The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise.

(1) Action plan--A written document that includes specific measures to correct identified problems or areas of concern; identifies strategies for implementing system improvements; and includes outcome measures to indicate the effectiveness of system improvements in reducing, controlling or eliminating identified problem areas.

(2) Adverse event--An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient.

(3) Applicant--The person legally responsible for the operation of the facility, whether by lease or ownership, who seeks a license from the department.

(4) Board--The Texas Board of Health.

(5) Community center--A center established under Health and Safety Code, Chapter 534, Subchapter A.

(6) Contaminated linen--Linen which has been soiled with blood or other potentially infectious materials or may contain sharps. Other potentially infectious materials means: (A) the following human body fluids: semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids; (B) any unfixed tissue or organ (other than intact skin) from a human (living or dead); and (C) Human Immunodeficiency Virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or Hepatitis B Virus (HBV) containing culture medium or other solutions; and blood, organs, or other tissues from experimental animals infected with HIV or HBV.

(7) Crisis stabilization unit (CSU)--A mental health facility operated by a community center or other entity designated by the Texas Department of Mental Health and Mental Retardation in accordance with Texas Health and Safety Code, §534.054, that provides treatment to individuals who are the subject of a protective custody order issued in accordance with Texas Health and Safety Code, §574.022.

(8) Dentist--A person licensed to practice dentistry by the State Board of Dental Examiners. This includes a doctor of dental surgery or a doctor of dental medicine.

(9) Department--The Texas Department of Health, 1100 West 49th Street, Austin, Texas 78756-3199.

(10) Dietitian--A person who is currently licensed by the Texas State Board of Examiners of Dietitians as a licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with the American Dietetic Association.

(11) Director--The director of the Health Facility Licensing and Compliance Division, Texas Department of Health.

(12) Division--The Health Facility Licensing and Compliance Division, Texas Department of Health.

(13) Emergency medical condition--A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in one or all of the following: (A) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (B) serious impairment to bodily functions; (C) serious dysfunction of any bodily organ or part; or (D) with respect to a pregnant woman who is having contractions: (i) that there is inadequate time to effect a safe transfer to another hospital before delivery; or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.

(14) Facility--A private psychiatric hospital or a crisis stabilization unit.

(15) Facility administration--Administrative body of a facility headed by an individual who has the authority to represent the facility and who is responsible for the operation of the facility according to the policies and procedures of the facility governing body.

(16) Fast-track projects--A construction project in which it is necessary to begin initial phases of construction before later phases of the construction documents are fully completed in order to establish other design conditions or because of time constraints such as mandated deadlines.

(17) Governing body--The governing authority of a facility which is responsible for the facility's organization, management, control, and operation, including appointment of the medical staff; includes the owner or partners for facilities owned or operated by an individual or partners.

(18) Governmental unit--A political subdivision of the state, including a hospital district, county, or municipality, and any department, division, board, or other agency of a political subdivision.

(19) Hospital--A private psychiatric hospital.

(20) Inpatient services--Services provided to a patient admitted to a hospital for an intended length of stay of 24 hours or greater.

(21) Learning disability--When a severe discrepancy exists when the individual's assessed intellectual ability is above the mentally retarded range, but where the individual's assessed educational achievement in areas specified is more than one standard deviation below the individual's intellectual ability.

(22) Legally reproduced form--A medical record retained in hard copy, microform (microfilm or microfiche), or other electronic medium.

(23) Licensed vocational nurse--An individual who is currently licensed as a licensed vocational nurse (LVN) by the Board of Vocational Nurse Examiners in accordance with Texas Occupations Code, Chapter 302.

(24) Licensee--A person or governmental unit who has been granted a private psychiatric hospital license or crisis stabilization unit license.

(25) Medical error--The failure of a planned action to be completed as intended, the use of a wrong plan to achieve an aim, or the failure of an unplanned action that should have been completed, that results in an adverse event.

(26) Medical staff--Licensed physicians and other licensed practitioners permitted by law and by the facility to provide medical care independently in the facility.

(27) Mental health services--All services concerned with research, prevention, and detection of mental disorders and disabilities and all services necessary to treat, care for, supervise, and rehabilitate persons who have a mental illness.

(28) Mental illness--An illness, disease, or condition (other than a sole diagnosis of epilepsy, senility, substance use disorder, mental retardation, autism, or pervasive developmental disorder) that: (A) substantially impairs a person's thought, perception of reality, emotional process, or judgment; or (B) grossly impairs an individual's behavior as demonstrated by recent disturbed behavior.

