The following words and terms, when used in this chapter, shall
have the following meanings, unless the context clearly indicates
(1) Action plan--A written document that includes specific
measures to correct identified problems or areas of concern; identifies
strategies for implementing system improvements; and includes outcome
measures to indicate the effectiveness of system improvements in reducing,
controlling or eliminating identified problem areas.
(2) Adverse event--An event that results in unintended
harm to the patient by an act of commission or omission rather than
by the underlying disease or condition of the patient.
(3) Applicant--The person legally responsible for the
operation of the facility, whether by lease or ownership, who seeks
a license from the department.
(4) Board--The Texas Board of Health.
(5) Community center--A center established under Health
and Safety Code, Chapter 534, Subchapter A.
(6) Contaminated linen--Linen which has been soiled
with blood or other potentially infectious materials or may contain
sharps. Other potentially infectious materials means:
(A) the following human body fluids: semen, vaginal
secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial
fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures,
any body fluid that is visibly contaminated with blood, and all body
fluids in situations where it is difficult or impossible to differentiate
between body fluids;
(B) any unfixed tissue or organ (other than intact
skin) from a human (living or dead); and
(C) Human Immunodeficiency Virus (HIV)-containing cell
or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV)
containing culture medium or other solutions; and blood, organs, or
other tissues from experimental animals infected with HIV or HBV.
(7) Crisis stabilization unit (CSU)--A mental health
facility operated by a community center or other entity designated
by the Texas Department of Mental Health and Mental Retardation in
accordance with Texas Health and Safety Code, §534.054, that
provides treatment to individuals who are the subject of a protective
custody order issued in accordance with Texas Health and Safety Code,
(8) Dentist--A person licensed to practice dentistry
by the State Board of Dental Examiners. This includes a doctor of
dental surgery or a doctor of dental medicine.
(9) Department--The Texas Department of Health, 1100
West 49th Street, Austin, Texas 78756-3199.
(10) Dietitian--A person who is currently licensed
by the Texas State Board of Examiners of Dietitians as a licensed
dietitian or provisional licensed dietitian, or who is a registered
dietitian with the American Dietetic Association.
(11) Director--The director of the Health Facility
Licensing and Compliance Division, Texas Department of Health.
(12) Division--The Health Facility Licensing and Compliance
Division, Texas Department of Health.
(13) Emergency medical condition--A medical condition
manifesting itself by acute symptoms of sufficient severity (including
severe pain, psychiatric disturbances or symptoms of substance abuse)
such that the absence of immediate medical attention could reasonably
be expected to result in one or all of the following:
(A) placing the health of the individual (or with respect
to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy;
(B) serious impairment to bodily functions;
(C) serious dysfunction of any bodily organ or part;
(D) with respect to a pregnant woman who is having
(i) that there is inadequate time to effect a safe
transfer to another hospital before delivery; or
(ii) that transfer may pose a threat to the health
or safety of the woman or the unborn child.
(14) Facility--A private psychiatric hospital or a
crisis stabilization unit.
(15) Facility administration--Administrative body of
a facility headed by an individual who has the authority to represent
the facility and who is responsible for the operation of the facility
according to the policies and procedures of the facility governing
(16) Fast-track projects--A construction project in
which it is necessary to begin initial phases of construction before
later phases of the construction documents are fully completed in
order to establish other design conditions or because of time constraints
such as mandated deadlines.
(17) Governing body--The governing authority of a facility
which is responsible for the facility's organization, management,
control, and operation, including appointment of the medical staff;
includes the owner or partners for facilities owned or operated by
an individual or partners.
(18) Governmental unit--A political subdivision of
the state, including a hospital district, county, or municipality,
and any department, division, board, or other agency of a political
(19) Hospital--A private psychiatric hospital.
(20) Inpatient services--Services provided to a patient
admitted to a hospital for an intended length of stay of 24 hours
(21) Learning disability--When a severe discrepancy
exists when the individual's assessed intellectual ability is above
the mentally retarded range, but where the individual's assessed educational
achievement in areas specified is more than one standard deviation
below the individual's intellectual ability.
(22) Legally reproduced form--A medical record retained
in hard copy, microform (microfilm or microfiche), or other electronic
(23) Licensed vocational nurse--An individual who
is currently licensed as a licensed vocational nurse (LVN) by the
Board of Vocational Nurse Examiners in accordance with Texas Occupations
Code, Chapter 302.
(24) Licensee--A person or governmental unit who has
been granted a private psychiatric hospital license or crisis stabilization
(25) Medical error--The failure of a planned action
to be completed as intended, the use of a wrong plan to achieve an
aim, or the failure of an unplanned action that should have been completed,
that results in an adverse event.
(26) Medical staff--Licensed physicians and other licensed
practitioners permitted by law and by the facility to provide medical
care independently in the facility.
(27) Mental health services--All services concerned
with research, prevention, and detection of mental disorders and disabilities
and all services necessary to treat, care for, supervise, and rehabilitate
persons who have a mental illness.
