Adopted Rules Title 25

TITLE 25. HEALTH SERVICES

PART 1. DEPARTMENT OF STATE HEALTH SERVICES

The Texas Health and Human Services Commission (HHSC), on behalf of the Department of State Health Services (DSHS), adopts amendments to §448.801, concerning Screening; §448.803, concerning Assessment; and §448.911, concerning Treatment Services Provided Through Electronic Means.

The amendments to §§448.801, 448.803, and 448.911 are adopted with changes to the proposed text as published in the November 10, 2023, issue of the Texas Register (48 TexReg 6562). These rules will be republished.

BACKGROUND AND JUSTIFICATION

The amendments are necessary to comply with and implement House Bill (H.B.) 4, 87th Legislature, Regular Session, 2021. H.B. 4, Section 2, amended Texas Government Code Chapter 531 to require HHSC to determine which services are cost-effective and clinically effective and adopt rules to develop and implement a system to allow providers to provide certain behavioral health services using audio-only means to an individual receiving those services. The amendments allow a chemical dependency treatment facility (CDTF) to deliver certain audio-only substance use disorder treatment services that HHSC determined are clinically effective and safe.

The amendments are also necessary to update the requirements for providing services through electronic means to increase clarity and readability.

COMMENTS

The 31-day comment period ended December 11, 2023.

During this period, HHSC received comments regarding the proposed rules from 23 commenters: Disability Rights Texas (DRTx), Texas Medical Association (TMA), and 21 individuals. A summary of comments relating to the rules and HHSC's responses follows.

Comment: One individual stated the draft rules were well written and wanted HHSC to implement the rules accordingly.

Response: HHSC acknowledges this comment.

Comment: One individual expressed concern with §448.801 allowing the use of audiovisual technology for screening but not for inpatient services and asked for clarification regarding why the proposed rules do not allow facilities to screen individuals using audiovisual technology in inpatient settings.

Response: HHSC declines to revise §448.801 because Texas Health and Safety Code §462.015, Outpatient Treatment Services Provided Using Telecommunications or Information Technology, authorizes only outpatient CDTF programs to provide treatment services through electronic means.

Comment: One individual expressed concern with §448.801(b) requiring the use of a valid screening tool before admission. The commenter stated they administer the brief scale once a facility admits an individual and clarified they do not administer the scale prior to an individual's admission. The commenter requested clarification regarding whether providers must administer a valid assessment tool prior to admission. The commenter noted that qualified credentialed counselors (QCCs) are not able under current law to interpret standardized assessments and stated a licensed clinician or clinical psychologist should instead administer the assessment.

Response: HHSC declines to revise §448.801(b) because individuals who qualify as QCCs under Texas Administrative Code Title (TAC), Title 25 §140.400(38) include a wide range of providers, including individuals who hold master's through medical doctorate degrees. Additionally, HHSC notes that a provider gains qualifications for assessment tools and instruments through training, and that there are a variety of appropriate tools and instruments available to qualified providers based on the provider's skill set, education level, and work experience.

Comment: One individual stated that §448.801(e)(4), which requires the physician to examine the client in person and sign the admission order within 24 hours of authorizing admission, only refers to a "physician" and recommended revising the rule to also include the physician's designee to align with the current regulations and avoid creating an undue burden on facilities.

Response: HHSC revises §448.801(e)(4) to add "the physician's designee" as a qualified individual who may satisfy the requirement to examine a client in person and sign the admission order within 24 hours of authorizing admission to a detoxification program. HHSC also revises §448.801(e) and §448.801(e)(3) for consistency with the revision at §448.801(e)(4) by adding "the physician's designee" as a qualified individual who may screen an individual for admission to a detoxification program and who may determine the appropriateness for and authorize the individual's admission.

Comment: DRTx stated §448.801(g) implies that screenings for programs other than detoxification programs must occur in person, and noted the language in the proposed rule does not clearly communicate that implication. DRTx recommended HHSC revise the language to clarify which programs may conduct virtual screenings and which programs are prohibited from conducting virtual screenings.

