Revision 24-2; Effective Dec. 2, 2024

1310 Allegations

Revision 24-2; Effective Dec. 2, 2024

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.

When the alleged perpetrator is a direct provider, or is unknown, Provider Investigations (PI) investigates the following allegation types:

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

Refer to Definitions in 1200.

PI also investigates:

  • the pregnancy of a person receiving services from a facility or facility contractor if there is:
    • medical verification that conception could have occurred while the person receiving services was a resident of the facility or of a facility contractor; and
    • a reasonable expectation that conception occurred while the individual was a resident of the facility or of a facility contractor;
    • the sexually transmitted disease (STD) of a person receiving services from a facility or of a facility contractor, if the individual could have acquired the STD while a resident of the facility or of a facility contractor; and
  • an injury of unknown origin to a person receiving services if appropriate medical personnel, after examining the person, suspect the injury is the result of abuse or neglect.

Refer to related 26 TAC Section 711.5.

1320 Providers and Entities

Revision 24-2; Effective Dec. 2, 2024

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.

PI investigates allegations of abuse, neglect and exploitation that involve these providers:

  • state hospitals;
  • residential child-care facilities where an elderly person or an adult with a disability lives or receives care in a General Residential Operations (GROs) and Child-Placing Agencies (CPAs).
  • HHSC-operated community services;
  • a person contracting with a Health and Human Services (HHS) agency to provide inpatient mental health services;
  • community centers and local authorities;
  • a person who contracts with an HHS agency or a managed care organization (MCO) to provide home and community-based services (HCBS), except for home and community support services agencies (HCSSAs);
  • a person who contracts with an MCO to provide behavioral health services (BHS);
  • an MCO
  • an officer, employee, agent, contractor or subcontractor of the above; and
  • an employee, agent, manager, coordinator of a person who participates in the consumer directed services (CDS) option.

PI investigates allegations of abuse, neglect, and exploitation that involve:

  • persons who live in an HCS group home who may or may not receive services under the provider’s waiver program; and
  • independent school districts (ISDs) that contract with the provider.

1330 Cooperating with PI Investigations

Revision 24-2; Effective Dec. 2, 2024

State Hospitals

A state hospital administrator assigns a staff person to serve as a liaison to PI.

HHSC Health and Specialty Care System rules provide direction to state hospital employees about cooperation with a PI investigation.

Review related 25 TAC Section 417.508(c).

Local Authorities and Community Centers

A local authority and community center administrator assigns a staff person to serve as a liaison to PI.

Administrators and contractor CEOs of local authorities and community centers follow directions outlined in 26 TAC, Chapter 301, Subchapter M about cooperation with a PI Investigation.

Review related 26 TAC Section 565.31(e) and 26 TAC Section 566.15(e).

1340 Other State Agencies and Investigative Entities

Revision 24-2; Effective Dec. 2, 2024

PI does not investigate allegations of abuse, neglect, and exploitation if another division of HHSC or another state agency is responsible under state law for the investigation. PI may refer these allegations to HHSC Complaint and Incident Intake (CII) or the administrator of the provider where the incident occurred. In certain circumstances, PI forwards the report to other agencies for investigation. Some agencies and entities PI may forward reports to include:

Texas Department of Family and Protective Services

For information on Texas DFPS investigative authority, refer to the Texas DFPS webpage.

Texas Department of State Health Services

For information on Texas DSHS investigations, refer to the DSHS Division for Regulatory Services webpage.

The University of Texas

PI does not have jurisdiction to investigate allegations from a hospital or psychiatric center operated by The University of Texas, unless the private psychiatric center contracts directly with HHSC. PI refers these allegations to the administrator of the facility where the incident occurred.

Attorney General of Texas

The Office of the Attorney General’s (OAG) Medicaid Fraud Control Unit (MFCU) has broad authority to investigate abuse, neglect, and exploitation within Medicaid.

Refer to the OAG Criminal Justice Divisions webpage for information.

Office of Inspector General

  • U.S. Department of Health and Human Services Office of Inspector General (HHS OIG)

HHS OIG is the largest inspector general’s office in the federal government, with approximately 1,600 employees dedicated to combating fraud, waste, and abuse and to improving efficiency in HHS programs. A majority of HHS OIG’s resources go toward the oversight of Medicare and Medicaid.

Refer to the federal HHS OIG's webpage for more information.

  • Texas Health and Human Services Commission Office of Inspector General (HHSC OIG)

PI reports suspected fraud or abuse of Medicare, Medicaid or social services program funding or resources to the Texas Health and Human Services Commission, Office of Inspector General (HHSC-OIG).

Refer to the HHSC OIG's Medicaid Fraud Control Units webpage for more information.

Indian Reservations

An Indian reservation is a legal designation for an area of land managed by a Native American tribe under the U.S. Bureau of Indian Affairs. PI has no authority to conduct an investigation on Indian reservations without permission from reservation officials.

Refer to the United States Department of the Interior Indian Affairs webpage for more information.

Out-of-State Allegations

If the report concerns alleged abuse, neglect, or exploitation of a person receiving services in another state, the investigator takes sufficient information to notify the appropriate out-of-state agency by phone or fax.

Refer to the National Center on Elder Abuse webpage for information about out-of-state agencies.