Provider Investigations Handbook

Revision 24-2; Effective Dec. 2, 2024

The following words and terms have the following meanings when used in this handbook unless the context clearly shows otherwise. Note: A person receiving services in this handbook refers to an individual receiving services as defined in 26 Texas Administrative Code (TAC) Section 711.3.

For definitions quoted verbatim in TAC, visit 26 TAC Section 711.3.

TAC definitions modified for plain language and definitions not included in TAC are listed below.

A

Administrator: The person in charge of a provider or that person's designee. The term does not apply to the assistant commissioner for mental health substance abuse services.

Adult: A person 18 years or older, or a person under 18 years old who is or has been married or who has had the disabilities of minority removed for general purposes.

Adult with a disability: An adult with a mental, physical, or intellectual or developmental disability that substantially impairs their ability to provide adequately for their own care or protection. Such a person is or may be:

1. eligible for Social Security Administration (SSA), Supplemental Security Income (SSI);
2. diagnosed with an intellectual developmental disability;
3. diagnosed with a mental health disability;
4. diagnosed with a physical disability; or
5. eligible for Medicaid services.

Agency: State agencies including Texas Health and Human Services Commission, Texas Department of State Health Services, and the Texas Department of Family and Protective Services.

Agent: A person not employed by but working under the guidance of a service provider or contractor. For example, a student or volunteer.

Allegation: A report by someone that a person receiving services has been or is being abused, neglected, or exploited.

Allegation type: Per 26 TAC Chapter 711, the Provider Investigation (PI) program investigates the following allegation types:

• exploitation;
• neglect;
• physical abuse;
• sexual abuse; and
• verbal or emotional abuse.

Alleged Perpetrator: A direct provider alleged to have committed an act of abuse, neglect, or exploitation.

Alleged Victim: A person receiving services who is alleged to have been abused, neglected, or exploited.

B

Behavioral Health Services (BHS):

• services concerning research, prevention, and detection of mental disorders and disabilities;
• services necessary to treat, care for, control, supervise, and rehabilitate people who have a mental disorder or disability, including people whose mental disorders or disabilities result from a substance abuse disorder, alcoholism, or drug addiction; and
• interventions to treat:
  • abuse of alcohol or a controlled substance;
  • psychological or physical dependence on alcohol or a controlled substance; or
  • addiction to alcohol or a controlled substance.

C

Child: A minor person under 18 years old who has not been married and has not had the disabilities of minority removed for general purposes.

Child Care Regulation (CCR): An HHSC division that licenses and regulates 24-hour child care programs, including residential treatment centers and emergency shelters.

Children's Advocacy Center (CAC): Centers throughout Texas designated to provide specialized forensic interviews conducted by trained, neutral professionals using research and practice-informed techniques as part of a larger investigative process. CAC services are intended to minimize the need for multiple interviews by community agencies that serve victims of abuse.

Child-Placing Agency (CPA): An agency, organization, or person other than a child’s parent that places or plans for the placement of the child in a foster or adoptive home or other residential care setting. This excludes consummated adoptive homes.

• CPA adoptive home: A home approved by a child-placing agency for the purpose of adoption.
• CPA foster family home: A home regulated by a child-placing agency that is the primary residence of the foster parents and is verified to provide care for six or fewer children up to age 18.

Child-Placing Agency Administrator: A person who supervises and exercises direct control over a child-placing agency, as per 26 TAC Section 745.37(3)(D). The administrator is responsible for the child-placing agency's programs and personnel, regardless of if the person has an ownership interest in the agency or shares duties with anyone.

Clinical practice: A licensed professional's demonstration of professional competence, as described by the licensing professional board.

Collateral witness: Any person who can provide direct or circumstantial information about the alleged incident who is not the alleged victim or alleged perpetrator.

Community center: Serves people with mental health or intellectual disabilities and is established under the Texas Health and Safety Code Chapter 534, Subchapter A.

Community provider: Excluding Home and Community-based Services (HCS) and Texas Home Living (TxHmL) waiver program providers and home and community support services agencies, a community provider includes:

• a person who contracts with a health and human services agency or managed care organization to provide home and community-based services;
• a person who contracts with a Medicaid managed care organization to provide behavioral health services;
• a managed care organization;
• an officer, employee, agent, contractor, or subcontractor of a person or entity listed in the bullets above; and
• an employee, fiscal agent, case manager, or service coordinator of an individual employer participating in the consumer directed service option, as per Texas Government Code Section 531.051(a)(3).

Confirmed: Term used to describe an allegation in which a preponderance of credible evidence exists to support that abuse, neglect or exploitation occurred.

Consumer Directed Services (CDS): A service delivery option in which a person receiving services or their legally authorized representative employs and retains service providers and directs the delivery of program services.

