(a) Promulgate and implement policies and procedures. Each local authority and community center shall promulgate and implement policies and procedures that meet the requirements of this section.     
      (b) Prohibition of abuse, neglect, and exploitation. Each local authority, community center, and contractor shall ensure that its employees and agents are informed of the prohibition of abuse, neglect, and exploitation of persons served.     
      (c) Identifying programs and investigatory agencies.      
        (1) Each local authority, community center, and contractor shall ensure that the name and phone number of the investigatory agency are clearly identified and displayed for its employees and agents at each of its  program and service delivery sites.       
        (2) Each local authority and community center shall provide to each investigatory agency a list of the names and addresses of its contracted and non-contracted program and service delivery sites in the investigatory agency's purview, including the name of the staff who will serve as contact for investigators, as required in subsection (g)(1) of this section.       
      (d) Reporting abuse, neglect, and exploitation and securing evidence.      
        (1) Each local authority, community center, and contractor shall require its employees and agents who suspect or have knowledge of abuse, neglect, or exploitation of a person served to:                  (A) make a verbal report to the  investigatory agency immediately, but in no case more than one hour after suspicion or knowledge of the abuse, neglect, or exploitation, in compliance with existing state laws, rules, memorandums of understanding, and this subchapter;                   (B) as needed, assist any individual in making a report when the individual alleging abuse, neglect, or exploitation is not an employee or agent, (e.g., a person served, a guest); and                   (C) secure evidence related to the allegation in accordance with "Guidelines for Securing Evidence" referenced as Exhibit B in §414.562 of this title (relating to Exhibits).         
        (2) Failure to make reports of abuse, neglect, or exploitation immediately without sufficient justification is  considered a violation of this section and makes the employee or agent subject to disciplinary or other appropriate action and possible criminal prosecution.       
        (3) In addition to the reporting requirement described in paragraph (1)(A) of this subsection, reports regarding alleged sexual exploitation committed by a mental health services provider are made to the prosecuting attorney in the county in which the alleged sexual exploitation occurred and any state licensing board that has responsibility for the mental health services provider's licensing in accordance with the Texas Civil Practice and Remedies Code, §81.006. A copy of the Texas Civil Practice and Remedies Code, §81.006, and §81.001, which includes the definitions of "sexual  exploitation" and "mental health services provider," is referenced as Exhibit C in §414.562 of this title (relating to Exhibits).       
      (e) Notifying contractor CEO. If the administrator is notified of an allegation involving a contractor, then the administrator must immediately notify the contractor CEO of the allegation unless the contractor CEO is the alleged perpetrator. If the contractor CEO is the alleged perpetrator, then the administrator shall ensure the activities described in subsections (f), (h), and (i) are accomplished.     
      (f) Safeguarding the alleged victim. Immediately upon notification of an allegation by the investigatory agency the administrator or contractor CEO shall ensure necessary measures are taken to  secure the safety of the alleged victim(s) involved in the allegation, including:      
        (1) ensuring immediate and on-going medical and psychological attention is provided to the alleged victim(s), as necessary; and       
        (2) separating the alleged victim(s) from the alleged perpetrator(s) until an investigation has been completed.       
      (g) Prohibiting retaliatory action. Any employee or agent, or any individual affiliated with an employee or agent is prohibited from engaging in retaliatory action against an employee, agent, or person served who in good faith reports an allegation. Any employee or agent found to have engaged in retaliatory action is subject to disciplinary or other appropriate action.      
        (1) Any employee or agent who believes he or she is being subjected to retaliatory action upon making a report of abuse, neglect, or exploitation, or who believes an allegation has been ignored without cause, should immediately contact the administrator or contractor CEO and may also contact the Office of Consumer Services and Rights Protection - Ombudsman at TDMHMR's Central Office, at the toll free number 1-800-252-8154.       
        (2) Retaliatory action against a person served which might be considered abuse, neglect, or exploitation must be reported in accordance with this section.       
      (h) Facilitating investigations.      
        (1) Administrators and contractor CEOs shall ensure the designation of a contact staff at  each program and service delivery site who will be responsible for coordinating with the investigator to ensure the availability of and access to private interview space, private telephones, and employees, agents, and persons served.       
        (2) Administrators and contractor CEOs shall require employees and agents to cooperate with investigators so that investigators are afforded immediate access to persons served, employees, agents, records of persons served, and other documents requested by the investigator.       
        (3) Falsification of fact during an investigation is considered a violation of this section and makes the employee or agent subject to disciplinary or other appropriate action and possible criminal prosecution.       
      (i) Referring allegations involving clinical practice. If the investigator refers to the administrator or contractor CEO an allegation involving the clinical practice of a licensed professional, then the administrator or contractor CEO shall refer the allegation for professional review or, if the local authority, community center, or contractor does not have a professional review process, the administrator or contractor CEO shall refer the allegation to the appropriate licensing authority. The administrator or contractor CEO shall ensure relevant conclusions of a professional review are submitted to the appropriate licensing authority.     
      (j) Facilitating resolution of other issues.      
        (1) Administrators and contractor CEOs  shall ensure that general complaints and administrative issues that are referred to them by an investigator are reviewed and resolved in a timely manner.       
        (2) Local authorities, community centers, and contractors shall afford TDMHMR immediate access to persons served, employees, agents, records of persons served, and other documents when TDMHMR responds to a complaint that the health, welfare, or safety of a person served may be jeopardized.       
     Source Note:        The provisions of this §414.554 adopted to be effective July 1, 2001, 26 TexReg 4708