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Hot Topics - Health Facility Program


Topics are in chronological order, with the most recent item listed first.

Implementation of rules related to Neonatal Levels of Care Designation- Stakeholder meeting November 10, 2014. View Proposed Draft Rules. (Updated November 7, 2014)

Chapter 448 Standards of Care for Substance Use Disorder Treatment Facilities - This draft will be discussed at the stakeholder meeting on Friday, November 7, 2014. Please contact Allison Hughes at (512) 834-6700 x 6775 if you have any questions regarding the revised draft or the upcoming meeting. Stakeholder letter and parking permit.

Guidance Concerning Chapter 415 Restraint and Seclusion Reporting Requirements, October 16, 2014 Frequently Asked Questions Concerning Chapter 415 Restraint and Seclusion Reporting  (October 31, 2014)

Community Wide Designated Hospitals for Sexual Assault Survivors (Excel file)

End Stage Renal Disease Facilities (ESRDs) in Texas and Dialysis Machines in New Facilities

SB 1191 (SANE program) Hospital Follow Up Letter – Urgent Response Requested

Hospital Compliance with House Bill 1376 - Clarification 4/2/14

Texas Chapter 117 Guidance Regarding ESRD Facility Training Rooms 

Chapter 415 Restraint and Seclusion Proposed Rules (Updated 11/14/13) – Comments can be submitted to Allison Hughes at allison.hughes@dshs.state.tx.us.

Hospital Provider Letter Regarding House Bill 705 and House Bill 729

Birthing Center Reporting

Additional Information to Preadmission Screening and Resident Review (PASRR) Redesign (REVISED 7/24/13) 

Preadmission Screening and Resident Review (PASRR) Redesign – UPDATE 7/17/13

Guidance for Hospitals Providing Hospice Services

Infectious Disease Prevention and Vaccination Policy Survey

Guidance Regarding the Location of Dressing Rooms near the Diagnostic Radiographic (X-ray) Room in a Freestanding Emergency Medical Care (FEMC) Facility

Preadmission Screening and Resident Review (PASRR) Redesign – Implementation May 24, 2013

For additional information, you may visit the Department of Aging and Disability Services (DADS) website at http://www.dads.state.tx.us/providers/pasarr/index.html or the Department of State Health Services (DSHS) – Mental Health and Substance Abuse website at: http://www.dshs.state.tx.us/mhsa/pasrr/.


Amendments to Abortion Facility Reporting and Licensing Rules, Chapter 139 – Abortion Complications Reporting

HOSPITAL LICENSING RULES, CHAPTER 133 – AMENDED NOVEMBER 11, 2012. Amendments to the Hospital Licensing Rules include:

  • Requirement to use "person first respectful language" when referring to individuals with disabilities in agency rules, reference materials, publications, and electronic media.
  • Requirement for all hospitals that provide obstetrical services to perform, either directly or through a transfer agreement, audiological screenings on all newborns or infants born at the facility for identification of hearing loss prior to discharge.
  • Requirement for hospitals that provide obstetrical services to collaborate with their physicians to develop quality initiatives to reduce the number of elective or nonmedically indicated induced deliveries or cesarean sections performed at the hospital on a woman before the 39th week of gestation.
  • Requirement to provide written notice to a patient, on the date the patient is treated or as soon as reasonably practicable following emergency treatment, that the hospital may authorize disposal of medical records relating to the patient on or after the time periods specified in Texas Health and Safety Code §241.103(a) and (b).

Chapter 117 ESRD Rule Clarifications and Instructions for Completing ESRD Facility Incident Report.

    Meeting documents:
    Pre-Admission Screening and Evaluation (PASRR)
    The Conditions of Participation Draft Rules


Chapter 133, Hospital Licensing Draft Rules – relating to ED physician staffing and to wrist band ID

Additional Information- The proposed rule amendments to the Hospital Licensing Rules relating to physician staffing in emergency treatment areas and a standardized patient risk identification system will be discussed at the SHS Council Work Session on September 5, 2012, at 2:00 p.m., and will also be presented at the SHS Council Meeting on September 6, 2012, at 9:00 a.m. The work session and meeting will be held at the Criss Cole Rehabilitation Center Auditorium located at 4800 North Lamar, Austin, Texas. These proposed rule amendments will be discussed and presented for approval for publication in the Texas Register as proposed rules.  Both the work session and meeting are open to the public and we encourage you to attend. Agendas for the SHS Council Work Session and the SHS Council Meeting, in addition to the proposed rule amendments can be found on the DSHS Website at: http://www.dshs.state.tx.us/council/agenda.shtm. Please contact Ellen Cooper, R.N., Manager, Health Facility Licensing Group, at: ellen.cooper@dshs.state.tx.us or via phone at: (512) 834-6639 if you have any questions or comments regarding these proposed rule amendments.

