Minimum Standards

for General Residential

Operations

Child Care Regulation

Texas Health and Human

Services Commission

December 2024

Revised: 12/2024
 Table of Contents
Table of Contents ................................................................................... 2

Introduction ........................................................................................... 7
Minimum Standards ............................................................................ 7
Deficiencies ....................................................................................... 7
Weights ............................................................................................ 7
Maintaining Compliance ....................................................................... 8
The Inspection ................................................................................... 8
Technical Assistance............................................................................ 8
Investigations .................................................................................... 9
Your Rights and Entitlements ................................................................ 9
For Further Information ....................................................................... 9

Subchapter A, Purpose and Scope ........................................................ 10

Subchapter B, Definitions and Services ................................................ 14

Division 1, Definitions ........................................................................ 14
Division 2, Services ........................................................................... 27
Division 3, Care of Unlawfully Present Individuals................................... 33

Subchapter C, Organization and Administration ................................... 36

Division 1, Required Plans and Policies, Including During the Application
Process ........................................................................................... 36
Division 2, Operational Responsibilities and Notifications ......................... 61
Division 3, General Fiscal Requirements ............................................... 67
Division 4, Required Postings .............................................................. 67

Subchapter D, Reports and Record Keeping ......................................... 68

Division 1, Reporting Serious Incidents and Other Occurrences ................ 68
Division 2, Operation Records ............................................................. 87
Division 3, Personnel Records ............................................................. 89
Division 4, Child Records .................................................................... 92
Division 5, Record Retention ............................................................... 94
Division 6, Unauthorized Absences ...................................................... 95

Subchapter E, Personnel .................................................................... 100

Division 1, General Requirements ...................................................... 100
Division 2, Child-Care Administrator .................................................. 104
Division 3, Professional Level Service Providers ................................... 108
Division 4, Treatment Director .......................................................... 115
Division 5, Caregivers...................................................................... 118
Division 6, Normalcy ....................................................................... 121
Division 7, Contract Staff and Volunteers ............................................ 124
Division 8, Pre-Employment Screening ............................................... 127

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Subchapter F, Training and Professional Development ...................... 132
Division 1, Definitions ...................................................................... 132
Division 2, Overview of Training and Experience Requirements............... 133
Division 3, Orientation ..................................................................... 135
Division 4, Pre-Service Experience and Training ................................... 136
Division 5, Curriculum Components for Pre-Service Training .................. 144
Division 6, First-Aid and CPR Certification ........................................... 149
Division 7, Annual Training ............................................................... 151
Division 8, Topics and Curriculum Components for Annual Training ......... 161

Subchapter G, Child/Caregiver Ratios ................................................ 166

Subchapter H, Child Rights ................................................................. 128

Subchapter I, Admission, Service Planning, and Discharge ................ 137

Division 1, Admission ...................................................................... 125
Division 2, Emergency Admission ...................................................... 142
Division 3, Educational Services ........................................................ 145
Division 4, Service Plans .................................................................. 147
Division 5, Service Plan Reviews and Updates...................................... 159
Division 6, Discharge and Transfer Planning ........................................ 162
Division 7, Release of Child .............................................................. 166

Subchapter J, Child Care .................................................................... 167

Division 1, Dental Care .................................................................... 167
Division 2, Medical Care ................................................................... 169
Division 3, Communicable Diseases ................................................... 177
Division 4, Protective Devices ........................................................... 180
Division 5, Supportive Devices .......................................................... 182
Division 6, Tobacco and E-Cigarette Use ............................................. 184
Division 7, Nutrition and Hydration .................................................... 184
Division 8, Additional Requirements for Infant Care .............................. 198
Division 9, Additional Requirements for Toddler Care ............................ 208
Division 10, Additional Requirements for Pregnant and Parenting Children 210

Subchapter K, Operations That Provide Care for Children and Adults . 213
Division 1, Scope ............................................................................ 213
Division 2, General Requirements ...................................................... 213

Subchapter L, Medication ................................................................... 218

Division 1, Administration of Medication ............................................. 218
Division 2, Self-Administration of Medication ....................................... 221
Division 3, Medication Storage and Destruction.................................... 223
Division 4, Medication Records .......................................................... 225
Division 5, Medication and Label Errors .............................................. 227
Division 6, Side Effects and Adverse Reactions to Medication ................. 229
Division 7, Use of Psychotropic Medication .......................................... 231
Division 8, Unassigned Epinephrine Auto-Injectors ............................... 235

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Subchapter M, Discipline and Punishment .......................................... 236

Subchapter N, Emergency Behavior Intervention ............................... 240

Division 1, Definitions ...................................................................... 240
Division 2, Types of Emergency Behavior Intervention That May Be
Administered ................................................................................. 240
Division 3, Orders ........................................................................... 244
Division 4, Responsibilities During Administration of Any Type of Emergency
Behavior Intervention ...................................................................... 248
Division 5, Additional Responsibilities During Administration of a Personal
Restraint ....................................................................................... 252
Division 6, Additional Responsibilities During Administration of Seclusion.. 254
Division 7, Additional Responsibilities During Administration of a Mechanical
Restraint ....................................................................................... 255
Division 8, Successive Use and Combinations of Emergency Behavior
Intervention................................................................................... 258
Division 9, Time Restrictions for Emergency Behavior Intervention ......... 261
Division 10, General Caregiver Responsibilities, Including Documentation,
After the Administration of Emergency Behavior Intervention ................. 265
Division 11, Triggered Reviews ......................................................... 270
Division 12, Overall Operation Evaluation ........................................... 273

Subchapter O, Safety and Emergency Practices ................................. 276

Division 1, Sanitation and Health Practices .......................................... 276
Division 2, Natural Gas and Liquefied Petroleum .................................. 281
Division 3, Fire Safety Practices ........................................................ 283
Division 4, Heating Devices .............................................................. 287
Division 5, Carbon Monoxide Safety Practices ...................................... 288
Division 6, Emergency Evacuation and Relocation ................................ 290
Division 7, First-Aid Kits ................................................................... 293
Division 8, Product Safety ................................................................ 295

Subchapter P, Physical Site ................................................................ 296

Division 1, Grounds and General Requirements.................................... 296
Division 2, Interior Space ................................................................. 302
Division 3, Toilet and Bath Facilities ................................................... 309
Division 4, Poisons .......................................................................... 312
Division 5, Food Preparation, Storage, and Equipment .......................... 312
Division 6, Play Equipment and Safety Requirements ............................ 316
Division 7, Playground Use Zones ...................................................... 320
Division 8, Protective Surfacing ......................................................... 323
Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs........ 325

Subchapter Q, Recreation Activities ................................................... 328

Division 1, General Requirements ...................................................... 328
Division 2, Swimming Activities ......................................................... 334
Division 3, Watercraft Activities ......................................................... 340
Division 4, Wilderness Hiking and Camping Excursions .......................... 343

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 Division 5, Trampoline Use ............................................................... 353
Division 6, Weapons, Firearms, Explosive Materials, and Projectiles ........ 355

Subchapter R, Transportation ............................................................ 357

Division 1, General Requirements ...................................................... 357
Division 2, Safety Restraints ............................................................. 361
Division 3, Vehicle and Vehicle Maintenance ........................................ 364
Division 4, Transportation Records..................................................... 364

Subchapter S, Additional Requirements for Operations That Provide

Emergency Care Services............................................................... 366
Division 1, Service Management ........................................................ 367
Division 2, Admission Assessment ..................................................... 370
Division 3, Respite Child-Care Services............................................... 372

Subchapter T, Additional Requirements for Operations That Provide an

Assessment Services Program ....................................................... 376
Division 1, Regulation ...................................................................... 376
Division 2, Admission ...................................................................... 376
Division 3, Assessment Plan ............................................................. 377
Division 4, Assessment Report .......................................................... 379

Subchapter U, Additional Requirements for Operations That Provide

Therapeutic Camp Services............................................................ 383
Division 1, Definitions ...................................................................... 383
Division 2, Activities Requiring Spotting or Belaying ............................. 385
Division 3, Primitive Camping Excursions ............................................ 386

Subchapter V, Additional Requirements for Operations that Provide

Trafficking Victim Services ............................................................ 390
Division 1, Definitions and Scope ....................................................... 390
Division 2, Policies and Procedures .................................................... 393
Division 3, Personnel ....................................................................... 395
Division 4, Training ......................................................................... 396
Division 5, Child/Caregiver Ratios ...................................................... 402
Division 6, Admission and Service Planning ......................................... 403

Subchapter W, Additional Requirements for Operations that Provide

Psychiatric Health Treatments and Services .................................. 409
Division 1, Definitions and Scope ....................................................... 409
Division 2, Policies, Notifications, and Postings .................................... 412
Division 3, Personnel ....................................................................... 414
Division 4, Training ......................................................................... 415
Division 5, Child to Caregiver Ratio .................................................... 419
Division 6, Admission and Service Plans ............................................. 420
Division 7, Providing Care to Children and Adults ................................. 425

Appendix A: Definitions ...................................................................... 426

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Appendix B, Vaccine-Preventable Diseases ........................................ 431

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Introduction

Minimum Standards
These minimum standards tell you (the child care operation permit holder) what requirements
you, your employees, and your caregivers must follow.

These minimum standards:

● were developed by the Texas Health and Human Services Commission (HHSC) with the
assistance of child-care operations, parents, stakeholders, and other experts in a variety
of fields;
● reflect what the citizens of Texas consider to be reasonable and minimum; and
● meet the guidelines set forth in Chapter 42 of the Texas Human Resources Code (law) for
what must be included in the minimum standards.

The Administrative Procedure and Texas Register Act requires that proposed standards be
published for public comment before they are adopted as rules. All members of the public,
including providers, are encouraged to provide input when proposed minimum standards are
published for comment. The commission considers recommendations from interested persons or
groups in formulating the final draft, which is filed as rules with the Secretary of State.

Deficiencies
A deficiency is any failure to comply with a minimum standard, rule in Texas Administrative Code
Chapter 745, law, specific term of the permit, or specific condition of probation or suspension.

Weights
The minimum standards are weighted based on a common understanding of the risk to children
presented if the standard or rule is violated. The weights are: high, medium-high, medium,
medium-low, and low. The assigned weights do not change based on the scope or severity of an
actual deficiency. Scope and severity are assessed by Child Care Regulation (CCR) staff,
documented, and considered in conjunction with the weight when making CCR decisions. You
will see the weight is noted at the end of each standard or subsection in green. Only those
minimum standards which can be cited as a deficiency are weighted. For example, the minimum
standard prohibiting physical discipline is weighted but minimum standards that are definitions
are not weighted.

Revised: 12/2024
Maintaining Compliance
It is essential that you, your employees, and your caregivers recognize four critical aspects of
CCR’s efforts to protect the children in care and to help operation employees and caregivers
comply with the law, rules, and standards. The four aspects are:

● Inspection
● Technical assistance
● Investigations
● Caregiver’s rights and entitlements

The Inspection
Various aspects of regulated operations are evaluated for compliance with the minimum
standards, rules, and laws during regular inspections. The emphasis on these inspections is to
prevent risk to children in care. The frequency of inspections will fluctuate depending on the type
of permit and the operation’s history of compliance with the minimum standards, rules, and law.

During any inspection, if we find that your operation does not meet minimum standard, rule, or
law, the deficiencies are discussed with the person in charge at the time of the inspection. You
will be given the opportunity to correct deficiencies within a specified period of time. If you have
questions, concerns, or disagree with the citation, we encourage you to talk with us before we
leave your operation. If your concerns are not resolved, you may request an administrative
review.