Contractor: Any organization, entity or person who contracts with a provider to provide services directly to a person with physical, mental or intellectual disabilities. The term includes:

• a foster care provider; and
• a local independent school district with which a facility, local authority, or community center has a memorandum of understanding with for educational services.

Contractor Chief Executive Officer (CEO): The person in charge of a contractor that has one or more employees, excluding the CEO.

D

Designated Perpetrator: A direct provider who has committed an act of abuse, neglect, or exploitation.

Direct provider: The person, employee, agent, contractor or subcontractor responsible for providing services to the person receiving services.

DSHS: Texas Department of State Health Services.

E

Exploitation: When the alleged perpetrator is a direct provider to a person receiving services, exploitation is the illegal or improper act or process of using a person receiving services or their resources for monetary or personal benefit, profit or gain. Exploitation excludes:

• theft per the Texas Penal Code Chapter 31;
• allegations less than $25; and
• a loan, which includes money or property given to someone to use for a period with an understanding it will be paid back or returned, made by  a person receiving services to a direct provider of a community provider.

Examples of exploitation allegations are in 2150.

Refer to related 26 TAC Section 711.21.

F

Facility: This term refers to any of the following:

• HHSC central offices, state hospitals, the Rio Grande State Center, the Waco Center for Youth and the El Paso Psychiatric Center, including community services operated by Health and Specialty Care System.
• A person contracting with a health and human services agency to provide inpatient mental health services.
• Residential child-care facilities, at which an elderly person or an adult with a disability resides or is in the facility’s care (GROs and CPAs).

Financial Management Services Agency (FMSA): An agency contracting with HHSC or an MCO that provides financial management services for an employer who participates in the CDS option.

Refer to related 26 TAC, Chapter 264.

G

General Residential Operation (GRO): An operation that provides child care for seven or more children up to age 18. The care may include treatment and other programmatic services. Residential treatment centers and emergency shelters are types of GROs per Human Resources Code (HRC) Section 42.002(4).

H

HHSC: Texas Health and Human Services Commission.

HHSC Complaint and Incident Intake (CII): A program within the HHSC Regulatory Services Division that protects the rights of people receiving services.

HHSC Provider inspector or investigator: An employee of the Texas Health and Human Services Commission who:

• investigates allegations of abuse, neglect, and exploitation per HRC Chapter 48, Subchapter F and Texas Family Code Chapter 261;
• has expertise and demonstrated competence in conducting investigations; and
• has received training on techniques for communicating effectively with people with a disability.

Home and Community-based Services (HCBS): Services provided in the home or community per 42 U.S.C. Section 1315, 42 U.S.C. Section 1315a, 42 U.S.C. Section 1396a or 42 U.S.C. Section 1396n. Refer to related HRC Section 48.251(a)(5).

Home and Community-based Services – Adult Mental Health Program (HCBS-AMH): A program authorized under Section 1915(i) of the Social Security Act (42 U.S.C. Section 1396n) that provides HCBS to Medicaid and non-Medicaid people with serious mental illness who have extended tenure in state mental health facilities.

Home and Community-based Services (HCS) Waiver Program: Medicaid program authorized under Section 1915(c) of the federal Social Security Act (42 U.S.C. Section 1396n(c)) for the provision of services to people with an intellectual or developmental disability described by Texas Government Code Section 534.001(11)(B) and 26 TAC, Chapter 565.

I

Incitement: To spur to action or instigate into activity. This term implies responsibility for initiating another person's actions.

Inconclusive: Term used to describe that there is not a preponderance of credible evidence to indicate that abuse, neglect, or exploitation did or did not occur because of a lack of witnesses or other available evidence.

Person receiving services: This term refers to:

• an adult or child who receives services from a provider, as that term is defined below; or
• an adult or child who lives in a residence that is owned, operated, or controlled by an HCS waiver program provider, regardless of if the person is receiving HCS waiver program services.

L

Limited Service Provider (LSP): The company or person that provides only certain services meaning a specialty provider. An MCO, HCS, or TxHmL provider may contract with an LSP to provide certain services to a person receiving services.

Local Authority: Either a local mental health authority, local behavioral authority, or a local intellectual and developmental disability authority.

Local Behavioral Health Authority (LBHA): Provides services to a specific geographic area in Texas called the local service area. A LBHA may be designated by DSHS per Texas Health and Safety Code Section 533.0356, and has all the responsibilities and duties of a local mental health authority, as per Texas Health and Safety Code Section 533.035.

Local Intellectual and Developmental Disability Authority (LIDDA): Designated by the HHSC executive commissioner per Texas Health and Safety Code Section 533A.035 and as per Texas Health and Safety Code Section 531.002(12). LIDDAs serve as the point of entry for publicly funded intellectual and developmental disability programs provided by public or private entities. For more information about LIDDAs, refer to LIDDA Statutes and Rules.