Response: HHSC declines to revise §448.801(g) because §448.801(h) clarifies a treatment program that is not a detoxification program may offer screenings in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1).

Comment: Fourteen individuals provided substantially similar comments and requested HHSC revise §448.801(h)(1), §448.803(b)(1), and §448.911(d)(2) to relax the requirement for counselor interns to pass the chemical dependency counselor licensing exam before providing telehealth services. These commenters stated Level III counselor interns already operate under the supervision of a QCC to provide services in person and have substantial training and experience, which should allow them to provide services electronically. These commenters also stated allowing counselor interns to provide services through electronic means could enhance accessibility to mental health care for individuals who may face barriers to in-person appointments.

Response: HHSC declines to revise §448.801(h)(1), renumbered to §448.801(h)(1)(B); §448.803(b)(1), renumbered to §448.803(b)(1)(B); and §448.911(d)(2) because the chemical dependency counselor licensing exam is necessary to demonstrate the intern's skill set and proficiency in service delivery.

Comment: One individual requested clarification on whether the 2,000 hours of supervised experience requirement, before a counselor or counselor intern may provide services through electronic means, would allow a licensed master social worker (LMSW) or licensed professional counselor assistant (LPC-A) to qualify under these paragraphs as being able to screen individuals using electronic means once they achieve the 2,000 hours and are under a board-approved supervision plan.

Response: HHSC revises §448.801(h)(1) and §448.803(b)(1) by dividing these paragraphs into two new subparagraphs and relocating "prior to screening an individual through electronic means" to the beginning of these paragraphs. HHSC revises §448.801(h)(1), renumbered to §448.801(h)(1)(A) and §448.803(b)(1), renumbered to §448.803(b)(1)(A), to clarify LMSWs or LPC-As, in addition to counselor interns, may conduct screenings and assessments if they meet the requirements of those subparagraphs.

HHSC also revises §448.801(h)(1), renumbered to §448.801(h)(1)(B), and §448.803(b)(1), renumbered to §448.803(b)(1)(B), to clarify that if the provider conducting the screening or assessment is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam because LMSWs and LPC-As may conduct screenings and assessments without having to pass the chemical dependency counselor licensing exam.

Comment: One individual stated §448.801(h)(3)(A), which only allows CDTFs to screen individuals using audio-only technology during a declared state of disaster, is too narrow and limiting for both the prospective client and the organization completing the screening. The commenter stated this limitation disproportionately impacts indigent, low socio-economic-status, and rural populations that may not have cell phone service, data, or access to reliable broadband internet. The commenter also stated this limitation makes maintaining an individual's privacy during the screening process more difficult as the individual being screened may go to a place with public Wi-Fi, and in those situations, the individual's ability to have privacy is greatly reduced. The commenter further stated clients who are incarcerated often have limited options to complete screenings and being able to be screened over the phone may be an incarcerated individual's only means of being accepted into a treatment program. The commenter recommended revising the rule to expand the exceptions for using audio-only technology beyond a declared state of disaster and include the circumstances the commenter noted in their comment.

Response: HHSC declines to revise §448.801(h)(3)(A) because the language allowing the use of audio-only technology for screening purposes only during declared states of disaster is consistent with HHSC Medicaid Managed Care rules at 1 TAC Chapter 353, Subchapter R, Telecommunications in Managed Care Service Coordination and Assessments.

Comment: One individual recommended revising §448.801(h)(3)(B) to require the organization completing the screening to document a justification for using audio-only technology that clearly outlines the reason why they did not use synchronous audiovisual technology to screen the individual.

Response: HHSC revises §448.801(h)(3)(B) and §448.803(b)(3)(B) to require the justification for using audio-only technology to include the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen or assess the individual, in addition to requiring the justification for their determination that using synchronous audio-only technology is safe and clinically appropriate for the individual being screened or assessed.

