| (a) Purpose. The purpose of this section is to promote
the public health, safety, and welfare by providing for the development,
establishment, and enforcement of standards:
(1) for the habilitation of residents based on an active
treatment program in facilities governed by this chapter; and
(2) for the establishment, construction, maintenance,
and operation of such facilities that view an intellectual disability
and related conditions within the context of a developmental model
in accordance with the principle of normalization.
(b) Active treatment. A facility regulated by the standards
in this section is known as an intermediate care facility for individuals
with an intellectual disability or related conditions (ICF/IID). A
resident living in a facility has the same civil rights, equal liberties,
and due process of law as other individuals, plus the right to receive
active treatment and habilitation. A facility must provide and promote
services that enhance the development of each resident, maximize their
achievement through an interdisciplinary approach, and create an environment,
to the extent possible, that is normalized and normalizing. A facility
must:
(1) have the interdisciplinary team (IDT) prepare and
implement, for each resident, an individual program plan (IPP) within
30 days after admission;
(2) ensure each resident receives a continuous active
treatment program consisting of needed interventions and services
in sufficient number and frequency to support the achievement of the
objectives identified in the IPP, as identified by the IDT; and
(3) ensure each resident's IPP is reviewed at least
annually by a qualified intellectual disability professional (QIDP)
and revised as necessary, including situations in which a resident
has successfully completed an objective identified in the IPP.
(c) Standards. Each ICF/IID must comply with regulations
promulgated by the United States Department of Health and Human Services
in 42 CFR, Part 483, Subpart I §§483.400 - 483.480. Additionally,
HHSC adopts by reference the federal regulations governing conditions
of participation for the ICF/IID program as specified in 42 CFR Part
483, Subpart I §§483.410, 483.420, 483.430, 483.440, 483.450,
483.460, 483.470, 483.475, and 483.480 as licensing standards.
(d) Precertification training conference for new providers
of service. Each new provider must attend the precertification/prelicensure
training conference prior to licensing by HHSC. The purpose of the
training is to ensure that providers of services are familiar with
the licensing requirements and to facilitate the delivery of quality
services to residents in facilities serving persons with an intellectual
disability or related conditions.
(1) A new provider is an entity that has not had at
least one year of administering services in a facility serving persons
with an intellectual disability or related conditions in Texas. All
new providers must attend a precertification training conference prior
to the life safety code survey.
(2) Each new provider must designate at least one individual
who will be involved with the direct management of the facility to
attend the training conference prior to a health survey being scheduled.
(3) Each new provider will be responsible for taking
the required training.
(e) Additional requirements.
(1) Abuse, neglect, and exploitation. A facility must
develop and implement policies and procedures for reporting abuse,
neglect, and exploitation, and other reportable incidents, to HHSC.
(2) Cardiopulmonary resuscitation (CPR). A facility
must ensure:
(A) at least one staff person per shift and on duty
is trained by a CPR instructor and certified by an organization, such
as the American Heart Association or the Red Cross, whose training
includes a hands-on in-person skills assessment; and
(B) that staff members maintain their certification
as recommended by the training organization.
(3) Behavior management. Seclusion of residents may
not be used.
(4) Physical restraints.
(A) A facility must not use a restraint:
(i) in a manner that:
(I) obstructs a resident's airway, including the placement
of anything in, on, or over the resident's mouth or nose;
(II) impairs a resident's breathing by putting pressure
on the resident's torso;
(III) interferes with a resident's ability to communicate;
(IV) extends a resident's muscle groups away from each
other;
(V) uses hyperextension of joints on a resident; or
(VI) uses pressure points or pain on a resident;
(ii) for disciplinary purposes, that is, as retaliation
or retribution;
(iii) for the convenience of staff or other residents;
or
(iv) as a substitute for effective treatment or habilitation.
(B) A facility may use a restraint:
(i) in a behavioral emergency;
(ii) as an intervention in a behavior therapy program
that addresses inappropriate behavior exhibited voluntarily by a resident;
(iii) during a medical or dental procedure if necessary
to protect the resident or others and as a follow-up after a medical
or dental procedure or following an injury to promote the healing
of wounds;
(iv) to protect the resident from involuntary self-injury;
or
(v) to provide postural support to the resident or
to assist the resident in obtaining and maintaining normative bodily
functioning.
(C) In order to decrease the frequency of the use of
restraint and to minimize the risk of harm to a resident, a facility
must ensure that the IDT:
(i) with the participation of a physician, or a physician
assistant or an advanced practice nurse acting within the scope of
his or her practice, identifies:
(I) the resident's known physical or medical conditions
that might constitute a risk to the resident during the use of restraint;
(II) the resident's ability to communicate; and
(III) other factors that must be taken into account
if the use of restraint is considered, including the resident's:
(-a-) cognitive functioning level;
(-b-) height;
(-c-) weight;
(-d-) emotional condition (including whether a resident
has a history of having been physically or sexually abused); and
(-e-) age;
(ii) documents the conditions and factors identified
in accordance with clause (i) of this subparagraph, and, as applicable,
limitations on specific restraint techniques or mechanical restraint
devices in the resident's record; and
(iii) reviews and updates with a physician, physician
assistant, or licensed nurse, at least annually or when a condition
or factor documented in accordance with clause (ii) of this subparagraph
changes significantly, information in the resident's record related
to the identified condition, factor, or limitation.