Technical Assistance
We are available to offer consultation to potential applicants, applicants, and permit holders
regarding how to comply with minimum standards, rules, and laws. While we most often provide
technical assistance during inspections and investigations, technical assistance can be requested
at any time.

The Child Care Regulation section of the HHSC web site has a Technical Assistance Library that
allows you to view or download information about a variety of topics related to child care. You
can view it by going to [Link]
services-providers/child-care-licensing and selecting Technical Assistance Library from the
Resources section.

A feature of the minimum standards publication are the Technical Assistance boxes that follow
certain minimum standards to provide additional guidance, clarification, resources, and/or best
practices related to the applicable rule.

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Investigations
When a report alleges a violation of minimum standards, rule, or law, CCR staff must investigate
the report, notify you of the investigation, and provide a written report to you of the
investigation results within prescribed time frames.

Your Rights and Entitlements

Waivers and Variances

You may request a waiver If your operation is unable to comply with a standard for economic
reasons. You may request a variance if your operation wishes to meet the intent of a standard in
a way that is different from what the standard specifies. Waiver and variance requests are
submitted through your online provider account or made in writing to your assigned CCR
inspector.

Administrative Review
If you disagree with a CCR decision or action, you may request an administrative review, during
which you are given an opportunity to show compliance with applicable minimum standard, rule,
law, action, permit restriction(s) and/or permit conditions.

Appeal Hearing
You may request an appeal hearing on a CCR decision to deny an application, revoke, suspend,
or refuse to renew a permit or a condition placed on the permit after initial issuance.

Appeal hearings are conducted by the State Office of Administrative Hearings (SOAH).

For Further Information

It is important that you, your employees, and your caregivers clearly understand the purpose of
minimum standards and the reasons for CCR’s inspections and investigations. Do not hesitate to
ask us questions that will help you understand any aspect of our regulation. You may obtain
information about minimum standards or procedures by calling your local CCR office or by
visiting the HHSC web site at [Link]
portals/protective-services-providers/child-care-licensing.

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Subchapter A, Purpose and Scope

§748.1. What is the purpose of this chapter?

Subchapter A, Purpose and Scope
January 2007

The purpose of this chapter is to set forth rules that apply to General Residential Operations and
Residential Treatment Centers.

§748.3. Who is responsible for complying with these

minimum standards?
Subchapter A, Purpose and Scope
January 2017

(a) For a licensed general residential operation, the permit holder must ensure
compliance with the minimum standards in this chapter at all times, with the
exception of those minimum standards identified for specific types of services that
your operation does not offer. For example, if we license your operation to offer
emergency care services only, you do not have to comply with the minimum
standards that apply to treatment services for a child with an emotional disorder,
treatment services for a child with an intellectual disability, or a transitional living
program; however, you must comply with all other applicable minimum standards of
this chapter. [High]
(b) For an unlicensed general residential operation that is subject to Licensing’s
regulation, the operation’s administrator, owner, or operator or any other controlling
person who has the ability to influence or direct the operation’s management,
expenditures, or policies must ensure compliance with all the minimum standards in
this chapter at all times, with the exception of those minimum standards identified
for specific types of services that the unlicensed operation does not offer. [High]

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§748.5. How do Residential Treatment Centers comply with
the rules of this chapter?
Subchapter A, Purpose and Scope
September 2010

Residential Treatment Centers (RTCs) are general residential operations that provide treatment
services to children with emotional disorders. RTCs, by definition, must always comply with the
rules of this chapter as if 100% of the children in their care require treatment services for
emotional disorders. This includes, but is not limited to, services to individual children, personnel
requirements, and child/caregiver ratio requirements.

§748.7. How are these regulations applied to family

residential centers?
Subchapter A, Purpose and Scope
July 2022

(a) Definition. A family residential center is one that meets all of the following requirements:
(1) The center is operated by or under a contract with United States Immigration and
Customs Enforcement;
(2) The center is operated to enforce federal immigration laws;
(3) Each child at the center is detained with a parent or other adult family member, who
remains with the child at the center; and
(4) A parent or family member with a child provides the direct care for the child except for
specific circumstances when the child is cared for directly by the center or another
adult in the custody of the center.
(b) Classification. A family residential center is a general residential operation (GRO) and
must comply with all associated requirements for GROs, unless the family residential
center is approved for an individual waiver or variance or an exception is provided in this
section. The department is responsible for regulating the provision of childcare as
authorized by Chapters 40 and 42, Texas Human Resources Code and Chapter 261, Texas
Human Resources Code. The department does not oversee requirements that pertain to
other law, including whether the facilities are classified as secure or in compliance with
any operable settlement agreements or other state or federal restrictions.

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(c) Exceptions. A family residential center is not required to comply with all terms of the
following Minimum Standards:
(1) the limitation of room occupants to four in §748.3357 of this title (relating to What
are the requirements for floor space in a bedroom used by a child?), except that
nothing in this exception shall be construed to require fewer than 60 square feet
per child;
(2) the limitation on a child sharing a bedroom with an adult in §748.3361 of this title
(relating to May a child in care share a bedroom with an adult?), if the bedroom is
being shared in order to allow a child to remain with the child’s parent or other
family member; and
(3) the limitations on children of the opposite gender sharing a room in §748.3363 of
this title (relating to May children of opposite genders share a bedroom?), except
that nothing in this exception shall be construed to permit children from different
families who are over the age of six and members of the opposite gender to share a
bedroom.
(d) Limitation of exception. Notwithstanding subsection (c) of this section, and as further
described in §745.8313 of this title (relating to Is a waiver or variance unconditional?),
the department retains the authority for placing conditions on the scope of the exceptions
authorized for a family residential center, including conditions related to limiting
occupancy in accordance with fire safety standards, limitations related to allowing children
and adults of the opposite gender to occupy the same room only if they are part of the
same family, and any other limitation determined by the department to be necessary to
the health, safety, or welfare of children in care.
(e) Division of responsibility. In addition to the application materials described in §745.243(6)
of this title (relating to What does a completed application for a permit include?), an
applicant for a license under this section must submit the policies, procedures, and any
other documentation that the department deems necessary to clarify the division of
supervisory and caretaking responsibility between employees of the facility and the
parents and other adult family members who are housed with the children. The
department must approve the documentation during the application process and any
subsequent amendments to the policies and procedures.

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(f) This rule is applicable only to the extent that a GRO may provide care to children who are
unlawfully present in the United States and in the custody of the federal government.

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Subchapter B, Definitions and Services

Division 1, Definitions

§748.41. What do certain pronouns mean in this chapter?

Subchapter B, Definitions and Services
Division 1, Definitions
January 2007

The following words have the following meanings in this chapter:

(1) I, my, you, and your – An applicant or permit holder, unless otherwise stated.

(2) We, us, our, and Licensing – The Licensing Division of the Department of Family and
Protective Services (DFPS).

§748.43. What do certain words and terms mean in this

chapter?
Subchapter B, Definitions and Services
Division 1, Definitions
December 2022

The words and terms used in this chapter have the meanings assigned to them under §745.21 of
this title (relating to What do the following words and terms mean when used in this chapter?),
unless another meaning is assigned in this section or unless the context clearly indicates
otherwise. The following words and terms have the following meanings unless the context clearly
indicates otherwise:

(1) Accredited college or university – An institution of higher education accredited by one of

the following regional accrediting entities:

(A) The Southern Association of Colleges and Schools Commission on Colleges, a

subdivision of the Southern Association of Colleges and Schools;

(B) The Middle States Commission on Higher Education, a component of the Middle
States Association of Colleges and Schools;

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 (C)The Commission on Institutions of Higher Education, a subdivision of the New
England Association of Schools and Colleges;

(D) The Higher Learning Commission (formerly part of the North Central Association of
Colleges and Schools);

(E) The Northwest Commission on Colleges and Universities;

(F) The Accrediting Commission for Senior Colleges and Universities, a subdivision of
the Western Association of Schools and Colleges; or

(G) The Accrediting Commission for Community and Junior Colleges, a subdivision of
the Western Association of Schools and Colleges.

(2) Activity space – An area or room used for child activities.

(3) Adaptive functioning – Refers to how effectively a person copes with common life
demands and how well the person meets standards of personal independence expected of
someone in his particular age group, sociocultural background, and community setting.

(4) Adult – A person 18 years old or older.

(5) Caregiver – A person counted in the child/caregiver ratio, whose duties include the direct
care, supervision, guidance, and protection of a child. This does not include a contract
service provider who:

(A) Provides a specific type of service to your operation for a limited number of hours
per week or month; or

(B) Works with one particular child.

(6) Certified lifeguard – A person who has been trained in rescue techniques, lifesaving, and
water safety by a qualified instructor from a recognized organization that awards a
certificate upon successful completion of the training. A certified lifeguard ensures the
safety of persons by preventing and responding to water related emergencies.

(7) Chemical restraint – A prohibited type of emergency behavior intervention that uses
chemicals or pharmaceuticals through topical application, oral administration, injection, or
other means to immobilize or sedate a child as a mechanism of control. The use of a
medication is not a chemical restraint under this chapter if the medication:

(A) Is prescribed by a treating health-care professional;

(B) Is administered solely for medical or dental reasons; and

(C)Has a secondary effect of immobilizing or sedating a child.

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Technical Assistance
A “secondary effect” describes a prescribed medication’s side effect that is unintended and is
not the reason for the medication being prescribed.

(8) Child in care – A child who is currently admitted as a resident of a general residential
operation, regardless of whether the child is temporarily away from the operation, as in
the case of a child at school or at work. Unless a child has been discharged from the
operation, the child is considered a child in care.

(9) Child passenger safety seat system--An infant or child passenger restraint system that
meets the federal standards for crash-tested restraint systems as set by the National
Highway Traffic Safety Administration. Child in care – A child who is currently admitted as
a resident of a general residential operation, regardless of whether the child is temporarily
away from the operation, as in the case of a child at school or at work. Unless a child has
been discharged from the operation, the child is considered a child in care.

(10)Child/caregiver ratio--The maximum number of children for whom one caregiver can be
responsible. Contract service provider – A person or entity that is contracting with the
operation to provide a service, whether paid or unpaid. Also referred to as “contract staff”
and “contractor” in this chapter.

(11)Childhood activities--Activities that are generally accepted as suitable for children of the
same chronological age, level of maturity, and developmental level as determined by a
reasonable and prudent parent standard as specified in §748.705 of this chapter (relating
to What is the "reasonable and prudent parent standard"?). Examples of childhood
activities include extracurricular activities, in-school and out-of-school activities,
enrichment activities, cultural activities, and employment opportunities. Childhood
activities include unsupervised childhood activities.

(12)Contract service provider--A person or entity that is contracting with the operation to
provide a service, whether paid or unpaid. Also referred to as “contract staff” and
“contractor” in this chapter.

(13)Corporation or other type of business entity – May include an association, corporation,

nonprofit association, nonprofit corporation, nonprofit association with religious affiliation,
nonprofit corporation with religious affiliation, limited liability company, political
subdivision, or state agency. For purposes of this chapter, this definition does not include
any type of “partnership,” which is defined separately.

