| (a) Reporting. Incidents of abuse, neglect, exploitation,
or illegal, unethical or unprofessional conduct as those terms are
defined in subsections (b) and (c) of this section shall be reported
to the Texas Health and Human Services Commission (HHSC) as provided
in subsections (b) and (c)(3) of this section.
(b) Abuse or neglect of a child, and abuse, neglect,
or exploitation of an elderly or disabled person. The following definitions
apply only to this subsection.
(1) Abuse or neglect of a child, as defined in §1.204(a)
and (b) of this title (relating to Abuse, Neglect, or Exploitation
Defined).
(2) Abuse, neglect, or exploitation of an elderly or
disabled person, as defined in §1.204(a) - (c) of this title.
(c) Abuse and neglect of individuals with mental illness,
and illegal, unethical, and unprofessional conduct. The requirements
of this subsection are in addition to the requirements of subsection
(b) of this section.
(1) Definitions. The following definitions are in accordance
with Texas Health and Safety Code (HSC) §161.131 and apply only
to this subsection.
(A) Abuse--
(i) Abuse (as the term is defined in United States
Code Title 42 (42 USC) Chapter 114 (relating to Protection and Advocacy
for Individuals with Mental Illness) is any act or failure to act
by an employee of a facility rendering care or treatment which was
performed, or which was failed to be performed, knowingly, recklessly,
or intentionally, and which caused, or may have caused, injury or
death to an individual with mental illness, and includes acts such
as:
(I) the rape or sexual assault of an individual with
mental illness;
(II) the striking of an individual with mental illness;
(III) the use of excessive force when placing an individual
with mental illness in bodily restraints; and
(IV) the use of bodily or chemical restraints on an
individual with mental illness which is not in compliance with federal
and state laws and regulations.
(ii) In accordance with HSC §161.132(j), abuse
also includes coercive or restrictive actions that are illegal or
not justified by the patient's condition and that are in response
to the patient's request for discharge or refusal of medication, therapy
or treatment.
(B) Illegal conduct--Illegal conduct (as the term is
defined in HSC §161.131(4)) is conduct prohibited by law.
(C) Neglect--Neglect (as the term is defined in 42
USC §10801 et seq.) is a negligent act or omission by any individual
responsible for providing services in a facility rendering care or
treatment which caused or may have caused injury or death to an individual
with mental illness or which placed an individual with mental illness
at risk of injury or death, and includes an act or omission such as
the failure to establish or carry out an appropriate individual program
plan or treatment plan for an individual with mental illness, the
failure to provide adequate nutrition, clothing, or health care to
an individual with mental illness, or the failure to provide a safe
environment for an individual with mental illness, including the failure
to maintain adequate numbers of appropriately trained staff.
(D) Unethical conduct--Unethical conduct (as the term
is defined in HSC §161.131(11)) is conduct prohibited by the
ethical standards adopted by state or national professional organizations
for their respective professions or by rules established by the state
licensing agency for the respective profession.
(E) Unprofessional conduct--Unprofessional conduct
(as the term is defined in HSC §161.131(12)) is conduct prohibited
under rules adopted by the state licensing agency for the respective
profession.
(2) Posting requirements. A hospital shall prominently
and conspicuously post for display in a public area that is readily
visible to patients, residents, volunteers, employees, and visitors
a statement of the duty to report abuse and neglect, or illegal, unethical,
or unprofessional conduct in accordance with HSC §161.132(e).
The statement shall be in English and in a second language appropriate
to the demographic makeup of the community served and contain the
current toll-free telephone number for submitting a complaint to HHSC
as specified on the HHSC website.
(3) Reporting responsibility.
(A) Reporting abuse and neglect. A person, including
an employee, volunteer, or other person associated with the hospital
who reasonably believes or who knows of information that would reasonably
cause a person to believe that the physical or mental health or welfare
of a patient of the hospital who is receiving mental health or chemical
dependency services has been, is, or will be adversely affected by
abuse or neglect (as those terms are defined in this subsection) by
any person shall as soon as possible report the information supporting
the belief to HHSC or to the appropriate state health care regulatory
agency in accordance with HSC §161.132(a).
(B) Reporting illegal, unprofessional, or unethical
conduct. An employee of or other person associated with a hospital,
including a health care professional, who reasonably believes or who
knows of information that would reasonably cause a person to believe
that the hospital or an employee or health care professional associated
with the hospital, has, is, or will be engaged in conduct that is
or might be illegal, unprofessional, or unethical and that relates
to the operation of the hospital or mental health or chemical dependency
services provided in the hospital shall as soon as possible report
the information supporting the belief to HHSC or to the appropriate
state health care regulatory agency in accordance with HSC §161.132(b).
(4) Training requirements. A hospital that provides
comprehensive medical rehabilitation, mental health, or substance
use services shall annually provide as a condition of continued licensure
a minimum of eight hours of in-service training designed to assist
employees and health care professionals associated with the hospital
in identifying patient abuse or neglect and illegal, unprofessional,
or unethical conduct by or in the hospital and establish a means for
monitoring compliance with the requirement.
(d) Investigations. A complaint under this subsection
will be investigated or referred by HHSC as follows.
(1) Allegations under subsection (b) of this section
will be investigated in accordance with §1.205 of this title
(relating to Reports and Investigations) and §1.206 of this title
(relating to Completion of Investigation).
(2) Allegations under subsection (c) of this section
will be investigated in accordance with §133.103 of this chapter
(relating to Complaint Investigations). Allegations concerning a health
care professional's failure to report abuse and neglect or illegal,
unprofessional, or unethical conduct will not be investigated by HHSC
but will be referred to the individual's licensing board for appropriate
disciplinary action.
(3) Allegations under both subsections (b) and (c)
will be investigated in accordance with §1.205 and §1.206
of this title except as noted in paragraph (2) of this subsection
concerning a health care professional's failure to report.
(e) Submission of complaints. A complaint made under
this section may be submitted in writing or verbally to HHSC.
(f) Notification.
(1) For complaints under subsection (b) of this section,
HHSC shall provide notification according to the following.
(A) HHSC shall notify the reporter, if known, in writing
of the outcome of the completed investigation.
(B) HHSC shall notify the alleged victim, and the alleged
victim's parent or guardian if a minor, in writing of the outcome
of the completed investigation.
(2) For complaints under subsection (c) of this section,
HHSC informs, in writing, the complainant who identifies themselves
by name and address of the following:
(A) the receipt of the complaint;
(B) if the complainant's allegations are potential
violations of this chapter warranting an investigation;
(C) whether the complaint will be investigated by HHSC;
(D) whether and to whom the complaint will be referred;
and
(E) the findings of the complaint investigation.
(g) HHSC reporting and referral.
(1) Reporting health care professional to licensing
board.
(A) In cases of abuse, neglect, or exploitation, as
those terms are defined in subsection (b) of this section, by a licensed,
certified, or registered health care professional, HHSC may forward
a copy of the completed investigative report to the state agency that
licenses, certifies, or registers the health care professional. Any
information which might reveal the identity of the reporter or any
other patients of the hospital must be blacked out or deidentified.
Cont'd... |
