicable; and
(ii) the individuals identified health and safety needs, physicians' orders, and goals, as documented and agreed upon by the individual or the individual's legally authorized representative (LAR); and
(2) develop and implement written policies and procedures for consistent and effective monitoring and documentation of an individual's progress towards person-centered objectives related to skill development and socialization, in accordance with the individuals IPC, IPP, PDP, or implementation plan as applicable.
(h) An individualized skills and socialization provider must not require an individual to take a skills test or meet other requirements to receive off-site individualized skills and socialization services.
(i) If an individual does not want to participate in a scheduled on-site or off-site individualized skills and socialization activity, or the individual's LAR does not want the individual to participate in a scheduled on-site or off-site individualized skills and socialization activity, the individualized skills and socialization provider must document the decision not to participate in the individual's record. Documentation is not required if an individual chooses one activity over another during the scheduled on-site or off-site individualized skills and socialization activity.
(j) If an individualized skills and socialization provider becomes aware that a modification or restriction to the services provided is needed based on a specific assessed need of an individual, the individualized skills and socialization provider must:
(1) inform the individual's program provider of the needed modification or restriction;
(2) obtain updated documentation from the program provider outlining the modification or restriction on the individual's person-centered service plan, which includes:
(A) for HCS and TxHmL, the individual's PDP; or
(B) for DBMD, the individual's IPP;
(3) ensure the updated person-centered service plan is received from the program provider and maintained in the individual's record, and that any updates are included on the individual information document as described in §559.225(e) of this division (relating to General Requirements) prior to the implementation of the modification or restriction;
(4) inform service providers of updates to an individual's person-centered service plan; and
(5) ensure the implementation of modifications or restrictions is in accordance with the individual's updated person-centered service plan.
(k) An individualized skills and socialization provider must provide on-site and off-site individualized skills and socialization services in-person.
(l) Training.
(1) Initial training.
(A) An individualized skills and socialization provider must:
(i) provide service providers with training on fire, disaster, and their responsibilities under the emergency response plan developed in accordance with §559.229 of this division (relating to Environment and Emergency Response Plan) within three workdays after the start of employment and document the training in the individualized skills and socialization provider's records; and
(ii) provide service providers with a minimum of eight hours of training during the first three months after the start of employment and document the training in the records of the individualized skills and socialization provider.
(B) The training provided in accordance with subparagraph (A)(ii) of this paragraph must include:
(i) any nationally or locally recognized adult CPR course or certification;
(ii) first aid;
(iii) infection control;
(iv) an overview of the population served by the individualized skills and socialization provider; and
(v) identification and reporting of abuse, neglect, or exploitation.
(2) Ongoing training. In addition to initial training requirements described in paragraph (1)(A) of this subsection, an individualized skills and socialization provider must:
(A) maintain current documentation of each service provider's CPR course completion or certification in CPR;
(B) retrain service providers on their responsibilities under the emergency response plan developed in accordance with §559.229 of this division at least biannually and when the service provider's responsibilities under the plan change;
(C) conduct training for service providers on infection control policies and procedures developed in accordance with subsection (o) of this section at least biannually;
(D) retrain service providers on the population served whenever there is an update to an individual's plan; and
(E) conduct training for service providers on the identification and reporting of abuse, neglect, or exploitation at least biannually.
(m) Medications.
(1) Administration.
(A) If individuals cannot or choose not to self-administer medications, an individualized skills and socialization provider must provide assistance with such medications and the performance of related tasks if:
(i) a registered nurse has assessed the need for assistance and related tasks and delegated such to the individualized skills and socialization provider in accordance with state law and rules; or
(ii) a physician has delegated the assistance and related tasks as a medical act to the individualized skills and socialization provider under Texas Occupations Code Chapter 157, as documented by the physician.
(B) An individualized skills and socialization provider must record an individual's medications, including over-the-counter medications, on the individual's medication profile record and ensure that medication labels are:
(i) original and current;
(ii) easily readable;
(iii) affixed to the corresponding prescription bottle, container, or packaging; and
(iv) include the appropriate accessory and cautionary instructions and prescription expiration date when applicable.