(14)Cottage or cottage home – A living arrangement for children who are not receiving
treatment services in which:

(A) Each group of children has separate living quarters;

(B) 12 or fewer children are in each group;

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 (C)Primary caregivers live in the children’s living quarters, 24 hours per day for at
least four days a week or 15 days a month; and

(D) Other caregivers are used only to meet the child-to-caregiver ratio in an
emergency or to supplement care provided by the primary caregivers.

(15)Counseling – A procedure used by professionals from various disciplines in guiding

individuals, families, groups, and communities by such activities as delineating
alternatives, helping to articulate goals, processing feelings and options, and providing
needed information. This definition does not include career counseling.

(16)Days – Calendar days, unless otherwise stated.

(17)De-escalation – Strategies used to defuse a volatile situation, to assist a child to regain

behavioral control, and to avoid a physical restraint or other behavioral intervention.

(18)Department – The Texas Department of Family and Protective Services (DFPS).

(19)Discipline – A form of guidance that is constructive or educational in nature and

appropriate to the child’s age, development, situation, and severity of the behavior.

(20)Emergency behavior intervention (EBI) – Interventions used in an emergency situation,

including personal restraints, mechanical restraints, emergency medication, and seclusion.

(21)Emergency medication – A type of emergency behavior intervention that uses chemicals

or pharmaceuticals through topical application, oral administration, injection, or other
means to modify a child’s behavior. The use of a medication is not an emergency
medication under this chapter if the medication:

(A) Is prescribed by a treating health-care professional;

(B) Is administered solely for a medical or dental reason (e.g. Benadryl for an allergic
reaction or medication to control seizures); and

(C)Has a secondary effect of modifying a child’s behavior.

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Technical Assistance
The distinguishing variable between a PRN (as needed) psychotropic medication and an
emergency medication is the circumstances under which the medication is given. A
medication given to help a child manage his/her behavior or to de-escalate a child who is
having trouble managing his/her behavior is regulated only as a PRN psychotropic
medication. However, if the medication is given in response to an emergency situation, it is
an emergency medication.
For example, a child becomes increasingly agitated after a family visit, to the point of
screaming and becoming verbally abusive to caregivers and other children. The child is not
able to use self-calming techniques. If the child is offered a PRN psychotropic medication
under these circumstances, it is not regulated as emergency medication, because there is no
emergency situation. The medication serves to help the child manage the behavior before it
escalates into an emergency.
However, if the child had escalated to the point of physically assaulting someone and
requiring physical restraint, then a medication offered during the restraint to help the child
calm would be regulated as an emergency medication.

(22)Emergency situation – A situation in which attempted preventative de-escalatory or

redirection techniques have not effectively reduced the potential for injury, so that
intervention is immediately necessary to prevent:

(A) Imminent probable death or substantial bodily harm to the child because the child
attempts or continually threatens to commit suicide or substantial bodily harm; or
(B) Imminent physical harm to another because of the child’s overt acts, including
attempting to harm others. These situations may include aggressive acts by the child,
including serious incidents of shoving or grabbing others over their objections. These
situations do not include verbal threats or verbal attacks.

(23)Employee – A person an operation employs full-time or part-time to work for wages,

salary, or other compensation. For the purposes of this chapter, employees include all
operation staff and any owner who is present at the operation or transports any child in
care.

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 (24)Family members – An individual related to another individual within the third degree of
consanguinity or affinity. For the definitions of consanguinity and affinity, see Chapter 745
of this title (relating to Licensing). The degree of the relationship is computed as described
in Texas Government Code, §573.023 (relating to Computation of Degree of
Consanguinity) and §573.025 (relating to Computation of Degree of Affinity).

Technical Assistance: Relationship of Consanguinity and Affinity

Person Related within 1st Degree Person Related Person Related

within 2nd Degree within 3rd Degree
• Parent; • Grandparent; • Great-
• Child; • Grandparent-In- Grandparent;
• Spouse; Law; • Great-
• Mother-In-Law and Father-In-Law; • Grandchild; Grandparent-
and • Grandchild-In- In-Law;
• Daughter-In-Law and Son-In-Law. Law; • Grandchild;
• Sister or Brother; • Grandchild-In-
*Step and half relationships (step-
and Law;
brother, step-father, half- sister, etc.) are
considered to be the same as blood • Sister/Brother- • Niece/Nephew;
relationships. In- Law. • Niece/Nephew-
In- Law;
• Aunt/Uncle; and
• Aunt/Uncle-In-
Law.

(25) Field trip – A group activity conducted away from the operation.
(26) Food service – The preparation or serving of meals or snacks.
(27) Full-time – At least 30 hours per week.
(28) Garbage – Food or items that when deteriorating cause offensive odors and/or attract
rodents, insects, and other pests.

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(29) General Residential Operation – A residential child-care operation that provides child
care for seven or more children or young adults. The care may include treatment services
or programmatic services. These operations include formerly titled emergency shelters,
operations providing basic child care, residential treatment centers, and halfway houses.
(30) Governing body – A group of persons or officers of the corporation or other type of
business entity having ultimate authority and responsibility for the operation.
(31)Grounds--Includes any parcel of land where the operation is located and any building,
other structure, body of water, play equipment, street, sidewalk, walkway, driveway,
parking garage, or parking lot on the parcel. Also referred to as “premises” in this chapter.
(32)Group of children – Children assigned to a specific caregiver or specific caregivers.
Generally, the group stays with the assigned caregivers throughout the day and may
move to different areas throughout the operation, indoors and out. For example, children
who are assigned to specific caregivers occupying a unit or cottage are considered a
group.
(33)Health-care professional – A licensed physician, licensed advanced practice registered
nurse (APRN), physician’s assistant, licensed vocational nurse (LVN), licensed registered
nurse (RN), or other licensed medical personnel providing health care to the child within
the scope of the person’s license. This does not include physicians, nurses, or other
medical personnel not licensed to practice in the United States or in the country in which
the person practices.
(34)High-risk behavior – Behavior of a child that creates an immediate safety risk to self or
others. Examples of high-risk behavior include suicide attempt, self-abuse, physical
aggression causing bodily injury, chronic running away, substance abuse, fire-setting, and
sexual aggression or perpetration.
(35)Human services field – A field of study that contains coursework in the social sciences of
psychology and social work including some counseling classes focusing on normal and
abnormal human development and interpersonal relationship skills from an accredited
college or university. Coursework in guidance counseling does not apply.

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(36)Immediate danger – A situation where a prudent person would conclude that bodily harm
would occur if there were no immediate interventions. Immediate danger includes a
serious risk of suicide, serious physical injury to self or others, or the probability of bodily
harm resulting from a child running away if less than 10 years old chronologically or
developmentally. Immediate danger does not include:
a. Harm that might occur over time or at a later time; or
b. Verbal threats or verbal attacks.
(37)Infant – A child from birth through 17 months.
(38)Livestock – An animal raised for human consumption or an equine animal.
(39)Living quarters – A structure or part of a structure where a group of children reside, such
as a building, house, cottage home, or unit.
(40)Mechanical restraint – A type of emergency behavior intervention that uses the
application of a device to restrict the free movement of all or part of a child’s body in
order to control physical activity.
(41)Mental health professional – Refers to:
a. A psychiatrist licensed by the Texas Medical Board;
b. A psychologist licensed by the Texas State Board of Examiners of Psychologists;
c. A master’s level social worker or higher licensed by the Texas State Board of Social
Work Examiners;
d. A professional counselor licensed by the Texas State Board of Examiners of
Professional Counselors;
e. A marriage and family therapist licensed by the Texas State Board of Examiners of
Marriage and Family Therapists; and
f. A master’s level or higher nurse licensed as an Advanced Practice Registered Nurse
by the Texas Board of Nursing and board certified in Psychiatric/Mental Health.
(42)Non-ambulatory – A child that is only able to move from place to place with assistance,
such as a walker, crutches, a wheelchair, or prosthetic leg.
(43) Non-mobile – A child that is not able to move from place to place, even with assistance.
(44) Normalcy – See §748.701 of this chapter (relating to What is “normalcy”?).
(45)Operation – General residential operations, including residential treatment centers.
(46) Owner – The sole proprietor, partnership, or corporation or other type of business entity
who owns the operation.

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(47) Parent – A person or entity that has legal responsibility for or legal custody of a child,
including the managing conservator or legal guardian of the child or a legally authorized
representative of an entity with that status.
(48) Partnership – A partnership may be a general partnership, (general) limited liability
partnership, limited partnership, or limited partnership as limited liability partnership.
(49) Permit holder – The owner of the operation that is granted the permit.
(50) Permit is no longer valid – For purposes of this chapter, a permit remains valid through
the renewal process. A permit only becomes invalid when your operation voluntarily closes
or is required to close through an enforcement action in Subchapter L of Chapter 745
(relating to Enforcement Actions).
(51) Person legally authorized to give consent – The person legally authorized to give consent
by the Texas Family Code or a person authorized by the court.
(52) Personal restraint – A type of emergency behavior intervention that uses the application
of physical force without the use of any device to restrict the free movement of all or part
of a child’s body in order to control physical activity. Personal restraint includes escorting,
which is when a caregiver uses physical force to move or direct a child who physically
resists moving with the caregiver to another location.
(53) Physical force – Pressure applied to a child’s body that reduces or eliminates the child’s
ability to move freely.
(54)Premises--See the term “grounds” and its definition in this section.
(55) PRN – A standing order or prescription that applies “pro re nata” or “as needed
according to circumstances.”
(56) Prone restraint – A restraint in which the child is placed in a chest-down hold.
(57)Psychosocial assessment – An evaluation by a mental health professional of a child’s
mental health that includes a:
a. Clinical interview of the child;
b. Diagnosis from the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-
5), or statement that rules out a DSM-5 diagnosis;

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 c. Treatment plan for the child, including whether further evaluation of the child is
needed (for example: is a psychiatric evaluation needed to determine if the child
would benefit from psychotropic medication or hospitalization; or is a psychological
evaluation with psychometric testing needed to determine if the child has a learning
disability or an intellectual disability); and
d. Written summary of the assessment.
(58) Re-evaluate – Re-assessing all factors required for the initial evaluation for the purpose
of determining if any substantive changes have occurred. If substantive changes have
occurred, these areas must be fully evaluated.
(59) Regularly – On a recurring, scheduled basis. Note: For the definition for “regularly or
frequently present at an operation” as it applies to background checks, see §745.601 of
this title (relating to What words must I know to understand this subchapter?).
(60)Residential child-care operation – A licensed or certified operation that provides
residential child care. Also referred to as a “residential child-care facility.”
(61)Residential Treatment Center (RTC) – A general residential operation for seven or more
children or young adults that exclusively provides treatment services for children with
emotional disorders.
(62)Sanitize – The use of a product (usually a disinfecting solution) registered by the
Environmental Protection Agency (EPA) that substantially reduces germs on inanimate
objects to levels considered safe by public health requirements. Many bleach and
hydrogen peroxide products are EPA-registered. You must follow the product’s labelling
instructions for sanitizing (paying particular attention to any instructions regarding contact
time and toxicity on surfaces likely to be mouthed by children, such as toys and crib rails).
For an EPA-registered sanitizing product or disinfecting solution that does not include
labelling instructions for sanitizing (a bleach product, for example), you must conduct
these steps in the following order:
a. Washing with water and soap;
b. Rinsing with clear water;
c. Soaking in or spraying on a disinfecting solution for at least two minutes. Rinsing
with cool water only those items that a child is likely to place in his mouth; and
d. Allowing the surface or item to air-dry.