(29) Mental retardation--Significantly subaverage general intellectual functioning that is concurrent with deficits in adaptive behavior and originates during the developmental period.

(30) Minor--A person under 18 years of age who is not and has not been married or who has not had the disabilities of minority removed for general purposes.

(31) Mobile unit--Any pre-manufactured structure, trailer, or self-propelled unit equipped with a chassis on wheels and intended to provide shared medical services to the community on a temporary basis. Some of these units are equipped with expanding walls, and designed to be moved on a daily basis.

(32) Oral surgeon--A person licensed by the State Board of Dental Examiners in the specialty of dentistry which includes the diagnosis, surgical and adjunctive treatment of diseases, injuries, and defects involving both the functional and esthetic aspects of the hard and soft tissues of the oral and maxillofacial regions.

(33) Outpatient services--Services provided to patients whose medical needs can be met in less than 24 hours and are provided within the facility.

(34) Owner--One of the following persons which will hold or does hold a license issued under Health and Safety Code, Chapter 577, in the person's name or the person's assumed name: (A) a corporation; (B) a governmental unit; (C) a limited liability company; (D) an individual; (E) a partnership if a partnership name is stated in a written partnership agreement or an assumed name certificate; (F) all partners in a partnership if a partnership name is not stated in a written partnership agreement or an assumed name certificate; or (G) all co-owners under any other business arrangement.

(35) Patient--An individual who is receiving mental health services under this chapter.

(36) Person--An individual, firm, partnership, corporation, association, joint stock company, joint venture, or local authority, and includes a receiver, trustee, assignee, or other similar representative of those entities.

(37) Pharmacist--A person who is licensed to practice pharmacy by the Texas Board of Pharmacy in accordance with Texas Occupations Code, Chapter 558.

(38) Physician--An individual who is: (A) licensed as a physician by the Texas State Board of Medical Examiners in accordance with Chapter 155 of the Texas Occupations Code; or (B) authorized to perform medical acts under an institutional permit at a Texas postgraduate training program approved by the Accreditation Council on Graduate Medical Education, the American Osteopathic Association, or the Texas State Board of Medical Examiners.

(39) Podiatrist--A podiatrist licensed by the Texas State Board of Podiatry Examiners.

(40) Political subdivision--A county, municipality, or hospital district in this state but does not include a department, board, or agency of the state that has statewide authority and responsibility.

(41) Practitioner--A health care professional licensed in the State of Texas, other than a physician.

(42) Premises--A premises may be any of the following: (A) a single building where inpatients receive hospital services; or (B) multiple buildings where inpatients receive hospital services, provided that the following criteria are met: (i) all inpatient buildings and inpatient services are subject to the control and direction of the governing body of the hospital; (ii) all inpatient buildings are within a 30-mile radius of the main address of the licensee; (iii) there is integration of the organized medical staff of the hospital; (iv) there is a single chief executive officer who reports directly to the governing body and through whom all administrative authority flows and who exercises control and surveillance over all administrative activities of the hospital; (v) there is a single chief medical officer who reports directly to the governing body and who is responsible for all medical staff activities of the hospital; and (vi) each building that is geographically separate from other buildings contains at least one nursing unit for inpatients, unless providing only diagnostic or laboratory services, or a combination thereof, in the building for hospital inpatients.

(43) Private psychiatric hospital--A hospital that provides inpatient mental health services to individuals with a mental illness or with a substance use disorder except that, at all times, a majority of the individuals admitted are individuals with a mental illness. Such services include psychiatric assessment and diagnostic services, physician services, professional nursing services, and monitoring for patient safety provided in a restricted environment.

(44) Registered nurse--An individual who is licensed as a registered nurse by the Board of Nurse Examiners in accordance with Texas Occupations Code, Chapter 301.

(45) Relocatable unit--Any structure, not on wheels, built to be relocated at any time and provide medical services. These structures vary in size.

(46) Reportable event--A medical error or adverse event or occurrence which the facility is required to report to the department, as set out in §134.47 of this title (relating to Patient Safety Program).

(47) Root cause analysis--An interdisciplinary review process for identifying the basic or contributing causal factors that underlie a variation in performance associated with an adverse event or reportable event. It focuses primarily on systems and processes, includes an analysis of underlying cause and effect, progresses from special causes in clinical processes to common causes in organizational processes, and identifies potential improvements in processes or systems.

Cont'd...