Comment: DRTx requested HHSC add language in the rules to clarify that a counselor or counselor intern must obtain the individual's consent before using electronic means to screen or treat the individual. DRTx further stated counselors or counselor interns must discuss with the individual how the counselor or counselor intern will conduct the screening or treatment, and if the individual chooses to utilize electronic means, that individual's choice must be documented in the individual's client record, as required by similar language in §448.803. DRTx noted their recommended revisions are consistent with 1 TAC Chapter 353, Subchapter R.

Response: HHSC revises §448.801(h)(4) and §448.803(b)(4) to clarify that the requirement to conduct an in-person and face-to-face screening or assessment with an individual when the individual does not provide their verbal consent to participate in a screening or assessment through electronic means is required by §448.911(u). HHSC notes §448.801(h) and §448.803(b) require a facility offering screenings and assessments through electronic means to comply with the applicable requirements under §448.911, including consent and consent documentation requirements.

Comment: One individual expressed concern with §448.803(d) requiring the assessment to result in a comprehensive diagnostic impression and stated licensed chemical dependency counselors (LCDCs) are not allowed to formulate comprehensive diagnostic impressions. The commenter further stated only a master's level professional licensed within the scope of their practice may formulate comprehensive diagnostic impressions from assessment results. The commenter recommended HHSC revise the rules to require only a fully licensed diagnostic clinician to properly review and approve a screening and assessment.

Response: HHSC revises §448.803(d) to clarify licensed interns or other providers must operate within the scope of their license when providing assessments. HHSC notes LCDCs are allowed under 25 TAC §140.424(a)(1)(B), Standards for Private Practice, to diagnose a patient based on an assessment.

Comment: TMA stated the "verbal consent" definition at §448.911(a)(5) could cause confusion because the definition uses the terms "medical consenter" and "legally authorized representative," which are synonymous. TMA further stated the current Texas Department of State Health Services chemical dependency treatment facility rules use the term "consenter," which could raise the question of whether "medical consenter" has a different meaning. TMA recommended revising the definition to either only include one of the terms or instead use the term "consenter" in place of "legally authorized representative and "medical consenter" to prevent confusion.

TMA also suggested revising §448.911(t), which uses the term "legally authorized representative," by replacing the term with "consenter" for consistency with their suggested revisions at §448.911(a)(5) and other rules for chemical dependency treatment services.

Response: HHSC revises the verbal consent definition in §448.911(a)(5) by removing "or a client's medical consenter" so the definition reads, "The spoken agreement of a client or a client's legally authorized representative to participate in treatment services through electronic means." HHSC notes the term "medical consenter" is defined at 1 TAC §353.1502(20).

HHSC declines to revise §448.911(t) because the term "legally authorized representative" in that subsection is appropriate and consistent with revised §448.911(a)(5).

Comment: One individual stated that while the proposed rule changes are well-intentioned, the commenter expressed concern with the audio-only rules preventing counselors from achieving any type of non-verbal observations by phone, including facial expressions, gaze, eye contact, gestures, posture, physical closeness, clothes, and grooming. The commenter expressed further concern with facilities being able to provide audio-only services under §448.911(k) as an everyday service but noted providing audio-only services during emergencies or catastrophes would make "perfect sense." The commenter also stated they could think of no other form of healthcare where audio-only services would be accepted or encouraged because a treatment provider must see the individual to provide quality services and effectively treat them.

Response: HHSC declines to revise §448.911(k) because the amended rule is authorized by Texas Health and Safety Code §462.015 and consistent with the rules at 1 TAC Chapter 353, Subchapter R.

Comment: One individual stated audio-only services should be reserved for screening purposes only and that any service requiring clinical assessment or insight should require direct client observation. The commenter further stated groups and individual sessions should require a visual of the client, assuming there are no limitations or unsuspected technology issues.