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(63) School-age child – A child who is five years old or older and is enrolled in or has
completed kindergarten.
(64) Seat belt – A lap belt and any shoulder strap included as original equipment on or
added to a motor vehicle.
(65) Seclusion – A type of emergency behavior intervention that involves the
involuntary separation of a child from other children and the placement of the child
alone in an area from which the child is prevented from leaving. Examples of such
an area include where the child is prevented from leaving by a physical barrier,
force, or threat of force.
(66) Service plan – A plan that identifies a child’s basic and specific needs and how
those needs will be met.
(67) Short personal restraint – A personal restraint that does not last longer than one
minute before the child is released.
(68) State or local fire authority – A fire official who is authorized to conduct fire
safety inspections on behalf of the city, county, or state government, including
certified fire inspectors.
(69) State or local sanitation official – A sanitation official who is authorized to conduct
environmental sanitation inspections on behalf of the city, county, or state
government.
(70) Substantial physical injury – Physical injury serious enough that a reasonable
person would conclude that the injury needs treatment by a medical professional,
including dislocated, fractured, or broken bones; concussions; lacerations requiring
stitches; second and third degree burns; and damages to internal organs. Evidence
that physical injury is serious includes the location, severity of the bodily harm, and
age of the child. Substantial physical injury does not include minor bruising, the risk
of minor bruising, or similar forms of minor bodily harm that will resolve healthily
without professional medical attention.
(71) Supine restraint – Placing a child in a chest up restraint hold.
(72) Supplements – Includes vitamins, herbs, and any supplement labeled dietary
supplement.
(73)Swimming activities – Activities related to the use of swimming pools, wading/splashing
pools, hot tubs, or other bodies of water.

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(74)Toddler – A child from 18 months through 35 months.
(75)Trafficking victim – A child who has been recruited, harbored, transported, provided or
obtained for the purpose of forced labor or commercial sexual activity, including any child
subjected to an act or practice as specified in Texas Penal Code §20A.02 or §20A.03.
(76)Trauma informed care (TIC) – Care for children that is child-centered and considers the
unique culture, experiences, and beliefs of the child. TIC takes into consideration:
a. The impact that traumatic experiences have on the lives of children;
b. The symptoms of childhood trauma;
c. An understanding of a child’s personal trauma history;
d. The recognition of a child’s trauma triggers; and
e. Methods of responding that improve a child’s ability to trust, to feel safe, and to
adapt to changes in the child’s environment.
(77)Treatment director – The person responsible for the overall treatment program providing
treatment services. A treatment director may have other responsibilities and may
designate treatment director responsibilities to other qualified persons.
(78) Universal precautions – An approach to infection control where all human blood and
certain human bodily fluids are treated as if known to be infectious for the human
immunodeficiency virus (HIV), the hepatitis B virus (HBV), and other blood-borne
pathogens.
(79) Unsupervised childhood activities – Childhood activities that a child in care participates
in away from the operation and the caregivers. Childhood activities that an operation
sponsors, conducts, or supervises are not unsupervised childhood activities. Unsupervised
childhood activities may include playing sports, going on field trips, spending the night
with a friend, going to the mall, or dating. Unsupervised childhood activities may last one
or more days.
(80) Vaccine-preventable disease – A disease that is included in the most current
recommendations of the Advisory Committee on Immunization Practices of the Centers for
Disease Control and Prevention.
(81) Volunteer – A person who provides:
(1) Child-care services, treatment services, or programmatic services under the
auspices of the operation without monetary compensation; or

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 (2) Any type of services under the auspices of the operation without monetary
compensation when the person has unsupervised access to a child in care.
(82) Young adult – An adult whose chronological age is between 18 and 22 years, who is
currently in a residential child-care operation, and who continues to need child-care
services.

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Division 2, Services

§748.61. What types of services are subject to regulation

under this chapter?
Subchapter B, Definitions and Services
Division 2, Services
October 2024

The following types of services are subject to regulation under this chapter:

(1) Child-Care Services – Services that meet a child’s basic need for shelter,
nutrition, clothing, nurture, socialization and interpersonal skills, care for
personal health and hygiene, supervision, education, and service planning;
(2) Treatment Services – In addition to child-care services, a specialized type of child-
care services designed to treat and support children:
(A) With an Emotional Disorder who have a:
(i) Current Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5) diagnosis, such as mood disorders, psychotic disorders, or
dissociative disorders, and demonstrate two or more of the following:
(I) Major self-injurious actions, including a suicide attempt within the
last 12 months;
(II)Difficulties that present a significant risk of harm to others,
including frequent or unpredictable physical aggression; or
(III) An additional DSM-5 diagnosis of substance-related or addictive
disorder with severe impairment; or
(ii) Severe emotional disturbance as defined by §748.4801 of this
chapter (relating to What do the following terms mean when used
in this subchapter?) who are admitted to a certified psychiatric
residential youth treatment facility also defined at §748.4801 of
this chapter, in addition to young adults 18 to 21 years of age who
also qualify for these services;

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Technical Assistance
Regarding subsection (2)(A), neither attending counseling nor taking a psychotropic
medication factors into a child being eligible for treatment services for an emotional disorder.
Only the indicators noted above are considered when determining eligibility for treatment
services. However, you may offer treatment services to a child you assess as needing those
services, regardless of the indicators above.

(B) With a DSM-5 diagnosis of Intellectual Disability that is characterized by

prominent, severe deficits and pervasive impairment in one or more of
the following areas:
(i) Conceptual, social, and practical adaptive skills to include daily
living and self-care;
(ii) Communication, cognition, or expressions of affect;
(iii) Self-care activities or participation in social activities;
(iv) Responding appropriately to an emergency; or
(v) Multiple physical disabilities, including sensory impairments;

Technical Assistance
Regarding subsection (2)(B), a DSM-5 diagnoses of Intellectual Disability also requires a
severity level (mild, moderate, severe, or profound). If a severity level is provided, the
severity information may be helpful in determining whether the child is characterized by
prominent, severe deficits and pervasive impairment.

(C) With a DSM-5 diagnosis of Autism Spectrum Disorder that is

characterized by prominent, severe deficits and pervasive impairment in
one or more of the following areas of development:
(i) Conceptual, social, and practical adaptive skills to include daily living
and self-care;
(ii) Communication, cognition, or expressions of affect;
(iii) Self-care activities or participation in social activities;
(iv) Responding appropriately to an emergency; or
(v) Multiple physical disabilities including sensory impairments;

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Technical Assistance
Regarding subsection (2)(C), the Autism Spectrum Disorder includes previous DSM-IV
diagnoses of autistic disorder, Asperger’s disorder, pervasive development disorder-not
otherwise specified, and similar disorders associated with a known medical or genetic
disorder (e.g. Rett’s Disorder). This newly titled disorder is a single continuum of mild to
severe (Levels 1 - 3) impairments in the two domains of social communication and
restrictive repetitive behaviors/interests. A DSM-5 diagnosis does not mandate a severity
level; however, if a severity level is provided, then the severity information may be helpful in
determining whether the child is characterized by prominent, severe deficits and pervasive
impairment.

(D) With Primary Medical Needs, who cannot live without mechanical
supports or the services of others because of life-threatening
conditions, including:
(i) The inability to maintain an open airway without assistance,
which does not include the use of inhalers for asthma;
(ii) The inability to be fed except through a feeding tube, gastric tube, or
a parenteral route;
(iii) The use of sterile techniques or specialized procedures to promote
healing, prevent infection, prevent cross-infection or contamination,
or prevent tissue breakdown; or
(iv) Multiple physical disabilities including sensory impairments; and
(E) Determined to be a trafficking victim, including a child:
(i) Determined to be a trafficking victim as the result of a criminal
prosecution or who is currently alleged to be a trafficking victim in a
pending criminal investigation or prosecution;
(ii) Identified by the parent or agency that placed the child in the
operation as a trafficking victim; or
(iii) Determined by the operation to be a trafficking victim based on
reasonably reliable criteria, including one or more of the
following:
(I) The child’s own disclosure as a trafficking victim;

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 (II) The assessment of a counselor or other professional; or
(III) Evidence that the child was recruited, harbored, transported,
provided to another person, or obtained for the purpose of
forced labor or commercial sexual activity; and
(3) Additional Programmatic Services, which include:
(A) Emergency Care Services – A specialized type of child-care services designed
and offered to provide short-term child care to children who, upon admission,
are in an emergency constituting an immediate danger to the physical health or
safety of the child or the child’s offspring;
(B) Transitional Living Program – A residential services program designed to serve
children 14 years old or older for whom the service or treatment goal is basic
life skills development toward independent living, which includes basic life skills
training and the opportunity for children to practice those skills and is not an
independent living program;
(C) Assessment Services Program – Services to provide an initial evaluation of the
appropriate placement for a child to ensure that appropriate information is
obtained to facilitate service planning;
(D) Therapeutic Camp Services – A camping program to augment an operation's
treatment services with an experiential curriculum exclusively for a child with
an emotional disorder who has difficulty functioning in his home, school, or
community and is only available to children 13 years old and older; and
(E) Respite Child-Care Services – See §748.73 of this chapter (relating to What are
respite child-care services?).

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§748.63. Can I provide each type of service that Licensing
regulates?
Subchapter B, Definitions and Services
Division 2, Services
January 2007

You may provide each type of service that we regulate under the following conditions:
(1) On your permit, we list the type of service that you have been approved to provide
[Medium]; and
(2) Your operational policies and procedures ensure:
(A) Children are admitted appropriately [Medium-High];
(B) The needs of all children in care are met [Medium-High];
(C) Children are appropriately supervised [Medium-High];
(D) Children are protected from one another, if appropriate [Medium-High]; and
(E) You meet the applicable rules of this chapter. [Medium-High]

§748.65. What children are eligible to participate in a

transitional living program?
Subchapter B, Definitions and Services
Division 2, Services
January 2017

For a child to be eligible to participate in a transitional living program, the child must:

(1) Be 14 years old or older [Medium-Low]; and

(2) Not be receiving therapeutic camp services. [Medium-Low]

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§748.67. What are the requirements for a transitional living
program?
Subchapter B, Definitions and Services
Division 2, Services
January 2007

A transitional living program must have a training program for children that develops
competency in the following areas [Medium-Low]:
(1) Health, general safety, and fire safety practices [Medium];
(2) Money management [Low];
(3) Transportation skills [Low];
(4) Accessing community and other resources [Low]; and
(5) Child health and safety, child development, and parenting skills, if the child is a parent of a
child living with him. [Medium]

§748.69. What is an “independent living program”?

Subchapter B, Definitions and Services
Division 2, Services
January 2007
An “independent living program” is a program that provides case management services to a
child who lives independently, without supervision and child/caregiver ratio, and the constant
presence of an on-site caregiver.

§748.71. May I have an independent living program?

Subchapter B, Definitions and Services
Division 2, Services
January 2007

Your operation may not provide an independent living program for a child in care under 18 years
old. [Medium-Low]

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§748.73. What are respite child-care services?
Subchapter B, Definitions and Services
Division 2, Services
January 2007

Respite child-care services are planned alternative 24-hour care that an operation provides for a
child as part of the regulated child care.

§748.75. May I use or provide respite child-care services?

Subchapter B, Definitions and Services
Division 2, Services
January 2007

Only general residential operations that offer emergency care services may provide respite child-
care services. Other operations may not provide respite child-care services, and no operation
may use respite child-care services. The purpose of respite child-care services is to provide relief
to a child’s biological or foster parent, not an employee. Respite for an employee is provided
through time off, vacations, holidays, and sick leave. [Medium-Low]

Division 3, Care of Unlawfully Present Individuals

§748.81. What do certain terms mean in this division?

