1. (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. (1) for the habilitation of individuals based on an active treatment program in facilities governed by this chapter; and
   2. (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.
2. (b) Philosophy. 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). Individuals in these facilities have the same civil rights, equal liberties, and due process of law as other individuals, plus the right to receive active treatment and habilitation. Facilities shall provide and promote services that enhance the development of such individuals, maximize their achievement through an interdisciplinary approach based on developmental principles, and create an environment, to the extent possible, that is normalized and normalizing.
3. (c) Standards. Each ICF/IID must comply with regulations promulgated by the United States Department of Health and Human Services in Title 42, Code of Federal Regulations (CFR), Part 483, Subpart I, §§483.400 - 483.480. Additionally, DADS 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, and 483.480 as licensing standards.

4. (d) Precertification training conference for new providers of service. Each new provider must attend the precertification/prelicensure training conference prior to licensing by DADS. The purpose of the training is to assure 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. (1) A new provider is an entity which 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. (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. (3) Each new provider will be given a training schedule. DADS will schedule training sessions, and the date, time, and location of the training will be indicated on the schedule.

5. (e) Additional requirements.

   1. (1) A facility must develop and implement policies and procedures for reporting abuse, neglect, and exploitation to the Department of Family and Protective Services and reporting other incidents to DADS.

   2. (2) In the area of cardiopulmonary resuscitation (CPR), the following apply:

      1. (A) At least one staff person per shift and on duty must be trained by a CPR instructor certified by an organization such as the American Heart Association or the Red Cross.
      2. (B) The facility must ensure that staff members maintain their certification as recommended by such organizations.
   3. (3) In the area of behavior management, seclusion of residents may not be used.

   4. (4) In the area of physical restraints, the following apply:

      1. (A) A facility must not use restraint:

         1. (i) in a manner that:

            1. (I) obstructs the resident's airway, including the placement of anything in, on, or over the resident's mouth or nose;
            2. (II) impairs the resident's breathing by putting pressure on the resident's torso;
            3. (III) interferes with the resident's ability to communicate;
            4. (IV) extends muscle groups away from each other;
            5. (V) uses hyperextension of joints; or
            6. (VI) uses pressure points or pain;
         2. (ii) for disciplinary purposes, that is, as retaliation or retribution;
         3. (iii) for the convenience of staff or other residents; or
         4. (iv) as a substitute for effective treatment or habilitation.

      2. (B) A facility may use restraint:

         1. (i) in a behavioral emergency;
         2. (ii) as an intervention in a behavior therapy program that addresses inappropriate behavior exhibited voluntarily by a resident;
         3. (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;
         4. (iv) to protect the resident from involuntary self-injury; and
         5. (v) to provide postural support to the resident or to assist the resident in obtaining and maintaining normative bodily functioning.

      3. (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 interdisciplinary team:

         1. (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:

            1. (I) the resident's known physical or medical conditions that might constitute a risk to the resident during the use of restraint;
            2. (II) the resident's ability to communicate; and

            3. (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 the resident has a history of having been physically or sexually abused); and

               (-e-) age;

         2. (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
         3. (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.

      4. (D) If a facility restrains a resident as provided in subparagraph (B) of this paragraph, the facility must:

         1. (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;
         2. (ii) use the minimal amount of force or pressure that is reasonable and necessary to ensure the safety of the resident and others;
         3. (iii) safeguard the resident's dignity, privacy, and well-being; and
         4. (iv) not secure the resident to a stationary object while the resident is in a standing position.

      5. (E) If a facility uses restraint in a circumstance described in subparagraph (B)(i) or (ii) of this paragraph:

         1. (i) the facility may use only 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

         2. (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. The facility may only use a prone or supine hold:

            1. (I) as a transitional hold, and only for the shortest period of time necessary to ensure the protection of the resident or others;
            2. (II) as a last resort, when other less restrictive interventions have proven to be ineffective; and
            3. (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.