Another individual stated that while audio-only services would be appropriate for an established client in the middle to end parts of their treatment, a provider needs to be able to see the client in the earlier parts of the client's treatment to establish trust and gauge the client's understanding. The commenter further stated being able to monitor a person's body language allows a provider to better read a client's mood and determine whether the client is under the influence.

Response: HHSC declines to revise §448.803 and §448.911 because these rules are authorized by Texas Health and Safety Code §462.015 and consistent with the rules at 1 TAC Chapter 353, Subchapter R.

Comment: One individual identified themselves as an LCDC who works with juveniles and adults and stated delivering services virtually is too impersonal, lacks connection with the client, and does not foster an effective one-on-one environment where the practitioner can build empathy and a more effective professional relationship with the individual.

Response: HHSC declines to revise the rules because the rules are authorized by Texas Health and Safety Code §462.015 and consistent with the rules at 1 TAC Chapter 353, Subchapter R. HHSC notes the rules do not require providers to deliver services virtually but allow that option.

Comment: One individual requested clearer regulations for co-occurring diagnoses. The commenter stated 25 TAC Chapter 448 has a section outlining staffing requirements and stated on-site inspectors used to confirm whether providers truly could deliver treatment for co-occurring diagnoses. The commenter further stated on-site inspections used to occur every two years and such inspections are no longer occurring. The commenter also stated there are several facilities that claim to provide treatment for co-occurring diagnoses but do not have the required staff to provide such services. The commenter recommended HHSC clarify who can and cannot provide treatment for co-occurring diagnoses or require a separate license for facilities wanting to provide such treatment.

Response: HSHC declines to revise the rules as suggested because such revisions are beyond the scope of this project. HHSC notes the agency will consider this comment when updating the CDTF rules in the future.

HHSC made minor editorial changes to §§448.911(f)(1), 448.911(o), and 448.911(r) to ensure consistency when using the term "electronic means" throughout the rules.

SUBCHAPTER H. SCREENING AND ASSESSMENT

25 TAC §448.801, §448.803

STATUTORY AUTHORITY

The amendment is adopted under Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Health and Safety Code Chapter 462, which authorizes the Executive Commissioner to adopt rules governing the treatment of persons with chemical dependencies; and Chapter 464, which authorizes the Executive Commissioner to adopt rules governing the organization and structure, policies and procedures, staffing requirements, services, client rights, records, physical plant requirements, and standards for licensed CDTFs.

§448.801.Screening.

(a) To be eligible for admission to a treatment program, an individual must meet the current Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for substance use disorders (or substance withdrawal or intoxication in the case of a detoxification program). The facility shall use a screening process appropriate for the target population, individual's age, developmental level, culture, and gender, which includes the Texas Department of Insurance (TDI) criteria to determine eligibility for admission or referral including an assessment of the client's financial resources and insurance benefits.

(b) The screening process shall collect other information as necessary to determine the type of services that are required to meet the individual's needs. This may necessitate the administration of all or part of validated assessment instruments.

(d) Sufficient documentation shall be maintained in the client record to support the diagnosis and justify the referral or placement decision. Documentation shall include the date of the screening and the signature and credentials of the Qualified Credentialed Counselor (QCC) supervising the screening process.

(e) For admission to a detoxification program, the screening will be conducted by a physician, the physician's designee, physician assistant, nurse practitioner, registered nurse, or licensed vocational nurse (LVN). An LVN may conduct a screening under the following conditions:

(1) the LVN has completed detoxification training and demonstrated competency in the detoxification process;

(2) the training and competency verification is documented in the LVN's personnel file;

(3) the LVN shall convey in person or via telephone the medical data obtained during the screening process to a physician or the physician's designee, who shall determine the appropriateness of the admission and authorize the admission or give instructions for an alternative course of action; and

(4) the physician or the physician's designee shall examine the client in person and sign the admission order within 24 hours of authorizing admission.

(f) For admission to all other treatment programs, the screening will be conducted by a counselor or counselor intern.

(g) A detoxification program shall not offer screenings through electronic means.