Subchapter B, Definitions and Services
Division 3, Care of Unlawfully Present Individuals
July 2022

The terms used in this division have the following meanings:

(1) Exempt program--A child-care program that is exempt from or otherwise not subject to
regulation as a child-care operation by the Texas Health and Human Services Commission
(HHSC) under Chapter 42, Texas Human Resources Code (HRC), and Chapter 745,
Subchapter C of this title (relating to Operations that are Exempt from Regulation).

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 (2) Unlawfully present individual--An individual who is neither a citizen nor has a right to be
present in the United States under the Immigration and Nationality Act or accompanying
regulations or decisions, who is in the custody of the federal government. This term
includes a child who has no lawful immigration status in the United States and:
(E) With respect to whom, there is no parent or legal guardian in the United States, or
no parent or legal guardian in the United States available to provide care and
physical custody, as described in 6 U.S. Code §279(g)(2); or
(F) Who is detained with a parent or other adult family member who is not lawfully
present in the United States.

§748.83. May I provide care to or shelter an unlawfully

present individual?
Subchapter B, Definitions and Services
Division 3, Care of Unlawfully Present Individuals
July 2022

You may not provide care or shelter to an unlawfully present individual at your general
residential operation. However, you may operate an exempt program that provides care for an
unlawfully present individual separately from your general residential operation [Medium].

§748.85. What are the requirements if I operate my

general residential operation while an exempt program
separately provides care for an unlawfully present
individual?
Subchapter B, Definitions and Services
Division 3, Care of Unlawfully Present Individuals
July 2022

(a) If you provide care for an unlawfully present individual at an exempt program while you
operate your general residential operation:
(1) You must notify Licensing in writing [Medium];
(2) You must ensure that the exempt program:

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 (A) Has separate caregivers from your operation or caregivers that do not provide
care at your operation while they care for children at the exempt program
[Medium]; and
(B) Does not use an area of your building or grounds at the same time that your
operation is using the area, except that the exempt program and your
operation may share restrooms and indoor and outdoor activity areas under a
written plan regarding how caregivers from your operation and the exempt
program will supervise the children in the shared space [Medium].
(b) You must submit to Licensing a written plan for how the exempt program will operate
separately from your general residential operation, as required by subsection (a)(2) of
this section [Medium].

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Subchapter C, Organization and Administration

Division 1, Required Plans and Policies, Including During

the Application Process

§748.101. What plans must I submit for Licensing’s

approval as part of the application process?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

In addition to the relevant application forms required by §745.243 of this title (relating to What
does a completed application for a permit include?), as part of the application process, you must
submit the following plans to us for approval:

(1) A business plan that includes [Low]:

(A) The location and telephone numbers of all of your general residential operations
[Low]; and
(B) A list of persons or officers and their titles who comprise the governing body, if
applicable [Low];
(2) A fiscal plan that includes [Medium-Low]:
(A) A detailed estimate of the operating costs of the operation for the first three
months [Medium-Low];
(B) Documentation of reserve funds or available credit at least equal to operating
costs for the first three months [Medium];
(C) An estimated 12-month budget of income and expenses [Medium-Low]; and
(D) Predictable funds sufficient for the first year of operation [Medium];
(3) A sketch of the operation’s floor plan showing the dimensions and the purpose of all
rooms and specifying where children and caregivers, if applicable, will sleep [Low]; and
(4) An emergency evacuation and relocation plan that complies with Division 6 of
Subchapter O (relating to Emergency Evacuation and Relocation).

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§748.103. What policies and procedures must I submit for
Licensing’s approval as part of the application process?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

(a) You must develop the policies and procedures identified in subsection (b) of this section.
Your policies and procedures must comply with or exceed the minimum standards
specified in this chapter, Chapter 42 of the Human Resources Code, and Chapter 745 of
this title (relating to Licensing), and any other applicable law. [Medium]
(b) As part of the application process, you must submit the following policies and procedures
to us for our approval:
(1) Policies and procedures related to record keeping, including where the records will
be located. The policies must be consistent with Subchapter D of this chapter
(relating to Reports and Records Keeping) [Medium];
(2) Personnel policies and procedures consistent with §748.105 of this title (relating
to What are the requirements for my personnel policies and procedures?)
[Medium];
(3) Conflict of interest policies consistent with §748.107 of this title (relating to What
must my conflict of interest policies include?) [Medium];
(4) Admission policies consistent with §748.109 of this title (relating to What must
my admission policies include?) [Medium];
(5) Child-care policies consistent with §748.111 of this title (relating to What child-
care policies must I develop?) [Medium];
(6) Emergency behavior intervention policies consistent with §748.113 of this title
(relating to What emergency behavior intervention policies must I develop if my
operation is permitted to use emergency behavior intervention?) [Medium-High];
(7) Discipline policies consistent with §748.115 of this title (relating to What are the
requirements for my discipline policies for children in care?) [Medium];

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 (8) Policies for a transitional living program, if applicable, consistent with §748.117 of
this title (relating to What policies for a transitional living program must I
develop?) [Medium-Low];
(9) Volunteer policies consistent with §748.119 of this title (relating to What policies
must I develop if I use volunteers?) [Medium-Low];
(10) Abuse and neglect policies consistent with §748.121 of this title (relating to
What abuse and neglect policies must I develop?) [Medium-High]];
(11) Employee policies and procedures that protect children from vaccine-preventable
diseases. The policies must be consistent with §748.123 of this title (relating to
What must an employee policy for protecting children from vaccine-preventable
diseases include?) [Medium];
(12) A weapons, firearms, explosive materials, and projectiles policy consistent with
Division 6 of Subchapter Q (relating to Weapons, Firearms, Explosive Materials,
and Projectiles) [High];
(13) A tobacco and e-cigarette policy consistent with §748.1661 of this title (relating
to What policies must I enforce regarding tobacco products and e-cigarettes?).
[Medium-High]; and
(14) A suicide prevention, intervention, and postvention policy consistent with
§748.124 of this division (relating to What suicide prevention, intervention, and
postvention policy must I have?). [Medium-High]

§748.105. What are the requirements for my personnel

policies and procedures?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
August 2023

Your personnel policies and procedure must [Medium]:

(1) Include an organizational chart showing the administrative, professional, and staffing
structures and lines of authority [Medium];
(2) Include written job descriptions, including minimum qualifications and job responsibilities
for each position [Medium];

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(3) Include written procedures for screening applicants to determine suitability for any
position for which you are considering an applicant. These procedures must include
[Medium]:

(A) Verifying an applicant's employment history as required by §748.751 of this chapter

(relating to What are the requirements for obtaining and verifying an applicant's
employment history?); and

(B) Conducting reference checks as required by §748.753 of this chapter (relating to

What are the requirements for completing an applicant's reference checks?);

(4) Include a written professional staffing plan that [Medium]:

(A) Demonstrates that the number, qualifications, and responsibilities of professional

positions, including the child-care administrator, are appropriate for the size and
scope of your services and that workloads are reasonable enough to meet the
needs of the children in care [Medium];
(B) Describes in detail the qualifications, duties, responsibilities, and authority of
professional positions; for each position, the plan must show whether employment
is on a full-time, part-time, or continuing consultative basis; and for part-time and
consulting positions, the plan must specify the number of hours and frequency of
services [Medium];

(C)Documents your staffing patterns, including your child/caregiver ratios, hours of

coverage, and plans for providing backup caregivers in emergencies [Medium]; and
(D) Identifies, if you provide treatment services, your ability to have enough
caregivers, including caregivers who are awake throughout the night to supervise
children 24 hours a day, including frequent one- to-one monitoring whenever
necessary to meet the needs of a particular child [Medium];

(5) Include written training requirements for employees and caregivers [Medium];
(6) Include policies on whether your operation allows individual caregivers to take children
away from the operation for day or overnight visits. The policy must require obtaining the
parent’s written approval prior to allowing overnight visits with staff. The policy must also
address the issue outlined in §748.685(e) of this chapter (relating to What responsibilities
does a caregiver have when supervising a child or children?) [Medium];

(7) Comply with background check requirements outlined in Subchapter F of Chapter 745 of
this title (relating to Background Checks) [High];

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 (8) Require your employees to report serious incidents and suspected abuse, neglect, or
exploitation. An employee who suspects abuse, neglect, or exploitation must report the
employee’s suspicion directly to the Texas Abuse and Neglect Hotline, as directed by Texas
Family Code §261.101(b). An employee may not delegate the responsibility to make a
report, and you may not require an employee to seek approval to file a report or to notify
you that a report was made [High];

(9) Require that all employees and consulting, contracting, and volunteer professionals who
work with a child and others with access to information about a child be informed in
writing of their responsibility to maintain child confidentiality [Medium];
(10) Include either the model drug testing policy or a written drug testing policy that meets
or exceeds the criteria in the model policy provided in §745.4151 of this title (relating to
What drug testing policy must my residential child-care operation have?). [Medium-
High]
Technical Assistance
Regarding subsection (7), if it is known by others in the chain of command that someone
already reported a particular suspicion of abuse, neglect, or exploitation then those persons
are not required to make reports on that particular suspicion as well.

§748.107. What must my conflict of interest policies

include?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

Your conflict of interest policies must include [Medium]:

(1) A code of conduct on the relationship between your operation’s owners (including
members of the governing body, if applicable), employees, contract service providers,
children in placement, and children’s families, including required parameters for entering
into independent financial relationships or transactions [Medium]; and

(2) For corporations or other types of business entities, a statement that the majority of the
voting members of the governing body must consist of persons who do not have a conflict
of interest that would potentially interfere with objective decision making. Persons who
have such a conflict of interest include the following [Medium]:

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 (A) Family members of:

(i) An officer of the governing body;

(ii) The administrator or executive director of the operation; or

(iii) Any person with a controlling interest in the entity’s stock; or

(B) If the governing body is a non-profit entity, persons who benefit

financially from the operation, including persons employed by or working
at the operation, paid consultants, subcontractors, and vendors. [Medium]

Technical Assistance
The definition of “family members” is found at §748.43(22).

§748.109. What must my admission policies include?

Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

Your admission policies must include a description of each program you offer, including
[Medium]:

(1) The program’s goals and services provided, including whether the program accepts
emergency admissions [Medium]; and

(2) The characteristics of the population the program serves, such as gender, age range,
behaviors, and diagnoses. If the program includes treatment services, your policy must
describe the type of treatment services the program is designed to treat, including
emotional disorders, intellectual disability, autism spectrum disorder, primary medical
needs, or trafficking victim services. [Medium]

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§748.111. What child-care policies must I develop?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

You must develop policies that describe [Medium]:

(1) Visitation rights between the child and family members and the child and friends
[Medium];
(2) The child’s right to correspond by mail with family members and friends, including any
policies regarding mail restrictions and receipt of electronic messages and mail [Medium];
(3) The child’s right to correspond by telephone with family members and friends [Medium-
Low];
(4) The child’s right to receive and give gifts to family, friends, employees, or other children
in care, including any restrictions on gifts [Medium-Low];
(5) How a child obtains clothing [Medium-Low];
(6) Personal possessions a child is or is not allowed to have, where the possessions may be
stored, and search policies [Medium-Low];
(7) Emergency behavior intervention techniques if the use of emergency behavior
intervention is permitted in your operation. The policy must be consistent with
§748.113(5) of this title (relating to What emergency behavior intervention policies must I
develop if my operation is permitted to use emergency behavior intervention?) [Medium-
High];

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(8) Any religious program or activity that you offer, including whether children must
participate in the program or activity [Medium-Low];

(9) The plans for meeting the educational needs of each child [Medium-Low];

(10) When trips with caregivers away from the operation are allowed and what protocols will
be used [Medium];

(11) Program expectations and rules that apply to all children, including an overview of your
discipline policy [Medium];

(12) Child grievance procedures [Medium];

(13) The types and frequency of reports to parents [Medium];

(14) Procedures for routine and emergency diagnosis and treatment of medical and dental
problems [Medium];

(15) Routine health care relating to pregnancy and childbirth, if you admit and/or care for a
pregnant child [Medium];

(16) Your plan for providing health-care services to a child with primary medical needs
[Medium];

(17) Transitional living policies, if applicable [Medium-Low]; and

(18) If applicable, how you will determine whether it is appropriate for a child to use
weapons, firearms, explosive materials, and projectiles. This information must be
consistent with §748.103(b)(12) of this title (relating to What policies and procedures
must I submit for Licensing’s approval as part of the application process?). [Medium]

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§748.113. What emergency behavior intervention policies
must I develop if my operation is permitted to use
emergency behavior intervention?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

At a minimum, you must develop emergency behavior intervention policies to implement the
requirements in Subchapter N of this chapter (relating to Emergency Behavior Intervention). The
policies must include the following [Medium-High]:

(1) A complete description of emergency behavior interventions that you permit

caregivers to use [Medium-High];

(2) The specific techniques that caregivers can use [Medium-High];

(3) The qualifications for caregivers who assume the responsibility for emergency
behavior intervention implementation, including required experience and training, and
an evaluation component for determining when a specific caregiver meets the
requirements of a caregiver qualified in emergency behavior intervention. You must
have an on-going program to evaluate caregivers qualified in emergency behavior
intervention and the use of emergency behavior interventions [Medium-High];

(4) Your requirements for and restrictions on the use of permitted emergency behavior
interventions [Medium-High];

(5) For the orientation required in §748.1209(b)(6) of this title (relating to What
orientation must I provide a child?), how you will:

(A) Explain and document to a child in a manner that the child can understand
[Medium-High]:

(i) Who can use an emergency behavior intervention [Medium-High];

(ii) The actions a caregiver must first attempt to defuse the situation and
avoid the use of emergency behavior intervention [Medium-High];

(iii) The situations in which emergency behavior intervention may be used

[Medium-High];

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 (iv) The types of emergency behavior intervention you permit [Medium-
High];

(v) When the use of an emergency behavior intervention must cease

[Medium-High];

(vi) What action the child must exhibit to be released from the emergency
behavior intervention [Medium-High];

(vii) The way to report an inappropriate emergency behavior intervention

[Medium-High];

(viii) The way to provide voluntary comments during or after an emergency

behavior intervention [Medium]; and

(ix) The process for making written comments after an emergency

behavior intervention, such as comments regarding the incident that led
to the emergency behavior intervention, the manner in which a caregiver
intervened, and the manner in which the child was the subject or to
which they were a witness. You may create a standardized form that is
easily accessible or give children the permission to submit comments on
regular paper [Medium]; and

(B) Obtain each child’s input on preferred de-escalation techniques that caregivers
can use to assist the child in the de-escalation process [Medium-High];

(6) That you will either [Medium-High]:

(A) Post in a place where children and adult clients can view them, the emergency
behavior interventions that you permit at your operation; or

(B) Provide the children and adult clients at admission a personal copy of the
operation’s emergency behavior intervention policies;

(7) Requirements that caregivers must attempt less restrictive and less intrusive
emergency behavior interventions as preventive measures and de-escalating
interventions to avoid the use of emergency behavior intervention [Medium-High];

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 (8) Training for emergency behavior intervention. The policy must include a description of
the emergency behavior intervention training curriculum that meets the requirements
in the rules of this chapter, the amount and type of training required for different
levels of caregivers (if applicable), training content, and how the training will be
delivered [Medium-High]; and

(9) Prohibitions for discharging or otherwise retaliating against:

(A) An employee, child in care, adult client, resident, or other person for filing a
complaint, presenting a grievance, or otherwise providing in good faith
information relating to the misuse of emergency behavior intervention at the
operation [Medium-High]; or
(B) A child in care, adult client, or resident because someone on behalf of the client
or resident files a complaint, presents a grievance, or otherwise provides in
good faith information relating to the misuse of emergency behavior
intervention at the operation. [Medium-High]

§748.115. What are the requirements for my discipline

policies for children in care?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

The discipline policies you develop for children in care must be consistent with Subchapter M of
this chapter (relating to Discipline and Punishment). The discipline policies you develop must
also:

(1) Guide caregivers and employees in the methods used for the discipline of children
[Medium];

(2) Integrate trauma informed care into the care, treatment, and management of each child
[Medium];
(3) Include measures for positive responses to appropriate behavior [Medium];

(4) Include the importance of nurturing behavior, stimulation, and promptly meeting the
child’s needs [Medium]; and
(5) Include a statement that discipline of any type is not allowable for infants. [Medium]

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§748.117. What policies for a transitional living program
must I develop?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

For operations who offer a transitional living program, you must develop policies that address
the following [Medium-Low]:

(1) Criteria used to select participants for the program [Medium-Low];

(2) Supervision of participants consistent with §748.1019 of this title (relating to What are the
supervision requirements for a transitional living program?) and §748.1021 of this title
(relating to When does a child who is in a transitional living program not need
supervision?) [Medium-Low];

(3) Expected behaviors of participants and consequences for failure to comply [Medium];
(4) Training, education, and experiences to be achieved in the program [Low]; and
(5) Roles of participants, employees, contract staff, and caregivers. [Medium-Low]

§748.119. What policies must I develop if I use volunteers?

Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

If you use volunteers, you must develop policies that [Medium-Low]:

(1) Include job descriptions and/or responsibilities for the volunteers [Medium-Low];
(2) Address qualifications, screening, and selection procedures for the volunteers [Medium-
Low];

(3) Address orientation and training programs for the volunteers [Medium-Low];
(4) Address supervision of volunteers [Medium-Low]; and
(5) Address volunteer contact with children in care. [Medium-Low]

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§748.121. What abuse and neglect policies must I develop?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

You must develop policies on preventing, recognizing, and responding to abuse and neglect of
children, including [Medium-High]:
(1) Required annual training for employees [Medium-High];
(2) Methods for increasing employee awareness of issues regarding child abuse and neglect,
including warning signs that a child may be a victim of abuse or neglect [Medium-High];
(3) Methods for increasing employee awareness of prevention techniques for child abuse and
neglect [Medium-High];
(4) Strategies for coordination between the operation and appropriate community
organizations [Medium-High]; and
(5) Actions that the parent of a child who is a victim of abuse or neglect should take to obtain
assistance and intervention. [Medium-High]

§748.123. What must an employee policy for protecting

children from vaccine- preventable diseases include?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

A policy for protecting the children in your care from vaccine-preventable diseases must
[Medium]
(1) Specify any vaccines that you have determined an employee must have for vaccine-
preventable diseases based on the level of risk the employee presents to children by the
employee’s routine and direct exposure to children [Medium];
(2) Require each employee to receive each specified vaccine that the employee is not exempt
from having [Medium-High];
(3) Include procedures for verifying whether an employee has complied with your policy
[Medium];

(4) Include procedures for an employee to be exempt from having a required vaccine because
of [Medium]:

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 (A) Medical conditions identified as contraindications or precautions by the Centers for
Disease Control and Prevention (CDC) [Medium]; or

(B) Reasons of conscience, including a religious belief [Medium];

(5) Include procedures that an exempt employee must follow to protect children in your care
from exposure to disease, such as the use of protective medical equipment, including
gloves and masks, based on the level of risk the employee presents to children by the
employee’s routine and direct exposure to children [Medium-High];
(6) Prohibit discrimination or retaliatory action against an exempt employee, except that
required use of protective medical equipment, including gloves and masks, may not be
considered retaliatory action for purposes of this section [Medium-Low];
(7) Outline how you will maintain a written or electronic record of each employee’s
compliance with or exemption from your policy [Medium]; and

(8) State the disciplinary actions you may take against an employee who fails to comply with
your policy. [Medium]

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§748.124. What suicide prevention, intervention, and
postvention policy must I have?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
September 2022

(a) You must adopt either [Medium-High]:

(1) The model suicide prevention, intervention, and postvention policy in §748.125
of this division (relating to What is the model suicide prevention, intervention,
and postvention policy?); or
(2) Another suicide prevention, intervention, and postvention policy that is
approved by the Executive Commissioner of the Texas Health and Human
Services Commission or designee and:
(A)Addresses suicide prevention, intervention, and postvention;
(B)Is based on current and best evidence-based practices;
(C) Requires all caregivers and employees to receive annual suicide
prevention training that includes understanding of safety planning and
screening for risk;
(D) Promotes suicide prevention training for non-employees, as
appropriate; and
(E) Includes plans and procedures to support children who return to the
operation following hospitalization for a mental health condition.
(b) The suicide prevention, intervention, and postvention policy adopted under
subsection (a) of this section may be part of a broader mental health crisis plan if the
components of the plan include suicide prevention, intervention, and postvention.

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§748.125. What is the model suicide prevention,
intervention, and postvention policy?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
September 2022

(a) Purpose. The purpose of the model suicide prevention, intervention, and postvention
policy is to:
(1) Protect the health and well-being of children in the care of general residential
operations by implementing procedures to prevent suicide, including screening
and assessment procedures for risk of suicide;
(2) Require intervention when a child attempts or dies by suicide; and
(3) Address the needs of children in care and staff after a child attempts or dies by
suicide.
(b) Definitions.
(1) Postvention--Activities that promote healing and reduce the risk of suicide by a
person affected by the suicide of another.
(2) Protective factors of suicide--Characteristics that make it less likely that a child
will consider, attempt, or die by suicide, including:
(A)Effective behavioral health care;
(B)Connectedness to individuals, family, community, and social
institutions;
(C) Supportive relationships with caregivers;
(D) Problem-solving skills, coping skills, and ability to adapt to change;
(E) Self-esteem or sense of purpose; and
(F) Cultural or personal beliefs that discourage suicide.
(3) Risk factors of suicide--Characteristics or conditions that increase the chance
that a child may consider, attempt, or die by suicide, including:
(A)A prior suicide attempt;
(B)Knowing someone who died by suicide, particularly a family member,
friend, peer, or hero;