(D) If a facility restrains a resident as provided
in subparagraph (B) of this paragraph, the facility must:
(i) take into account the conditions, factors, and
limitations on specific restraint techniques or mechanical restraint
devices documented in accordance with subparagraph (C)(ii) and (iii)
of this paragraph;
(ii) use the minimal amount of force or pressure that
is reasonable and necessary to ensure the safety of the resident and
others;
(iii) safeguard the resident's dignity, privacy, and
well-being; and
(iv) not secure the resident to a stationary object
while the resident is in a standing position.
(E) If a facility uses a restraint in a circumstance
described in subparagraph (B)(i) or (ii) of this paragraph:
(i) the facility may only use a personal hold in which
the resident's limbs are held close to the body to limit or prevent
movement and that does not violate the provisions of subparagraph
(A)(i) of this paragraph; and
(ii) if a resident rolls into a prone or supine position
during restraint, the facility must transition the resident to a side,
sitting, or standing position as soon as possible. A facility may
only use a prone or supine hold:
(I) as a transitional hold, and only for the shortest
period of time necessary to ensure the protection of the resident
or others;
(II) as a last resort, when other less restrictive
interventions have proven to be ineffective; and
(III) except in a small facility, when an observer
who is trained to identify risks associated with positional, compression,
or restraint asphyxiation and with prone and supine holds is ensuring
that the resident's breathing is not impaired.
(F) A facility must release a resident from a restraint:
(i) as soon as the resident no longer poses a risk
of imminent physical harm to the resident or others; or
(ii) if the resident in restraint experiences a medical
emergency, as soon as possible as indicated by the medical emergency.
(G) If a facility restrains a resident as provided
in subparagraph (B)(i) of this paragraph, the facility must obtain
a written order authorizing the restraint from a health care professional
acting within his or her scope of practice by the end of the first
business day after the use of a restraint.
(H) A facility must ensure that each resident and the
resident's legally authorized representative (LAR) are notified of
HHSC rules and the facility's policies related to restraint and seclusion.
(I) A facility may adopt policies that allow less use
of restraint than allowed by the rules of this chapter.
(5) Pharmacy services.
(A) All pharmacy services must comply with the Texas
State Board of Pharmacy requirements, the Texas Pharmacy Act, and
rules adopted thereunder, the Texas Controlled Substances Act, and
Texas Health and Safety Code, Chapter 483 (relating to Dangerous Drugs).
(B) All medications must be ordered orally or in writing
by a health care professional acting within the scope of his or her
practice. Oral orders may be taken only by a licensed nurse, a pharmacist,
physician assistant, or physician, and must be immediately transcribed
and signed by the individual taking the order. Oral orders must be
signed by the health care professional who ordered the medication
within seven working days after issuing the order.
(C) A facility, with input from the consultant pharmacist
and a health care professional acting within the scope of his or her
practice, must develop and implement procedures regarding automatic
stop orders for medications. These procedures must be utilized when
the order for a medication does not specify the number of doses to
be given or the time for discontinuance or re-order.
(6) Specialized nutrition support (delivery of parenteral
nutrients and enteral feedings by nasogastric, gastrostomy, or jejunostomy
tubes) must be given:
(A) by a health care professional acting within the
scope of his or her practice or by a person to whom a health care
professional has properly delegated performance of the task; and
(B) in accordance with an order issued by a health
care professional acting within the scope of his or her practice.
(7) Self-administration of medication and emergency
medication kits.
(A) A resident who has demonstrated the competency
for self-administration of medication must have access to and maintain
his or her own medication. The resident must have an individual storage
space that permits him or her to store the medication under lock and
key.
(B) A resident may participate in a self-administration
of medication training program if the IDT determines that self-administration
of medication is an appropriate objective. A resident participating
in a self-administration of medication training program must have
training in coordination with and as part of the resident's total
active treatment program. The resident's training plan must be evaluated
as necessary by a licensed nurse. The supervision and implementation
of a self-administration of medication training program may be conducted
by staff described in §551.43(a)(1), (3), and (4) of this subchapter
(relating to Administration of Medication).
(C) A facility may maintain a supply of controlled
substances in an emergency medication kit for a resident's emergency
medication needs, as outlined under §551.324 and §551.325
of this chapter (relating to Emergency Medication Kit and Controlled
Substances).
(8) Infection prevention and control.
(A) A facility must establish, implement, enforce,
and maintain an infection prevention and control policy and procedure
designated to provide a safe, sanitary, and comfortable environment
and to help prevent the development and transmission of disease and
infection.
(B) A facility must comply with rules regarding special
waste in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment,
and Disposition of Special Waste from Health-Care Related Facilities).
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