(28) Mental illness--An illness, disease, or condition
(other than a sole diagnosis of epilepsy, senility, substance use
disorder, mental retardation, autism, or pervasive developmental disorder)
(A) substantially impairs a person's thought, perception
of reality, emotional process, or judgment; or
(B) grossly impairs an individual's behavior as demonstrated
by recent disturbed behavior.
(29) Mental retardation--Significantly subaverage
general intellectual functioning that is concurrent with deficits
in adaptive behavior and originates during the developmental period.
(30) Minor--A person under 18 years of age who is not
and has not been married or who has not had the disabilities of minority
removed for general purposes.
(31) Mobile unit--Any pre-manufactured structure, trailer,
or self-propelled unit equipped with a chassis on wheels and intended
to provide shared medical services to the community on a temporary
basis. Some of these units are equipped with expanding walls, and
designed to be moved on a daily basis.
(32) Oral surgeon--A person licensed by the State Board
of Dental Examiners in the specialty of dentistry which includes
the diagnosis, surgical and adjunctive treatment of diseases, injuries,
and defects involving both the functional and esthetic aspects of
the hard and soft tissues of the oral and maxillofacial regions.
(33) Outpatient services--Services provided to patients
whose medical needs can be met in less than 24 hours and are provided
within the facility.
(34) Owner--One of the following persons which will
hold or does hold a license issued under Health and Safety Code, Chapter
577, in the person's name or the person's assumed name:
(A) a corporation;
(B) a governmental unit;
(C) a limited liability company;
(D) an individual;
(E) a partnership if a partnership name is stated in
a written partnership agreement or an assumed name certificate;
(F) all partners in a partnership if a partnership
name is not stated in a written partnership agreement or an assumed
name certificate; or
(G) all co-owners under any other business arrangement.
(35) Patient--An individual who is receiving mental
health services under this chapter.
(36) Person--An individual, firm, partnership, corporation,
association, joint stock company, joint venture, or local authority,
and includes a receiver, trustee, assignee, or other similar representative
of those entities.
(37) Pharmacist--A person who is licensed to practice
pharmacy by the Texas Board of Pharmacy in accordance with Texas Occupations
Code, Chapter 558.
(38) Physician--An individual who is:
(A) licensed as a physician by the Texas State Board
of Medical Examiners in accordance with Chapter 155 of the Texas Occupations
(B) authorized to perform medical acts under an institutional
permit at a Texas postgraduate training program approved by the Accreditation
Council on Graduate Medical Education, the American Osteopathic Association,
or the Texas State Board of Medical Examiners.
(39) Podiatrist--A podiatrist licensed by the Texas
State Board of Podiatry Examiners.
(40) Political subdivision--A county, municipality,
or hospital district in this state but does not include a department,
board, or agency of the state that has statewide authority and responsibility.
(41) Practitioner--A health care professional licensed
in the State of Texas, other than a physician.
(42) Premises--A premises may be any of the following:
(A) a single building where inpatients receive hospital
(B) multiple buildings where inpatients receive hospital
services, provided that the following criteria are met:
(i) all inpatient buildings and inpatient services
are subject to the control and direction of the governing body of
(ii) all inpatient buildings are within a 30-mile radius
of the main address of the licensee;
(iii) there is integration of the organized medical
staff of the hospital;
(iv) there is a single chief executive officer who
reports directly to the governing body and through whom all administrative
authority flows and who exercises control and surveillance over all
administrative activities of the hospital;
(v) there is a single chief medical officer who reports
directly to the governing body and who is responsible for all medical
staff activities of the hospital; and
(vi) each building that is geographically separate
from other buildings contains at least one nursing unit for inpatients,
unless providing only diagnostic or laboratory services, or a combination
thereof, in the building for hospital inpatients.
(43) Private psychiatric hospital--A hospital that
provides inpatient mental health services to individuals with a mental
illness or with a substance use disorder except that, at all times,
a majority of the individuals admitted are individuals with a mental
illness. Such services include psychiatric assessment and diagnostic
services, physician services, professional nursing services, and monitoring
for patient safety provided in a restricted environment.
(44) Registered nurse--An individual who is licensed
as a registered nurse by the Board of Nurse Examiners in accordance
with Texas Occupations Code, Chapter 301.
(45) Relocatable unit--Any structure, not on wheels,
built to be relocated at any time and provide medical services. These
structures vary in size.
(46) Reportable event--A medical error or adverse event
or occurrence which the facility is required to report to the department,
as set out in §134.47 of this title (relating to Patient Safety
(47) Root cause analysis--An interdisciplinary review
process for identifying the basic or contributing causal factors that
underlie a variation in performance associated with an adverse event
or reportable event. It focuses primarily on systems and processes,
includes an analysis of underlying cause and effect, progresses from
special causes in clinical processes to common causes in organizational
processes, and identifies potential improvements in processes or systems.