(a) Enforcement is a process by which a sanction is proposed, and if warranted, imposed on an applicant or licensee regulated by the Texas Health and Human Services Commission (HHSC) for failure to comply with applicable statutes, rules, or orders.     
      (b) HHSC has jurisdiction to enforce violations of Texas Health and Safety Code (HSC) Chapter 241 (relating to Hospitals) and this chapter. HHSC may deny, suspend, or revoke a license or impose an administrative penalty on a limited services rural hospital (LSRH) for the following reasons:      
        (1) failure to comply with any applicable provision of the HSC, including Chapters 241, 311 (relating to Powers and Duties of Hospitals), and 327 (relating to Disclosure of Prices);       
        (2) failure to comply with any provision of this chapter or any other applicable laws;       
        (3) the LSRH, or any of its employees, commits an act which causes actual harm or risk of harm to the health or safety of a patient;       
        (4) the LSRH, or any of its employees, materially alters any license issued by HHSC;       
        (5) failure to comply with minimum standards for licensure;       
        (6) failure to provide a complete license application;       
        (7) failure to comply with an order of the executive commissioner or another enforcement procedure under HSC Chapters 241, 311, or 327;       
        (8) a history of failure to comply with the applicable rules relating to patient environment, health, safety, and rights that reflects more than nominal noncompliance;       
        (9) the LSRH has aided, committed, abetted or permitted the commission of an illegal act;       
        (10) the LSRH, or any of its employees, commits fraud, misrepresentation, or concealment of a material fact on any documents an LSRH is required to submit to HHSC or required to maintain pursuant to HSC Chapter 241, 311, or 327, and the provisions of this chapter;       
        (11) failure to comply with other state and federal laws affecting the health, safety, and rights of LSRH patients;       
        (12) failure to timely pay an assessed administrative penalty as required by HHSC;       
        (13) failure to submit an acceptable plan of correction (POC) for cited deficiencies within the timeframe required by HHSC;       
        (14) failure to timely implement POCs for deficiencies cited by HHSC within the dates designated in the POC;       
        (15) failure to comply with applicable requirements within a designated probation period; or       
        (16) if the LSRH is participating under Title XVIII and the Centers for Medicare & Medicaid Services terminates the LSRH's Medicare provider agreement.       
      (c) HHSC has jurisdiction to enforce violations of HSC Chapters 241, 311, and 327 and this chapter. HHSC may deny a license if the applicant:      
        (1) fails to provide timely and sufficient information required by HHSC that is directly related to the application;       
        (2) has had the following actions taken against the applicant within the two-year period preceding the application:                  (A) decertification or cancellation of its contract under the Medicare or Medicaid program in any state;                   (B) federal Medicare or state Medicaid sanctions or penalties;                   (C) unsatisfied federal or state tax liens;                   (D) unsatisfied final judgments;                   (E) eviction involving any property or space used as an LSRH or health care facility in any state;                   (F) unresolved federal Medicare or state Medicaid audit exceptions;                   (G) denial, suspension, or revocation of an LSRH license, a private psychiatric hospital license, or a license for any health care facility in any state; or                   (H) a court injunction prohibiting ownership or operation of an LSRH.         
      (d) Following notice and opportunity for hearing, the executive commissioner of HHSC or a person designated by the executive commissioner may issue an emergency order in relation to the operation of an LSRH licensed under this chapter if the executive commissioner or the executive commissioner's designee determines that the LSRH is violating this chapter, a rule adopted pursuant to this chapter, a special license provision, injunctive relief, an order of the executive commissioner or the executive commissioner's designee, or another enforcement procedure permitted under this chapter and the provision, rule, license provision, injunctive relief, order, or enforcement procedure relates to the health or safety of the LSRH's patients.      
        (1) HHSC shall send written notice of the hearing and shall include within the notice the time and place of the hearing. The hearing must be held within 10 days after the date of the LSRH's receipt of the notice.       
        (2) The hearing shall be held in accordance with HHSC's informal hearing rules.       
        (3) The order shall be effective on delivery to the LSRH or at a later date specified in the order.       
      (e) In lieu of denying, suspending, or revoking the license, HHSC may place the LSRH on probation for a period of not less than 30 days, if the LSRH is found in repeated noncompliance with these rules or HSC Chapter 241 and the LSRH's noncompliance does not endanger the health and safety of the public.      
        (1) HHSC shall provide notice to the LSRH of the probation and of the items of noncompliance not later than the 10th day before the probation period begins.       
        (2) During the probation period, the LSRH must correct the items that were in noncompliance and report the corrections to HHSC for approval.       
        (3) HHSC has jurisdiction to impose an administrative penalty against an LSRH licensed or regulated under this chapter for violations of HSC Chapters 241, 311, and 327 and this chapter. The imposition of an administrative penalty shall be in accordance with the provisions of HSC §241.059 (relating to Administrative Penalty), §241.060 (relating to Administrative Penalty for Mental Health, Chemical Dependency, or Rehabilitation Services), and §327.008 (relating to Administrative Penalty).       