(h) A treatment program, other than a detoxification program, may offer screenings in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1) of this chapter (relating to Treatment Services Provided by Electronic Means). A facility offering screenings through electronic means shall comply with the applicable requirements under §448.911 of this chapter and the following requirements.

(1) Prior to screening an individual through electronic means:

(A) a counselor intern, licensed professional counselor assistant (LPC-A), or licensed master social worker (LMSW) must have more than 2,000 hours of supervised work experience or have a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure); and

(B) if the provider is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam.

(2) A counselor or counselor intern screening an individual through electronic means shall use synchronous audiovisual technology, as that term is defined by §448.911(a)(4) of this chapter, except as provided under paragraph (3) of this subsection.

(3) To the extent allowed by federal law and only when all the following criteria are met, the counselor or counselor intern may screen an individual using synchronous audio-only technology, as that term is defined by §448.911(a)(3) of this chapter, when:

(A) the screening occurs during a declared state of disaster under Texas Government Code §418.014 (relating to Declaration of State of Disaster) in the county in which the facility where the client signed the client's consent for treatment form is located;

(B) the counselor or counselor intern determines and documents a justification for their determination in the individual's record that screening the individual using synchronous audio-only technology is safe and clinically appropriate for the individual being screened and the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen the individual; and

(C) the individual being screened agrees and provides verbal consent, as that term is defined by §448.911(a)(5) of this chapter, to participate in a screening using synchronous audio-only technology.

(4) The counselor or counselor intern shall conduct an in-person and face-to-face screening with an individual at the individual's request or if the individual does not provide their verbal consent to participate in a screening through electronic means as required by §448.911(u) of this chapter.

§448.803.Assessment.

(a) A counselor or counselor intern shall conduct and document a comprehensive psychosocial assessment with the client admitted to the facility. The assessment shall document and elicit enough information about the client's past and present status to provide a thorough understanding of the following areas:

(1) presenting problems resulting in admission;

(2) alcohol and other drug use;

(3) psychiatric and chemical dependency treatment;

(4) medical history and current health status, to include an assessment of Tuberculosis (TB), HIV and other sexually transmitted disease (STD) risk behaviors as permitted by law;

(5) relationships with family;

(6) social and leisure activities;

(7) education and vocational training;

(8) employment history;

(9) legal problems;

(10) mental/emotional functioning; and

(11) strengths and weaknesses.

(b) The counselor or counselor intern may conduct the assessment with a client in-person and face-to-face, or through electronic means, as that term is defined by §448.911(a)(1) of this chapter (relating to Treatment Services Provided by Electronic Means). A facility offering assessments through electronic means shall comply with the applicable requirements under §448.911 of this chapter and the following requirements.

(1) Prior to conducting an assessment through electronic means:

(B) if the provider is a counselor intern, the intern must have passed the chemical dependency counselor licensing exam.

(2) A counselor or counselor intern assessing a client through electronic means shall use synchronous audiovisual technology, as that term is defined by §448.911(a)(4) of this chapter, except as provided under paragraph (3) of this subsection.

(3) To the extent allowed by federal law and only when all the following criteria are met, the counselor or counselor intern may assess a client using synchronous audio-only technology, as that term is defined by §448.911(a)(3) of this chapter, when:

(A) the assessment occurs during a declared state of disaster under Texas Government Code §418.014 (relating to Declaration of State of Disaster) in the county in which the facility where the client signed their consent for treatment form is located;

(B) the counselor or counselor intern determines and documents a justification for their determination in the client's record that assessing the client using synchronous audio-only technology is safe and clinically appropriate for the client being assessed and the reason why the counselor or counselor intern did not use synchronous audiovisual technology to screen the individual; and

(C) the client being assessed agrees and provides verbal consent, as that term is defined by §448.911(a)(5) of this chapter, to participate in an assessment using synchronous audio-only technology.