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 (C) Access to lethal means;
(D) History of childhood trauma, including neglect, physical abuse, or
sexual abuse or assault;
(E) A history of being bullied;
(F) A mental health diagnosis, particularly depressive disorders and other
mood disorders;
(G) Abuse of alcohol or drugs;
(H)Social isolation;
(I)Severe or prolonged stress;
(J) Chronic physical pain or illness;
(K) Loss of a family member; or
(L)The ending of a relationship.
(4) Suicide contagion--Exposure to suicide or suicidal behaviors within a family, or
from friends or media reports, that can result in an increase in suicide or suicidal
behaviors.
(5) Suicide risk assessment--A comprehensive evaluation of a child by a medical
health professional to confirm suspected suicide risk, estimate the immediate
danger to the child, and decide on a course of treatment and a plan for
intervention to ensure the child’s safety.
(6) Suicide risk screening--A procedure in which a standardized instrument is used to
identify children who may be at risk of suicide. The screening may be done orally
(with the screener asking questions), with pencil and paper, or using a computer.
(7) Warning signs of suicide--Indicators that a child may be in danger of suicide and
need help, including:
(A)Talking about wanting to die or to hurt or kill oneself;
(B)Looking for a way to kill oneself;
(C) Being preoccupied with death in conversation, writing, or drawing;
(D) Talking about feeling hopeless or having no reason to live;
(E) A change in personality;
(F) Giving away belongings;
(G) Withdrawing from friends and family;
(H)Having aggressive or hostile behavior;

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 (I)Neglecting personal appearance;
(J) Running away from home or a residential placement; or
(K) Risk-taking behavior, such as reckless driving or being sexually
promiscuous.
(c) Prevention--Training.
(1) All caregivers and employees must complete at least one hour of annual suicide
prevention training [High] that meets the instructor and documentation
requirements of Subchapter F, Division 6 of this chapter (relating to Annual
Training) with a curriculum that includes:
(A)The risk factors, protective factors, and warning signs of suicide [Medium];
(B)Understanding safety planning, including [Medium]:
(i) How safety plans are created;
(ii) How safety plans are shared with employees and caregivers;
(iii)How safety plans are expected to be implemented by employees and
caregivers; and
(iv) Each employee’s or caregiver’s role in the prevention of suicide,
including never leaving a child alone if the suicide risk screening finds
that the child is a high risk for suicide, until a mental health
professional conducts a suicide risk assessment; and
(C) Understanding suicide screening, including clarifying [Medium]:
(i) Each person’s role in the screening process;
(ii) When an employee or caregiver should initiate a suicide risk screening
for a child; and
(iii)What actions an employee or caregiver must take to initiate a suicide
risk screening for a child.
(2) The operation must promote suicide prevention training for non-employees, as
appropriate. [Low]
(d) Prevention--Suicide Risk Screening.
(1) The policy must describe the suicide risk screening tool that you will use and the
process for implementing the screenings. [Medium]

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 (2) The suicide risk screening tool must be supported by evidence-based research
demonstrating the tool performs reliably regardless of who administers the tool or
performs the scoring or rating. [Medium-High]
(3) Any person who meets the conditions and training requirements of the screening
tool manual or instructions may administer the suicide risk screening to a child.
You must document that any person conducting a screening meets the conditions
and training requirements. [Medium-High]
(4) At a minimum, the screening tool must be administered:
(A)At admission for each child 10 years of age or older [Medium];
(B)At admission for each child younger than 10 years of age if:
(i) The information provided to the operation at the time of admission
indicates that the child has a history of suicide attempts or suicidal
thoughts [Medium-High]; or
(ii) The parent who admits the child or operation requests a screening to
be administered because of the child’s risk factors or warning signs of
suicide [Medium];
(C) Every 30 days after admission for each child 10 years of age or older in a
residential treatment center [Medium];
(D) Every 90 days after admission for each child 10 years of age or older in a
general residential operation that is not a residential treatment center
[Medium]; and
(E) Immediately for a child of any age whenever the child exhibits warning
signs of suicide that necessitate a suicide screening be conducted. [Medium-
High]
(5) Any screening must be performed in a manner that protects the child’s privacy.
[Medium-Low]
(6) Each screening must be documented. [Medium]
(e) Intervention--Based on the Results of a Suicide Risk Screening.
(1) If the suicide risk screening finds the child to be a high risk for suicide, the
operation must [High]:
(A)Immediately refer the child to a mental health professional for a suicide
risk assessment;

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 (B)Not leave the child alone until a mental health professional assesses the
child;
(C) Remove any harmful objects, chemicals, or substances that a child could
use to carry out a suicide attempt;
(D) Alert each person responsible for the child’s care or supervision of the high
risk for suicide and any new or updated safety plan; and
(E) Upon conclusion of the risk assessment, follow through on
recommendations by the mental health professional and update the child’s
safety plan and service plan accordingly.
(2) If the suicide risk screening finds the child to have a potential for risk of suicide,
the operation must [Medium-High]:
(A)Refer the child to a mental health professional for a suicide risk
assessment within 24 hours;
(B)Closely monitor the child to ensure the child’s safety until a mental health
professional assesses the child;
(C) Remove any harmful objects, chemicals, or substances that a child could
use to carry out a suicide attempt;
(D) Alert each person responsible for the child’s care or supervision of the
potential risk of suicide and any new or updated safety plan; and
(E) Upon conclusion of the risk assessment, follow through on
recommendations by the mental health professional and update the child’s
safety plan and service plan accordingly.
(f) Intervention--Returning Post Hospitalization. To ensure a child’s readiness to return to
the care of your operation following a mental health crisis (for example, from a suicide
attempt or psychiatric hospitalization):
(1) A professional level service provider must meet with the child within 24 hours of
the child’s return to an operation to discuss protocols that would help to ease the
child’s transition back into the operation, ensure the child’s safety, and reduce any
risk of suicide. [Medium-High]
(2) The protocols must include [Medium-High]:
(A)Weekly suicide risk screenings for the first 30 days or until the child is no
longer reporting suicidal thoughts, whichever is longer;

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 (B)Creating or reviewing and updating the child’s safety plan; and
(C) Removal of any harmful objects, chemicals, or substances that a child
could use to carry out a suicide attempt or self-harm for a period to be
determined by the treatment team, but not less than 30 days.
(3) The operation must alert any persons responsible for the child’s care or supervision
of the new protocols and new or updated safety plan. [High]
(g) Postvention.
(1) Addressing Suicide Deaths.
(A)Create a Postvention Team and Written Action Plan and Protocols. To
prevent suicide contagion and support the children and staff at the
operation, you must create a postvention team. This team is responsible for
developing a written action plan with protocols in the event of a death by
suicide. The postvention team should consider how a death would affect
other children and staff at the operation and consider how to provide
psychological first aid, crisis intervention, and other support to children and
staff at your operation. [Medium]
(B)While the action plan needs to be flexible for varying situations, the written
action plan must include:
(i) A communication strategy that [Medium]:
(I) Does not inadvertently glamorize or romanticize the child or the
death;
(II) Occurs in small group settings, allowing the postvention team
to monitor responses of individuals in the group;
(III)Strives to treat all deaths at the operation in the same way
(for example, having one approach for honoring a child who
dies from cancer, a car accident, or suicide);
(IV)Emphasizes the importance of seeking help for anyone with an
underlying mental health diagnosis, such as a mood disorder;
(V) Emphasizes the importance of staff and other children
recognizing the signs of suicide; and
(VI)Decreases the stigma associated with seeking help for mental
health concerns;

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 (ii) Mental health resources for children and staff who have a difficult
time coping, including [Medium]:
(I) Opportunities to debrief to process thoughts and feelings
related to the suicide death; and
(II) Referrals to grief counseling and suicide survivor support
groups to the extent possible; and
(iii)A review of lessons learned from the child’s death by suicide. All
communications regarding lessons learned should be approached in a
way that ensures a blame-free environment [Medium-High].
(2) Addressing Suicide Attempts. In the event of a suicide attempt according to
§748.305 of this chapter (relating to What constitutes a suicide attempt by a
child?), you must:
(A)As needed, immediately call emergency services and render first aid until
professional medical treatment can be provided [High];
(B)Not leave the child alone until a mental health professional assesses the
child [High];
(C) Move all other children out of the immediate area as soon as possible
[Medium];
(D) Report and document the suicide attempt as a serious incident as required
by:
(i) §748.303(a)(12) of this chapter (relating to When must I report and
document a serious incident?);
(ii) §748.311 of this chapter (relating to How must I document a serious
incident?); and
(iii)§748.313(1) of this chapter (relating to What additional
documentation must I include with a written serious incident report?);
and
(E) Offer mental health resources for children and staff who have a difficult
time coping, including [Medium]:
(i) Opportunities to debrief to process thoughts and feelings related to
the suicide attempt; and

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 (ii) Referrals to grief counseling and suicide survivor support groups to
the extent possible; and
(F) Conduct a review of lessons learned from the child’s suicide attempt. All
communications regarding lessons learned should be approached in a way
that ensures a blame-free environment. [Medium-High]

Technical Assistance

• Regarding subsection (c)(1) for annual suicide prevention training:

o More than likely training on suicide prevention will have to be tailored for each
operation because some of the training is based on an operation’s own safety
planning and the specific screening tool an operation uses to screen for risk.
However, related to training on risk factors, protective factors, and warning signs of
suicide, one resource that might be helpful is the AS+K? Basic Gatekeeper Training.
o An inspector should cite:
▪ §748.125(c)(1) (this rule) if a caregiver or employee does not have the
annual suicide prevention training;
▪ §748.935(a)(1) or (2) if a caregiver or employee has taken the training, but it
was not completed timely;
▪ §748.941(a)(1) – (4) if the training doesn’t meet the instructor-led
requirements;
▪ §748.949 if the training documentation requirements are not met; and
▪ §748.125(c)(1)(A) – (C) (this rule) if the training does not cover the
curriculum requirements.
• Regarding subsection (c)(1) annual suicide prevention training for caregivers and
employees and subsection (d)(3) training on the suicide risk screening tool, both types of
training may be used to complete the annual training requirements at §748.930 and
§748.931.
• Regarding subsection (c)(2):
o Examples of non-employees that may be appropriate for suicide prevention training
are non-employees that have routine contact with a child or perform a supervisory
role for the child; and
o Examples of the promotion of suicide prevention training may be to share your
suicide prevention policies and other relevant resources with the appropriate non-
employees or encourage appropriate non-employees to participate in other specific
suicide prevention training.
• Regarding subsection (d)(2), you may use any evidenced-based screening tool that is
appropriate for your program. Two screening tools that are free, evidence-based, and have
ample research supporting their validity and reliability, are the:
o Columbia-Suicide Severity Rating Scale (CSSRS); and
o Ask Suicide Screening Questions (ASQ).

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§748.126. What are the general requirements for an
operation’s policies and procedures?
Subchapter C, Organization and Administration

Division 1, Required Plans and Policies, Including During the Application Process
September 2022
(a) The requirements for policies only apply to your policies that are required or governed by
this chapter.

(b) All employees and caregivers must be aware of and follow your policies and procedures.
[Medium]

§748.127. What requirements must I follow when adopting

my operation’s plans, policies, and procedures?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

(a) Your operation’s plans, policies, and procedures must indicate the date on which
you adopted them and their effective date. [Medium-Low]
(b) You must formalize the adoption of your operation’s plans, policies, and
procedures as appropriate for your type of ownership:
(1) If you are a sole proprietor, you must sign them [Medium-Low];
(2) If you are a partnership, each partner must sign them [Medium-Low]; or
(3) If you are a corporation or other type of business entity, the governing body
must take a written action to adopt (sometimes this may be an order or the
adoption may be included in the minutes of the governing body). [Medium-
Low]

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§748.129. Can Licensing cite my operation for a deficiency
if I fail to operate according to my approved plans, policies,
and procedures?
Subchapter C, Organization and Administration
Division 1, Required Plans and Policies, Including During the Application Process
January 2017

Yes, if you violate plans, policies, or procedures, then we may cite the relevant standard in
Division 1 of this Subchapter (relating to Plans and Policies Required for the Application Process)
as a deficiency;

Technical Assistance
● Licensing only enforces plans, policies, and procedures required by the minimum
standards. For example, Licensing does not enforce your policies on purchase
approvals. In addition, Licensing will not cite this standard if you meet a specific
minimum standard but do not meet your policy that requires more than the minimum
standard. For example, if your policy requires caregivers to complete 12 hours of
general pre-service training and inspection results indicate an employee only
completed ten hours of training, we will not cite you for failing to meet your policy.
● If this chapter contains another relevant minimum standard, then that standard would
be cited for failure to comply with a policy. For example and using the same example
as above, if an employee only completed six hours of general pre-service training, we
will cite §748.863(a)(1) because the minimum standards require eight hours of
general pre- service training. However, if there isn’t another relevant minimum
standard, then we would cite the relevant standard in Division 1. For example, if your
professional staffing plan became outdated, then we would cite §748.105(3).