(C) An individualized skills and socialization provider must ensure that information on the medication profile record:
(i) reflects current prescription orders as verified by the pharmacy label or updated healthcare provider order; and
(ii) includes the medication name, strength, dosage, doses received, directions for use, route of administration, prescription number, pharmacy name, and the date each medication was issued by the pharmacy.
(2) General.
(A) An individualized skills and socialization provider must immediately report to an individual's program provider any unusual reactions to a medication or treatment.
(B) When an individualized skills and socialization provider supervises or administers medications, the individualized skills and socialization provider must:
(i) maintain accurate, current, and accessible documentation of medication administration for each individual; and
(ii) document the date and time each medication was taken in accordance with recorded information on the individual's medication profile record.
(C) In the event of a medication error, or if an individual does not receive or take the medication or treatment as prescribed, the individualized skills and socialization provider must:
(i) document the date and time the medication dose should have been administered or provided to the individual; and
(ii) the name and strength of any medication missed.
(3) Storage.
(A) An individualized skills and socialization provider must provide a locked area for all medications, which may include:
(i) a central storage area;
(ii) a medication cart that, when not in use, is secured in the area designated for its storage; or
(iii) for off-site individualized skills and socialization services, a secure, portable, locked container under the direct control of authorized staff at all times.
(B) An individualized skills and socialization provider must store an individual's medication separately from other individuals' medications within the storage area.
(C) An on-site individualized skills and socialization provider must store medication requiring refrigeration in a locked refrigerator used only for medication storage, or in a separate, permanently attached, locked medication storage box in a refrigerator.
(D) An individualized skills and socialization provider must store poisonous substances and medications labeled for "external use only" separately within the locked area.
(E) An on-site individualized skills and socialization provider must store drugs covered by Schedule II of the Controlled Substances Act of 1970 in a locked, permanently attached cabinet, box, or drawer that is separate from the locked storage area for other medications.
(F) An individualized skills and socialization provider must store medications in accordance with manufacturer's instructions, under sanitary conditions, and with consideration of requirements pertaining to temperature, light, moisture, ventilation, segregation, and security.
(G) An individualized skills and socialization provider must ensure that during the provision of off-site individualized skills and socialization services, all medications for which the provider is responsible:
(i) remain in a secure, portable, locked container; and
(ii) remain under the direct control of authorized staff at all times.
(H) An individualized skills and socialization provider must ensure that, during the provision of off-site individualized skills and socialization services, all medications requiring refrigeration:
(i) are maintained at the manufacturer's recommended temperature using a portable, insulated, temperature-controlled container;
(ii) remain under the direct control and supervision of authorized staff at all times; and
(iii) have documented temperature maintenance and chain of custody in accordance with the requirements of this section.
(I) An individualized skills and socialization provider must ensure that, during the provision of off-site individualized skills and socialization services, medications classified as Schedule II under the Controlled Substances Act of 1970:
(i) are stored in a secure, locked container or drawer, separately from medications that are not Schedule II;
(ii) remain under direct control of authorized staff at all times; and
(iii) are handled in accordance with all state and federal requirements for long-term care providers relating to security and safeguarding of Schedule II controlled substances.
(J) An individualized skills and socialization provider must develop written policies and procedures addressing the storage, transportation, administration, and safeguarding of all medications for which the provider is responsible and ensure staff compliance with these policies and procedures. The provider's written policies and procedures must:
(i) designate authorized staff;
(ii) describe security and handling procedures, including off-site transportation and refrigeration;
(iii) specify documentation, accountability, and reporting requirements for discrepancies, loss, or theft; and
(iv) ensure compliance with the requirements of this subsection and any applicable federal requirements relating to the security and safeguarding of Schedule II controlled substances.
(n) Accident, injury, or acute illness.
(1) An individualized skills and socialization provider must stock and maintain in a single location in the on-site individualized skills and socialization location first aid supplies to treat burns, cuts, and poisoning.