(4) The counselor or counselor intern shall conduct an in-person and face-to-face assessment with a client at the client's request or if the client does not provide their verbal consent to participate in an assessment through electronic means, as required by §448.911(u) of this chapter.

(d) The assessment shall result in a comprehensive diagnostic impression. The diagnostic impression shall correspond to current Diagnostic and Statistical Manual of Mental Disorders (DSM) standards. A licensed intern or other provider shall operate within the scope of their license when conducting assessments.

(e) If the assessment identifies a potential mental health problem, the facility shall obtain a mental health assessment and seek appropriate mental health services when resources for mental health assessments or services, or both, are available internally or through referral at no additional cost to the program. These services shall be provided by a facility or person authorized to provide such services or a qualified professional as described in §448.901 of this chapter (relating to Requirements Applicable to all Treatment Services).

(f) The assessment shall be signed by a QCC and filed in the client record within three individual service days of admission.

(g) The program may accept an evaluation from an outside source if:

(1) it meets the criteria set forth herein;

(2) it was completed during the 30 days preceding admission or is received directly from a facility that is transferring the client; and

(3) a counselor reviews the information with the client and documents an update.

(h) For residential clients, a licensed health professional shall conduct a health assessment of the client's physical health status within 96 hours of admission. The facility may accept a health assessment from an outside source completed no more than 30 days before admission or received directly from a transferring facility. If the client has any physical complaints or indications of medical problems, the client shall be referred to a physician, physician assistant, or nurse practitioner for a history and physical examination. The examination, if needed, shall be completed within a reasonable time frame and the results filed in the client record.

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority.

Filed with the Office of the Secretary of State on February 2, 2024.

TRD-202400419

Karen Ray

Chief Counsel

Department of State Health Services

Effective date: February 22, 2024

Proposal publication date: November 10, 2023

For further information, please call: (512) 834-4591

SUBCHAPTER I. TREATMENT PROGRAM SERVICES

25 TAC §448.911

STATUTORY AUTHORITY

§448.911.Treatment Services Provided Through Electronic Means.

(a) In this section, the following words and terms have the following meanings:

(1) Electronic means--Live, synchronous, interactive treatment program services delivered using telecommunications or information technology by a health professional licensed, certified, or otherwise entitled to practice in this state and acting within the scope of the health professional's license, certification, or entitlement to a patient at a different physical location than the health professional. This term includes services delivered using synchronous audiovisual technology or synchronous audio-only technology but does not include pre-recorded videos.

(2) Existing clinical relationship--A relationship that occurs when a person has received at least one in-person or synchronous audiovisual treatment service from the same provider within the six months prior to the initial service delivered by synchronous telephone (audio-only) technology.

(3) Synchronous audio-only technology--An interactive, two-way audio telecommunications platform, including telephone technology, that uses only sound and meets the privacy requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

(4) Synchronous audiovisual technology--An interactive, two-way audio and video telecommunications platform that meets HIPPA privacy requirements.

(5) Verbal consent--The spoken agreement of a client or a client's legally authorized representative to participate in treatment services through electronic means.

(b) Except as provided under §448.801 of this chapter (relating to Screening) and §448.803 of this chapter (relating to Assessment), only a licensed outpatient chemical dependency treatment program may provide treatment program services through electronic means.

(c) The program providing treatment services through electronic means may provide treatment services to adult and adolescent clients to the extent allowed by the facility's license and shall comply with all requirements of this section.

(d) The program shall ensure only the following individuals provide services through electronic means under this section:

(1) a qualified credentialed counselor (QCC); or

(2) a counselor intern who has more than 2,000 hours of supervised work experience or a supervised work experience waiver under §140.408(b) of this title (relating to Requirements for LCDC Licensure) and who has passed the chemical dependency counselor licensing exam.

(e) The program's physical location shall be equipped to provide in-person, face-to-face treatment services with an individual at the individual's request.

(f) The program shall ensure all treatment sessions shall have the following two forms of access control:

(1) all contact between a QCC and clients via electronic means shall begin with a verification of the client through a name, password or pin number; and

(2) security as detailed in HIPAA.