Local Mental Health Authority (LMHA): Designated by the HHSC executive commissioner per Section 533.035, Texas Health and Safety Code and as per Section 531.002(13), Texas Health and Safety Code. LMHAs provide services to a specific geographic area of Texas, called the local service area.

M

Managed Care Organization (MCO): A health care provider or a group or organization of medical service providers who offers managed care health plans. Texas Medicaid uses managed care to provide health care services to most clients.

Medical intervention or treatment: Provided by a licensed medical doctor, osteopath, podiatrist, dentist, physician's assistant or advanced practice nurse. Does not include first aid, an examination, diagnostics, such as an X-ray or blood test, or prescribing oral or topical medication.

Mental health services provider: A person, licensed or unlicensed, who performs or claims to perform mental health services, including a:

• licensed social worker, as per Texas Occupations Code Section 505.002;
• chemical dependency counselor, as per Texas Occupations Code Section 504.001;
• licensed professional counselor, as per Texas Occupations Code Section 503.002;
• licensed marriage and family therapist, as per Texas Occupations Code Section 502.002;
• member of the clergy;
• physician who practices medicine, as per Texas Occupations Code Section 151.002;
• psychologist who offers psychological services, as per Texas Occupations Code Section 501.003, and
• special officer for mental health assignment certified under Texas Occupations Code Section 1701.404.

Refer to related Texas Civil Practice and Remedies Code, Section 81.001.

N

Neglect: When the alleged perpetrator is a direct provider to a person receiving services in or from a facility, local authority, community center, or HCS or TxHmL waiver program provider, neglect is defined as a negligent act or omission which caused or may have caused physical or emotional injury or death to a person receiving services or which placed a person receiving services at risk of physical or emotional injury or death.

Examples of neglect, if such failure results in physical or emotional injury or death to a person receiving services or which placed a person receiving services at risk of physical or emotional injury or death, include the failure to:

• establish or complete an appropriate individual program plan or treatment plan for a specific person receiving services;
• provide adequate nutrition, clothing, or health care to a specific person receiving services in a residential or inpatient program; or
• provide a safe environment for a specific person receiving services, including the failure to maintain adequate numbers of appropriately trained staff.

When the alleged perpetrator is a direct provider to a person receiving services from a community provider, neglect is defined as a negligent act or omission which caused physical or emotional injury or death to a person receiving services.

Examples of neglect allegations are in 2140.

Refer to related 26 TAC Section 711.19.

Non-serious physical injury:

• In state hospitals — any injury requiring minor first aid and determined not to be serious by a registered nurse, advanced practice nurse, or physician.
• For all other service providers — any injury determined not to be serious by the appropriate medical personnel. Examples of a non-serious physical injury may include:
  • a superficial laceration;
  • a contusion two and one-half inches in diameter or smaller; or
  • an abrasion.

Non-serious verbal or emotional abuse: Direct provider has used derogatory language that may be demoralizing or humiliating to the alleged victim.

P

Peer or Professional Review: A review of clinical and professional practices by peer professionals.

Physical abuse: When the alleged perpetrator is a direct provider, physical abuse is defined as:

• an act or failure to act performed knowingly, recklessly or intentionally, including incitement to act, which caused or may have caused physical injury or death to a person receiving services;
• an act of inappropriate or excessive force or corporal punishment, regardless of if the act results in a physical injury to a person receiving services; or
• the use of chemical or bodily restraints or seclusion on a person receiving services not in compliance with federal and state laws and regulations.

Examples of physical abuse allegations are in 2110. Also refer to  26 TAC Section 711.11.

Physical force: Pressure applied to a person's body.

Preponderance of evidence: The greater weight of evidence, or evidence more credible and convincing to the mind.

Provider: This term includes:

• a facility;
• a community center, local authority;
• a person who contracts with a health and human services agency or managed care organization to provide home and community-based services, except a home and community support services agency (HCSSA);
• a person who contracts with a Medicaid managed care organization to provide behavioral health services;
• a managed care organization;
• an officer, employee, agent, contractor or subcontractor of a person or entity listed above; and
• an employee, fiscal agent, case manager or service coordinator of an individual employer participating in the Consumer Directed Service option, as per Texas Government Code Section 531.051.

Refer to related HRC Section 48.251(a)(9).

R

Reasonable person: A hypothetical person who exercises average care, skill and judgment.

Reporter: The person who makes an allegation. 

Restraint: The use of physical contact, a mechanical device, or a chemical to involuntarily restrict the free movement or normal functioning of the whole or part of the body of a person receiving services. A restraint is used to control physical activity or behavior.