Guidance regarding 25 Texas Administrative Code (TAC), §448.401(b), which states: “The facility shall have a license for each physical location at which it provides residential services or outpatient services.

CMS Medicare Hospital Comparison

House Bill 15 Sonogram Guidance and Forms
Provider Notice Letter
Sonogram and abortion election form
Medical emergency abortion form
House Bill 15

Planning for Water Supply Interruptions: A Guide for Hospitals & Healthcare Facilities

Facility Compliance with Medical Waste Regulations

NEW - Changes to 25 Texas Administrative Code, Chapter 601 (Informed Consent), have been adopted and will become effective January 16, 2012.

Senate Bill 7 Rule Draft – relating to vaccine policy for preventable diseases

Senate Bill 78 Rule Draft - relating to adverse licensing, listing, or registration decisions by certain health and human services agencies

ESRD Guidance for Expansion of Services

Notice to Chemical Dependency Treatment Providers Regarding Facility Accreditation and Inspection (Senate Bill 1449)

The FDA has launched an effort on the safe reprocessing of reusable medical devices (not to be confused with reprocessing of single use devices)
New posting on Reusables: http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/ReprocessingofReusableMedicalDevices/ucm252941.htm

Prior info on Single Use devices (SUDs): http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/ReprocessingofSingle-UseDevices/default.htm

Information for Sexual Assault Patients. The Information for Sexual Assault Patients document has been revised in both English and Spanish. Please begin using the revised information sheets, effective immediately. (update posted November 22, 2010)

Surgical Technologists House Bill 643 (pdf 39KB) - Clarification on employing surgical technologists without certification on or after September 1, 2009. (Posted October 19, 2010)

Notice to Abortion Facilities Regarding Office of Attorney General Opinion

The Office of Attorney General (OAG) has issued an opinion that impacts licensed abortion facilities in Texas. OAG Opinion No. GA-0802, relates to whether an abortion facility may use a prerecorded telephone message or a one-way conference call to furnish the information required to be provided by section 171.012 of the Texas Health and Safety Code (Woman’s Right to Know Act) to a patient before an abortion is performed.

The AG found that the legislature intended section 171.012 to preclude an abortion facility from using a prerecorded telephone message or a one-way conference call to provide the required information under section 171.012.

If an abortion facility currently uses pre-recorded messages or one-way conference calls to convey the information required by this law, the abortion facility must change this practice immediately. The required information must be provided through live dialogue with the patient by phone or in person. The information under section 171.012(a)(1) must be provided by the physician who is to perform the abortion or the referring physician. The information under Section 171.012(a)(2) must be provided by the physician who is to perform the abortion or the physician’s agent.

This change will not require any rule modifications. This information is being provided to all licensed abortion facilities.

If you have questions please email Mary Smith or Ellen Cooper. (Revised October 15, 2010)

The Survey Audit Tool for Freestanding Emergency Rooms has been added to the Applications/Forms page.

Information Sheet for Psychiatric Patients – Hospital and Freestanding Emergency Medical Care Facilities shall provide information to patients in their emergency departments to help patients with psychiatric disorders understand the ER process and the law.

Hospital Alternative Care Sites during H1N1 Public Health Emergency (PDF 200KB, posted November 9, 2009)

A Guide for Laboratories Performing CLIA Non-waived Testing in Free-Standing Emergency Care Facilities (PDF 471KB) (posted September 23, 2009)

Nationwide Public Health Alert Issued Concerning Life-Threatening Risk Posed by Cocaine Laced with Veterinary Anti-Parasite Drug (PDF 86KB) (posted September 21, 2009)

CDC Releases Guidance on Shortage of Erythromycin Ointment (posted September 3, 2009)

LVN Functioning in the Charge Role in a Licensed End Stage Renal Disease Facility and Texas Board of Nursing Letter Regarding the Role of LVNs in a Dialysis Facility. (PDF 129KB -- posted July 20, 2009)

Outpatient Facilities Q & A (posted 3/20/07)

Clarification of Provider Number Nomenclature (posted 3/2/07)

Notice of Ownership Interest in a Niche Hospital - §199.5 effective 6/29/06. Link to Texas Medical Board rule page, which includes physician report form. (updated 7/20/06)

Educational and Informational Material Concerning Vaccination Against Influenza Virus and Pneumococcal Diseases (posted 1/3/06)



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Texas Department of State Health Services, Health Facillity Licensing Program
1100 West 49th Street - Austin, Texas 78756 - (512) 834-6646

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Last updated November 07, 2014