(g) A facility shall implement adequate security and encryption measures to ensure all patient communications, recordings and records are protected and adhere to federal and state privacy laws, including HIPAA and Texas Health and Safety Code Chapters 181, 464, and 466 (relating to Medical Records Privacy; Facilities Treating Persons with a Chemical Dependency, and Regulation of Narcotic Drug Treatment Programs).

(h) A program shall maintain compliance with HIPAA and Code of Federal Regulations (CFR) Title 42, Part 2 (relating to Confidentiality of Substance Use Disorder Patient Records).

(i) A program shall not use e-mail communications containing client identifying information.

(j) A program shall use synchronous audiovisual technology, except as provided in subsection (k) of this section.

(k) A program may provide outpatient individual and group counseling to clients using synchronous audio-only technology only when all the following criteria are met:

(1) the client and provider have an existing clinical relationship;

(2) the provider receives the client's verbal consent before each session; and

(3) the provider documents in the client's record the specific reason why the provider provided outpatient counseling services using synchronous audio-only technology.

(l) A program shall ensure timely access to individuals qualified in the technology as backup for systems problems.

(m) A program shall develop a contingency plan and maintain alternate means of communication for clients when technical problems occur during the provision of services.

(n) A program shall provide individuals and clients with a description of all services offered.

(o) A program shall provide developed criteria, in addition to the Diagnostic and Statistical Manual of Mental Disorders, to assess clients for appropriateness of utilizing services through electronic means.

(p) A program shall provide appropriate referrals for clients who do not meet the criteria for services.

(q) A program shall develop a grievance procedure and provide the website and phone number to the Texas Health and Human Services Commission (HHSC) for filing a complaint.

(r) Prior to clients engaging in services through electronic means, a program shall describe and provide in writing the potential risks to clients. The risks shall address at a minimum the following areas:

(1) clinical aspects;

(2) security; and

(3) confidentiality.

(s) In a HIPAA-compliant manner, a program shall document and maintain in a client's record the client's verbal consent to participate in services provided through electronic means. The program shall provide the verbal consent documentation to HHSC upon request.

(t) A program shall explain to the client or the client's legally authorized representative what verbal consent means and to what the client or client's legally authorized representative is consenting. The verbal consent a client provides when electing to participate in a treatment service delivered through electronic means only applies to one treatment service at a time. A program shall obtain the client's verbal consent before the client receives each service through electronic means.

(u) If the program does not obtain verbal consent for a treatment service through electronic means, the program shall provide the service to the client in-person and face-to-face.

(v) A program shall inform a client who chooses to receive services through electronic means that the program will:

(1) monitor services for evidence of fraud, waste, and abuse;

(2) determine whether the client needs additional social services or supports;

(3) ensure the provider documents, in writing and in the client's record, the client's verbal consent to participate in services provided through electronic means; and

(4) adhere to HIPPA, including using HIPAA-compliant technology for services provided through electronic means.

(w) A program shall create safeguards to ensure adolescents receive treatment services separately from adults and verify a client's identity and the identity of any authorized participant.

(x) A program shall provide clients with information to access online or a copy of the current version of the following chemical dependency treatment facility (CDTF) rules, statutes, and federal regulations to notify clients of applicable rules and laws regarding CDTFs:

(1) This chapter;

(2) Texas Health and Safety Code Chapter 464; and

(3) 42 CFR Part 2.

(y) A program shall provide the program's emergency contact information to the client.

(z) A program shall maintain resource information for the local area of the client.

(aa) A program shall provide reasonable Americans with Disabilities Act of 1990 (ADA) accommodations for clients upon request.

(bb) A program shall be located and perform services in Texas.

(cc) HHSC maintains the authority to regulate the program regardless of the location of the client.

(dd) The facility shall provide the facility's emergency contact information to the client.

(ee) The facility shall maintain resource information for the local area of the client.