S

Serious physical injury:

• In state hospitals — Any injury requiring medical intervention or hospitalization or determined to be serious by a physician or advanced practice nurse. Medical intervention is treatment by a licensed medical doctor, osteopath, podiatrist, dentist, physician assistant or advanced practice nurse. Medical intervention does not include first aid, an examination, diagnostics, such as an X-ray or blood test, or the prescribing of oral or topical medication.
• For all other service providers — any injury determined to be serious by the appropriate medical personnel who examined the person. Examples of serious physical injuries include:
  • a fracture;
  • a dislocation of any joint;
  • an internal injury;
  • a contusion larger than two and one-half inches in diameter;
  • a concussion;
  • a second or third-degree burn; or
  • any laceration requiring sutures.

Serious verbal or emotional abuse: Serious threats by a direct provider to harm or kill an alleged victim.

Service provider: The provider that employs, contracts with, or supervises the direct provider of services to a person receiving services.

Sexually transmitted infection: Any infection with or without symptoms or clinical manifestations that can be transmitted from one person to another by sexual contact. Also referred to as sexually transmitted disease.

Sexual abuse: When the alleged perpetrator is a direct provider, sexual abuse is defined as:

• any sexual activity, including:
  • kissing a person receiving services with sexual intent;
  • hugging a person receiving services with sexual intent;
  • stroking a person receiving services with sexual intent;
  • fondling a person receiving services with sexual intent;
• engaging in sexual conduct as per the Texas Penal Code, Section 43.01 or any activity that is obscene as per the Texas Penal Code, Section 43.21;
• requesting, soliciting or compelling a person receiving services to engage in:
  • sexual conduct as per the Texas Penal Code, Section 43.01, or
  • any activity that is obscene as per the Texas Penal Code, Section 43.21;
• while in the presence of a person receiving services:
  • engaging in or displaying any activity that is obscene, as per the Texas Penal Code Section 43.21; or
  • requesting, soliciting or compelling another person to engage in any activity that is obscene, as per the Texas Penal Code Section 43.21;
• committing sexual exploitation as per 26 TAC Section 711.13, against a person receiving services;
• committing sexual assault as per the Texas Penal Code Section 22.011, against a person receiving services;
• committing aggravated sexual assault as per the Texas Penal Code, Section 22.021, against a person receiving services; and
• causing, permitting, encouraging, engaging in, or allowing the photographing, filming, videotaping or depicting of a person receiving services if the direct provider knew or should have known that the resulting photograph, film, videotape, or depiction of the person receiving services is obscene as per the Texas Penal Code, Section 43.21, or is pornographic.

Consensual sexual activity between a direct provider and an adult receiving services is not considered sexual abuse if the consensual sexual relationship began before the direct provider became a direct provider.

Examples of sexual abuse allegations are in 2120.

See related 26 TAC Section 711.13.

Significant impairment: When a person experiences a negative physical, emotional or mental effect or decline in their social, occupational, or other areas of daily functioning, such as independence, self-care, or activities of daily living, as determined through observation, diagnosis, evaluation or assessment.

State hospitals: State hospitals provide patient-focused, inpatient psychiatric services for people of all ages. Additional information is on the HHSC website.

T

Texas Administrative Code (TAC): A compilation of state agency rules in Texas.

Texas Home Living Waiver Program (TxHmL): Medicaid waiver program authorized for the provision of community-based services and supports to eligible people with an intellectual or developmental disability who live in their own homes or the homes of their families. TxHmL is authorized under Section 1915(c) of the federal Social Security Act (42 U.S.C. Section 1396n(c)), Texas Government Code Section 534.001(11)(D), and 26 TAC Chapter 566.

U

Unconfirmed: Term used to describe an allegation in which a preponderance of evidence exists to prove that it did not occur.

Unfounded: Term used to describe an allegation that is false or obviously without factual basis. Refer to 26 TAC Section 711.421.

V

Verbal or emotional abuse: When the alleged perpetrator is a direct provider, verbal or emotional abuse is the willful infliction of an act or repeated acts of verbal or other communication, including gestures, to harass, intimidate, humiliate or degrade a person receiving services or threaten them with physical or emotional harm. The act or communication must:

• result in a person receiving services experiencing:
  • significant impairment to their physical, mental or emotional health; or
  • substantial physical or emotional distress as identified by an appropriate medical professional; or
• be of such a serious nature that a reasonable person would consider it causing significant impairment to the physical, mental or emotional health of the alleged victim.

Examples of verbal or emotional abuse allegations are in 2130.

Refer to related 26 TAC 711.17.

Victim: A person receiving services who is alleged to have been abused, neglected, or exploited by an alleged perpetrator. Refer to Alleged Victim.

Y

Youth Empowerment Services Waiver: A waiver authorized under Section 1915(c) of the Social Security Act, which prevents or reduces institutionalization of children and adolescents with severe emotional disturbance (SED). The waiver enables more flexibility in providing intensive community-based services for children and adolescents with SED, and provides support for their families by improving access to services.