(2) An individualized skills and socialization provider delivering off-site individualized skills and socialization must ensure first aid supplies to treat burns, cuts, and poisoning are immediately available at all times during service provision.
(3) In the event of accident or injury to an individual requiring emergency care, or in the event of death of an individual, an individualized skills and socialization provider must:
(A) arrange for emergency care or transfer to an appropriate place for treatment, including:
(i) a physician's office;
(ii) a clinic; or
(iii) a hospital;
(B) immediately notify an individual's program provider with which the individualized skills and socialization provider contracts to provide services to the individual; and
(C) describe and document the accident, injury, or illness on a separate report containing a statement of final disposition and maintain the report on file.
(o) An individualized skills and socialization provider must develop and enforce written policies and procedures for infection control, including spread of disease to ensure staff compliance with state law, the Occupational Safety and Health Administration, and the Centers for Disease Control and Prevention.
§559.228.
(a) An individualized skills and socialization provider must:
(1) provide each individual referenced in Texas Human Resources Code (HRC) §103.011 and the individual's legally authorized representative (LAR), as appropriate, with a written list of the individual's rights, as outlined under HRC §102.004 (relating to List of Rights); and
(2) comply with all applicable provisions of HRC Chapter 102 (relating to Rights of the Elderly).
(b) An individualized skills and socialization provider must ensure that individuals are informed of their rights and responsibilities and of grievance procedures in a language they comprehend:
(1) through the individual's preferred mode of communication; and
(2) in a manner accessible to the individual.
(c) An individualized skills and socialization provider must develop and implement written policies and procedures that protect and promote the rights of all individuals receiving services and ensure individuals can exercise their rights without interference, coercion, discrimination, or retaliation from the provider.
(d) An individualized skills and socialization provider must ensure that any deviation from the requirements of this section is based on an assessed need and documented in accordance with the requirements outlined in §559.227(j) of this division (relating to Program Requirements) prior to implementation. This includes an individual's right to:
(1) control and support personal schedules and activities;
(2) access personal food items at any time;
(3) receive visitors of the individual's choosing at any time; and
(4) physically access the building.
(e) An individualized skills and socialization provider must develop and implement policies and procedures for ensuring individuals:
(1) receive support and assistance from the individualized skills and socialization provider in addressing concerns with the program provider regarding the individual plan of care (IPC), individual program plan (IPP), person-directed plan (PDP), or implementation plan when the individual dislikes or disagrees with the services being rendered by the individualized skills and socialization provider;
(2) live free from abuse, neglect, or exploitation;
(3) receive services in a safe and clean environment;
(4) receive services in accordance with the individuals IPC, IPP, PDP, and implementation plan, as applicable, through service providers who are responsive to the needs of the individual;
(5) have privacy during treatment and care of personal needs; and
(6) participate in social, recreational, and group activities.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600194
Karen Ray
Chief Counsel
Health and Human Services Commission
Effective date: February 9, 2026
Proposal publication date: July 25, 2025
For further information, please call: (512) 438-3161
DIVISION 4. SURVEYS, INVESTIGATIONS, AND ENFORCEMENT
26 TAC §559.239STATUTORY AUTHORITY
The repeal is adopted under 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 §532.0051, which provides HHSC with the authority to administer federal funds and plan and direct the Medicaid program in each agency that operates a portion of the Medicaid program; and Texas Human Resources Code §32.021, which provides that HHSC adopt rules necessary for the proper and efficient operation of the Medicaid program, and §103.004, which requires the executive commissioner of HHSC to adopt rules and set standards implementing Chapter 103.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600195
Karen Ray
Chief Counsel
Health and Human Services Commission
Effective date: February 9, 2026
Proposal publication date: July 25, 2025
For further information, please call: (512) 438-3161
26 TAC §§559.241, 559.243, 559.253, 559.255, 559.257
STATUTORY AUTHORITY
The amendments and new sections are adopted under 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 §532.0051, which provides HHSC with the authority to administer federal funds and plan and direct the Medicaid program in each agency that operates a portion of the Medicaid program; and Texas Human Resources Code §32.021, which provides that HHSC adopt rules necessary for the proper and efficient operation of the Medicaid program, and §103.004, which requires the executive commissioner of HHSC to adopt rules and set standards implementing Chapter 103.