      6. (F) A facility must release a resident from restraint:

         1. (i) as soon as the resident no longer poses a risk of imminent physical harm to the resident or others; or
         2. (ii) if the resident in restraint experiences a medical emergency, as soon as possible as indicated by the medical emergency.
      7. (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 restraint.
      8. (H) A facility must ensure that each resident and the resident's legally authorized representative are notified of the DADS rules and the facility's policies related to restraint and seclusion.
      9. (I) A facility may adopt policies that allow less use of restraint than allowed by the rules of this chapter.

   5. (5) In the area of pharmacy services, the following applies.

      1. (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).
      2. (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.
      3. (C) The 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. (6) Specialized nutrition support (delivery of parenteral nutrients and enteral feedings by nasogastric, gastrostomy, or jejunostomy tubes) must be given:

      1. (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
      2. (B) in accordance with an order issued by a health care professional acting within the scope of his or her practice.

   7. (7) In the area of self-administration of medication and emergency medication kits, the following apply.

      1. (A) Residents who have demonstrated the competency for self-administration of medications must have access to and maintain their own medications. They must have an individual storage space that permits them to store their medications under lock and key.
      2. (B) Residents may participate in a self-administration of medication training program if the interdisciplinary team determines that self-administration of medications is an appropriate objective. Residents 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 personnel described in §90.43(a)(1), (3), and (4) of this subchapter (relating to Administration of Medication).
      3. (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 §90.324 and §90.325 of this chapter (relating to Emergency Medication Kit and Controlled Substances).
   8. (8) In the area of communicable diseases, the facility must have written policies and procedures for the control of communicable diseases in employees and residents. When any reportable communicable disease becomes evident, the facility must report in accordance with Communicable Disease and Prevention Act, Texas Health and Safety Code, Chapter 81, or as specified in 25 TAC §§97.1 - 97.13 (relating to Control of Communicable Diseases) and 25 TAC §§97.131 - 97.146 (relating to Sexually Transmitted Diseases Including Acquired Immunodeficiency Syndrome (AIDS) and Human Immunodeficiency Virus (HIV)) and in the publication titled, "Reportable Diseases in Texas," Publication 6-101a (Revised 1987). The local health authority should be contacted to assist the facility in determining the transmissibility of the disease and, in the case of employees, the ability of the employee to continue performing his duties. The facility must have written policies and procedures for infection control, which include implementation of universal precautions as recommended by the Centers for Disease Control and Prevention (CDC).

   9. (9) In the area of water activities, the facility must assure the safety of all individuals who participate in facility-sponsored events. For the purpose of 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 individuals participating in the event. To assure the safety of all individuals who participate, the requirements in subparagraphs (A) - (F) of this paragraph apply.

      1. (A) The facility must develop a policy statement regarding the water sites utilized by the facility. Water sites include, but are not limited to, lakes, amusement parks, and pools.
      2. (B) A minimum of one staff person with demonstrated proficiency in cardiopulmonary resuscitation (CPR) must be on duty and at the site when individuals are involved in water activities.
      3. (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.
      4. (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/or specific individuals.
      5. (E) Each individual's program plan must address each person's needs for safety when participating in water activities including, but not necessarily limited to, medical conditions; physical disabilities and/or behavioral needs which could pose a threat to safety; the ability to follow directions and instructions pertaining to water safety; the ability to swim independently; and, when called for, special precautions.
      6. (F) If the interdisciplinary team recommends the use of a flotation device as a precaution for any individual to engage in water activities, it must be identified and precautions outlined in the individual program plan. 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. (10) In the area of communication, a facility may not prohibit a resident or employee from communicating in the person's native language with another resident or employee for the purpose of acquiring or providing care, training, or treatment.

   11. (11) In the area of physical exams, a facility shall ensure that a resident is given at least one physical exam on a yearly basis by:

       1. (A) a person licensed to practice medicine in accordance with Texas Occupations Code, Chapter 155 (relating to License to Practice Medicine);
       2. (B) a person licensed as a physician assistant in accordance with Texas Occupations Code, Chapter 204 (relating to Physician Assistants); or
       3. (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.

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 tobe effective April 1, 1999, 24 TexReg 1816; amended to be effective May 1, 2000, 25 TexReg 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.