      (f) HHSC may deny a person or entity a license or suspend or revoke an existing license on the grounds that the person or entity has been convicted of a felony or misdemeanor that directly relates to the duties and responsibilities of the ownership or operation of an LSRH. HHSC shall apply the requirements of Texas Occupations Code Chapter 53 (relating to Consequences of Criminal Conviction).      
        (1) HHSC is entitled under Texas Government Code Chapter 411 (relating to Department of Public Safety of the State of Texas) to obtain criminal history information maintained by the Texas Department of Public Safety, the Federal Bureau of Investigation, or any other law enforcement agency to investigate the eligibility of an applicant for an initial or renewal license and to investigate the continued eligibility of a licensee.       
        (2) The following felonies and misdemeanors directly relate because these criminal offenses indicate an inability or a tendency for the person to be unable to own or operate an LSRH:                  (A) a misdemeanor violation of HSC Chapter 241;                   (B) a misdemeanor or felony involving moral turpitude;                   (C) a misdemeanor or felony relating to deceptive business practices;                   (D) a misdemeanor or felony of practicing any health-related profession without a required license;                   (E) a misdemeanor or felony under any federal or state law relating to drugs, dangerous drugs, or controlled substances;                   (F) a misdemeanor or felony under the Texas Penal Code (TPC) Title 5, involving a patient or a client of any health care facility, a home and community support services agency, or a health care professional; or                   (G) a misdemeanor or felony under the TPC:                      (i) Title 4, relating to offenses of attempting or conspiring to commit any of the offenses in this clause;                       (ii) Title 5, relating to offenses against the person;                       (iii) Title 7, relating to offenses against property;                       (iv) Title 8, relating to offenses against public administration;                       (v) Title 9, relating to offenses against public order and decency;                       (vi) Title 10, relating to offenses against public health, safety and morals; or                       (vii) Title 11, relating to offenses involving organized crime.           
      (g) Offenses listed in subsection (f)(2) of this section are not exclusive in that HHSC may consider similar criminal convictions from other state, federal, foreign, or military jurisdictions that indicate an inability or tendency for the person or entity to be unable to own or operate an LSRH.     
      (h) HHSC shall revoke a license on the licensee's conviction of a felony or revocation of community supervision.     
      (i) If HHSC proposes to deny, suspend or revoke a license, place on probation, or impose an administrative penalty, HHSC shall send a notice of the proposed action by certified mail, return receipt requested, at the address shown in the current records of HHSC. The notice to deny, suspend, or revoke a license, place on probation, or impose an administrative penalty, shall state the alleged facts or conduct to warrant the proposed action, provide an opportunity to demonstrate or achieve compliance, and shall state that the applicant or license holder has an opportunity for a hearing before taking the action.     
      (j) Within 20 calendar days after receipt of the notice, the applicant or licensee may notify HHSC, in writing, of acceptance of HHSC's determination or request a hearing. Receipt of the notice is presumed to occur on the third day after the date the notice is mailed by HHSC to the last known address of the applicant or licensee.     
      (k) A hearing shall be conducted pursuant to Texas Government Code Chapter 2001 and Texas Administrative Code Title 1 Chapter 357, Subchapter I (relating to Hearings under the Administrative Procedure Act).     
      (l) If the applicant or licensee fails to timely respond to the notice or does not request a hearing, in writing, within 30 calendar days after receipt of the notice, HHSC shall refer the matter to the State Office of Administrative Hearings.     
      (m) HHSC shall send the licensee or applicant a copy of HHSC’s decision for denial, suspension, or revocation of license or imposition of an administrative penalty by certified mail, which shall include the findings of fact and conclusions of law on which HHSC based its decision.     
      (n) On HHSC's determination to suspend or revoke a license, the license holder may not admit new patients until the license is reissued.     
      (o) When HHSC’s decision to suspend or revoke a license is final, the licensee shall immediately cease operation, unless a stay of such action is issued by the district court.     
      (p) On suspension, revocation, or non-renewal of the license, the original license shall be returned to HHSC within 30 calendar days of HHSC’s notification.     
      (q) One year after HHSC’s decision to deny or revoke, or the voluntary surrender of a license by an LSRH while enforcement action is pending, an LSRH may petition HHSC, in writing, for a license. Expiration of a license prior to HHSC's decision becoming final shall not affect the one-year waiting period required before a petition may be submitted.      
        (1) HHSC may allow a reapplication for licensure if there is proof that the reasons for the original action no longer exist.       
        (2) HHSC may deny reapplication for licensure if HHSC determines that:                  (A) the reasons for the original action continues;                   (B) the petitioner has failed to offer sufficient proof that conditions have changed; or                   (C) the petitioner has demonstrated a repeated history of failure to provide patients a safe environment or has violated patient rights.         
        (3) If HHSC allows a reapplication for licensure, the petitioner shall be required to meet the requirements as described in §511.12 of this chapter (relating to Application and Issuance of Initial License).       
      (r) An LSRH whose license expires during a suspension period may not reapply for license renewal until the end of the suspension period.     
      (s) In the event that enforcement, as defined in this subsection, is pending or reasonably imminent, the surrender of an LSRH license shall not deprive HHSC of jurisdiction in regard to enforcement against the LSRH.     
     Source Note:        The provisions of this §511.121 adopted to be effective October 5, 2023, 48 TexReg 5668