SECTION 551.42. Standards for a Facility

(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).

(C) A facility must immediately report the name of any resident of a facility with a reportable disease, as specified in 25 TAC Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority.

(D) A facility must have, implement, enforce, and maintain written policies for the control of communicable disease among employees and residents, which must address tuberculosis (TB) screening and the provision of a safe and sanitary environment for residents and employees.

(i) If an employee contracts a communicable disease that is transmissible to residents through food handling or direct resident care, the facility must exclude the employee from providing these services for the applicable period of communicability.

(ii) A facility must maintain evidence of compliance with local and state health codes or ordinances regarding employee and resident health status.

(iii) A facility must screen all employees for TB within two weeks of employment and annually, according to the Centers for Disease Control and Prevention (CDC) screening guidelines. A person who provides services under an outside resource contract must, upon request of the facility, provide evidence of compliance with this requirement.

(iv) A facility's policies and practices for resident TB screening must ensure compliance with the recommendations of a resident's attending physician and consistency with CDC guidelines.

(E) A facility's infection prevention and control program established under subparagraph (A) of this subsection must include written policies and procedures for:

(i) monitoring of key infectious agents, including multidrug-resistant organisms, as those terms are defined in §551.3 of this chapter (relating to Definitions);

(ii) wearing personal protective equipment, such as gloves, a gown, or a mask based on anticipated exposure, and properly cleaning hands before and after touching another resident;

(iii) cleaning and disinfecting environmental surfaces, including doorknobs, handrails, light switches, and handheld electronic control devices;

(iv) using universal precautions for blood and bodily fluids; and

(v) removing soiled items (such as used tissues, wound dressings, adult briefs, and soiled linens) from the environment at least once daily, or more often if an infection or infectious disease is present or suspected.

(F) A facility must establish, implement, enforce, and maintain written policies and procedures for making a rapid influenza diagnostic test, as defined in §551.3 of this chapter (relating to Definitions), available to a resident who is exhibiting flu-like symptoms.

(G) Staff must handle, store, process, and transport linens to prevent the spread of infection.

(H) A facility must use universal precautions in the care of all residents.

(9) Water activities. A facility must ensure the safety of all residents who participate in facility-sponsored events. For this section, a water activity is defined as an activity which occurs in or on water that is knee deep or deeper on the majority of residents participating in the event. To ensure the safety of all individuals who participate, the requirements in subparagraphs (A) - (F) of this paragraph apply.

(A) A facility must develop a policy statement regarding the water sites utilized by the facility. Water sites include lakes, amusement parks, and pools.

(B) A minimum of one staff person, who is certified and has demonstrated proficiency in CPR must be on duty and at the site when residents are involved in water activities.

(C) A minimum of one person with demonstrated proficiency in water life-saving skills must be on duty and at the site when activities take place in or on water that is deep enough to require swimming for life-saving retrieval. This person must maintain supervision of the activity for its duration.

(D) A sufficient number of staff or a combination of staff and volunteers must be available to meet the safety requirements of the group and specific residents.

(E) Each resident's IPP must address each person's needs for safety when participating in water activities including medical conditions; physical disabilities and behavioral needs which could pose a threat to safety; the ability of residents to follow directions and instructions pertaining to water safety; the ability of residents to swim independently; and, when called for, special precautions.

(F) If the IDT recommends the use of a flotation device as a precaution for any resident to engage in water activities, it must be identified and the precautions outlined in the IPP. The device must be approved by the United States Coast Guard or be a specialized therapy flotation device utilized in the individual's therapy program.

(10) Communication. A facility may not prohibit a resident or employee from communicating in the person's native language with another resident or employee for acquiring or providing care, training, or treatment.

(11) Physical exams. A facility must ensure that a resident is given at least one physical exam on a yearly basis by:

(A) a person licensed to practice medicine in accordance with Texas Occupations Code, Chapter 155 (relating to License to Practice Medicine);

(B) a person licensed as a physician assistant in accordance with Texas Occupations Code, Chapter 204 (relating to Physician Assistants); or

(C) a person licensed to practice professional nursing in accordance with Texas Occupations Code, Chapter 301 (relating to Nurses), and authorized by the Texas Board of Nursing to practice as an advanced practice nurse.

(f) Governing body and management. A facility must establish a governing body and the governing body must adopt, implement, and enforce the facility's policies and procedures. The governing body must review and update the facility policies and procedures at least annually.

(g) Client protections. A facility must ensure the rights of a resident and through oversight, policy, and investigative procedures to ensure a resident is free from all abuse, neglect, and exploitation.

(h) Facility staffing. A facility must ensure a resident receives professional and non-professional program services needed to implement the active treatment program defined by a resident's IPP.

(i) Active treatment services. A facility must ensure a resident receives a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services in the IPP created by the IDT.

(j) Client behavior and facility practices. A facility must develop and implement written policies and procedures for the management of conduct between staff and residents and the management of inappropriate resident behavior.

(k) Health care services. A facility must provide or obtain preventative and general medical care for a resident and ensure a resident receives nursing services in accordance with the resident's needs.

(l) Physical environment. A facility must provide sufficient space and equipment in dining, living, health services, recreation, and program areas to enable staff to provide a resident with needed services as required or identified in a resident's IPP. Additionally, a facility must ensure all fire safety and surrounding safety conditions are maintained in accordance with federal, state, and local regulations.

(m) Emergency preparedness. A facility must establish and maintain an emergency preparedness program that meets all federal, state, and local emergency preparedness requirements.

(n) Dietetic services. A facility must ensure a resident receives a nourishing, well-balanced diet including any modified or specifically prescribed diets.

Source Note: The provisions of this §551.42 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective April 1, 1994, 19 TexReg 1832; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective June 1, 1995, 20 TexReg 3573; amended to be effective July 1, 1996, 21 TexReg 5328; amended to be effective May 1, 1998, 23 TexReg 4060; amended tobeeffective April 1, 1999, 24 TexReg 1816; amended to be effective May 1, 2000, 25TexReg 3557; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective June 1, 2006, 31 TexReg 4463; amended to be effective November 1, 2009, 34 TexReg 7654; amended to be effective June 1, 2010, 35 TexReg 4469; amended to be effective September 1, 2012, 37 TexReg 3871; amended to be effective June 17, 2013, 38 TexReg 3806; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787