§559.253.
(a) The Texas Health and Human Services Commission (HHSC) may impose an administrative penalty if an individualized skills and socialization provider:
(1) fails to comply with Texas Human Resources Code (HRC) Chapter 103 or a rule, standard, or order adopted under HRC Chapter 103;
(2) makes a false statement of a material fact that the provider knows or should know is false:
(A) on an application for a license or a renewal of a license or in an attachment to the application; or
(B) with respect to a matter under investigation by HHSC;
(3) refuses to allow an HHSC representative to inspect:
(A) a book, record, or file required to be maintained by the provider; or
(B) any portion of the premises of the on-site location, or for off-site only providers, the designated place of business where records are kept;
(4) willfully interferes with the work of an HHSC representative who is preserving evidence of a violation of:
(A) HRC Chapter 103;
(B) a rule, standard, or order adopted under HRC Chapter 103; or
(C) a term of a license issued under this chapter;
(5) willfully interferes with the work of an HHSC representative or the enforcement of this chapter;
(6) fails to pay a penalty assessed under HRC Chapter 103, or a rule adopted under this chapter within 30 calendar days after the date the assessment of the penalty becomes final;
(7) fails to notify HHSC of a change of ownership in accordance with §559.211 of this subchapter (relating to Change of Ownership and Notice of Changes); or
(8) fails to submit an approved plan of correction to HHSC within 10 calendar days after receiving the final notification of assessed penalties.
(b) The range of the administrative penalty that may be imposed against the individualized skills and socialization provider each day for a violation described in subsection (a)(1) of this section is based on the scope and severity of the violation and whether it is an initial or repeated violation, as set forth in the following figure.
Figure: 26 TAC §559.253(b) (.pdf)
(c) HHSC imposes administrative penalties in accordance with the schedule of appropriate and graduated penalties established in this section. When determining the amount of an administrative penalty, HHSC considers:
(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the situation, and the hazard or potential hazard created by the situation to the health or safety of the public;
(2) the history of previous violations by a facility;
(3) the amount necessary to deter future violations;
(4) the facility's efforts to correct the violation; and
(5) any other matter that justice may require.
(d) If HHSC determines a violation is non-substantial, HHSC allows the individualized skills and socialization provider one opportunity to correct the violation to avoid an administrative penalty.
(e) If HHSC determines a violation is substantial as defined in §559.203 of this subchapter (relating to Definitions), HHSC does not allow the individualized skills and socialization provider an opportunity to correct the violation before HHSC imposes an administrative penalty.
(f) If HHSC imposes an administrative penalty for a violation as described in subsection (a) of this section, the administrative penalty begins accruing:
(1) for a substantial violation, on the date HHSC identifies the violation; or
(2) for a violation that is non-substantial, on the date of the exit conference of the post 45-day follow-up survey.
(g) An administrative penalty accrues each day until the individualized skills and socialization provider completes corrective action for that violation, as determined by HHSC.
(h) If an individualized skills and socialization provider demonstrates the corrective action is complete on the same day an administrative penalty begins accruing, HHSC imposes an administrative penalty for one day.
(i) For an administrative penalty imposed in accordance with subsection (a)(2) of this section:
(1) HHSC imposes the penalty no more than once per survey;
(2) HHSC does not allow the individualized skills and socialization provider an opportunity to correct the action before imposing the penalty; and
(3) the amount of the penalty is $500.
(j) If HHSC imposes an administrative penalty against the individualized skills and socialization provider in accordance with subsection (a)(2) - (8) of this section, HHSC does not, at the same time, impose a closing order or licensure suspension from the program provider for the same violation, action, or failure to act.
The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.
Filed with the Office of the Secretary of State on January 20, 2026.
TRD-202600196
Karen Ray
Chief Counsel
Health and Human Services Commission
Effective date: February 9, 2026
Proposal publication date: July 25, 2025
For further information, please call: (512) 438-3161