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Division 2, Operational Responsibilities and Notifications

§748.151. What are my operational responsibilities?

Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
January 2017

While you are operating, you must:

(1) Have a designated full-time child-care administrator who meets the minimum
qualifications of §748.531 of this chapter (relating to What qualifications must a child-care
administrator meet?) [High];

(2) Operate according to your approved plans, policies, and procedures [Medium];
(3) Maintain current, true, accurate, and complete records [Medium];
(4) Allow us to inspect your operation during its hours of operation [Medium-High];

(5) Not offer unrelated types of services that conflict or interfere with the best interests of a
child in care, a caregiver’s responsibilities, or operation space. If you offer more than one
type of service, you must determine and document that no conflict exists [Medium-High];

(6) Complying with the liability insurance requirements in this division [Medium]; and
(7) Prepare the annual budget and control expenditures and ensure compliance with Division
3 of this Subchapter (relating to General Fiscal Requirements). [Medium]

Technical Assistance
Regarding subsection (2), Licensing only enforces this requirement for plans, policies, and
procedures required by the minimum standards. For example, Licensing does not enforce
your policies on purchase approvals. In addition, Licensing will not cite this standard if you
meet a specific minimum standard but do not meet your policy that requires more than the
minimum standard. For example, if your policy requires caregivers to complete 12 hours of
general pre-service training and inspection results indicate an employee only completed ten
hours of training, we will not cite you for failing to meet your policy. But if an employee only
completed six hours of training, we will cite you for a deficiency because the minimum
standards require eight hours of general pre-service training.

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§748.153. What changes must I notify Licensing about
regarding my operation?
Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
October 2023

You must provide written notification to your Licensing Representative:

(1) As soon as possible, but at least 30 days before you:
(A) Change the legal structure of your operation or your governing body, if applicable
[Medium-Low];
(B) Move your operation to another location as required in §745.435 of this title
(relating to What must I do if I relocate my operation after I receive my license or
certification?) [Medium-High]; or
(C)Change your operating hours [Medium-Low]
(2) As soon as possible, but at least 15 days before:
(A) You make changes to the policies and procedures required in §748.103(b) of this
subchapter (relating to What policies and procedures must I submit for Licensing’s
approval as part of the application process?) [Medium-Low];
(B) Changes are made to the operation’s floor plan showing the dimensions and the
purpose of all rooms and specifying where children and caregivers, if applicable, will
sleep [Medium-Low]; and
(C)Construction begins on adding a swimming pool or other permanent body of water
[Medium];
(3) As soon as possible, but no later than two days after:
(A) You change your child-care administrator, or your child-care administrator position
becomes vacant [Medium-High];
(B) A new individual becomes a controlling person at your operation [Medium-High];
(C)An individual ceases to be a controlling person at your operation [Medium-High]; or
(D) There is a significant change in the information we maintain about a controlling
person, such as a name change or mailing address change [Medium-Low]; and

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 (4) Within 24 hours of the child’s placement, if you provide emergency care services and
exceed capacity according to §748.155(b) of this division (relating to May I exceed my
operation’s capacity?). [Medium]

Technical Assistance
Licensing does not automatically approve an action when you provide the required notice to
your Licensing Representative. Additional action may need to be taken by you or Licensing.
For example, changing the legal structure of your operation may require a new license.

§748.154. What is my timeframe for filling my child-care

administrator position if it becomes vacant while I do not
have a back-up administrator to carry out the administrator
duties?
Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
October 2023

If you do not have a back-up child-care administrator when your administrator

position becomes vacant, as required in §748.535 of this chapter (relating to What
responsibilities must the child-care administrator have?), you have 60 days from the
date the position becomes vacant to obtain a licensed child-care administrator before
we can cite you for not having an administrator.

§748.155. May I exceed my operation’s capacity?

Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
January 2017

(a) The number of children and young adults in your care must not exceed the
capacity stated on your permit, except as described in subsection (b) of this
section. [Medium-High]
(b) If you are licensed to provide emergency care services, you may temporarily
exceed your licensed capacity for not more than 48 hours to provide temporary
care for a child needing emergency care services.

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 (c) For the purpose of determining whether you exceed your capacity, the number of
children in your care includes a caregiver’s own children who are at the operation,
if they share general living space, bedroom, and/or bathroom space with children
in care, and any children receiving respite child-care services at an operation
providing emergency care services.

§748.157. May I provide child day care services?

Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
January 2017

You may provide child day care services under the following conditions:
(1) You don’t provide treatment services to children with emotional disorders [Medium];

(2) You care for and supervise children who receive day care services separately from the
children receiving residential services [Medium]; and

(3) You have separate administrative employees and caregivers for each program. [Medium]

§748.158. What are the liability insurance requirements?

Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
April 2021

Unless you have an acceptable reason not to have the insurance, you must:
(1) Maintain liability insurance coverage in the amount of $300,000 for each occurrence of
negligence that covers injury to a child while the child is on your premises or in your care
[Medium]; and
(2) Provide proof of coverage to Licensing each year by the anniversary date of the issuance
of your permit. [Medium]

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§748.159. What are acceptable reasons not to have liability
insurance?
Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
April 2021

(a) You do not have to have liability insurance that meets the requirements of §748.158 of
this division (relating to What are the liability insurance requirements?) if you cannot
carry insurance because:

(1) Of financial reasons;

(2) You are unable to locate an underwriter who is willing to issue a policy to the
operation; or

(3) You have already exhausted the limits of a policy that met the requirements.

(b) If you cannot carry liability insurance or stop carrying the insurance because of a reason
listed in subsection (a) of this section, you must send written notification to Licensing by
the anniversary date of the issuance of your permit. Your notification must include the
reason that you cannot carry the insurance. [Medium]

§748.160. When must I notify parents that I do not carry

liability insurance?
Subchapter C, Organization and Administration
Division 2, Operational Responsibilities and Notifications
April 2021

(a) If you do not carry liability insurance that meets the requirements of §748.158 of this
division (relating to What are the liability insurance requirements?), then you must notify
the parent of each child in your care in writing that you do not carry liability insurance
before you admit the child into your care. [Medium-High]

(b) If you previously carried the liability insurance and subsequently stop carrying the liability
insurance, then you must notify the parent of each child in your care in writing that you
do not carry the insurance within 14 days after you stop carrying it. [Medium-High]

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 (c) You may use the Form 2962, Verification of Liability Insurance, located on the Licensing
provider website, to notify parents. Regardless of whether you use this form, you must be
able to demonstrate that you provided written notice to the parents of each child in your
care.

Technical Assistance
It is important that parents both understand and acknowledge whether your operation carries
liability insurance. Possible means of communicating this requirement include:

● Using a form specific to liability insurance that requires a parent signature that you
maintain in the child’s file;
● Including a statement or addendum about liability insurance in your operational policies
or parent handbook, and maintain in the child’s file a document with a parent signature
or initials specifically acknowledging the liability insurance information; or
● Maintaining a copy of any electronic communication sent to a parent regarding liability
insurance, including the date and address to which the communication was sent.

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Division 3, General Fiscal Requirements

§748.161. What are my fiscal requirements?

Subchapter C, Organization and Administration
Division 3, General Fiscal Requirements
January 2017

(a) You must establish and maintain your operation on a sound fiscal basis, including
[Medium]
(1) Paying your employees timely [Medium]; and
(2) Making sure the needs of children in care are being met. [Medium]
(b) You must maintain complete financial records that comply with Generally Accepted
Accounting Principles, including accounting for a child’s money separately from the
funds of your operation. You may not use a child’s personal earnings, allowances,
or gifts to pay for the child’s room and board, unless such use is a part of the
child’s service plan and the child’s parent approves it in writing. You must give or
send the child’s money to the child, parent, or next placement within 30 days of
the child’s discharge. [Medium-Low]

Division 4, Required Postings

§748.191. What items must I post at my operation?

Subchapter C, Organization and Administration
Division 4, Required Postings
January 2017

The items listed below must be posted in a prominent and publicly accessible place where
employees, children, parents, and others may easily view them at all times:
(1) Your permit. An operation does not have to post its permit in its cottage homes,
as long as it posts the permit at the main office location [Medium-Low];
(2) The Licensing notice Keeping Children Safe [Medium-Low]; and

(3) Emergency and evacuation relocation plans posted in each building and living
quarters used by children. [Medium-High]

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Subchapter D, Reports and Record Keeping

Division 1, Reporting Serious Incidents and Other

Occurrences

§748.301 What do certain terms mean in this subchapter?

Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
June 2020

These terms have the following meanings in this subchapter:

(1) Serious incident--A non-routine occurrence that has or may have dangerous or
significant consequences for the care, supervision, or treatment of a child. The
different types of serious incidents are noted in §748.303 of this division (relating to
When must I report and document a serious incident?).
(2) Triggered review of a child’s unauthorized absences--A review of a specific child’s
pattern of unauthorized absences when the child has had three unauthorized
absences within a 60- day timeframe.
(3) Unauthorized absence--A child is absent from the grounds of an operation without
permission from a caregiver and cannot be located. This includes when an
unauthorized person has removed the child from the operation.

Technical Assistance
Regarding paragraph (3): Operations should use their best judgment based on the totality
of the circumstances on a case by case basis to determine if there is an unauthorized
absence. Example 1: if a teenager is routinely late in returning to the operation from an
extracurricular activity, the operation would likely take the child’s routine into account when
assessing the possibility of an unauthorized absence. Example 2: If a teenager is on an
unsupervised activity and calls and informs the staff that he/she will be late in returning to
the operation, this situation is not likely to be an unauthorized absence.

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§748.303. When must a general residential operation
(GRO) report and document a serious incident?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
December 2024

(a) A GRO must report and document the following types of serious incidents involving a
child in its care. The reports must be made to the following entities, and the
reporting and documenting must be within the specified time frames:

Figure: 26 TAC §748.303(a)

Serious Incident (i) To Child Care (i) To Parents? (i) To Law

Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(1) A child dies while in (A)(i) YES. (B)(i) YES. (C)(i) YES.
the GRO’s care. (A)(ii) As soon as (B)(ii) As soon as (C)(ii)
possible, but no possible, but no Immediately, but
later than 2 hours later than 2 hours no later than 1
after the child’s after the child’s hour after the
death. death. child’s death.
[Medium-High] [Medium-High] [Medium-High]

(2) A substantial (A)(i) YES. (B)(i) YES. (C)(i) NO.

physical injury or (A)(ii) Report as (B)(ii) (C)(ii) Not
critical illness soon as possible, Immediately after Applicable.
that a reasonable but no later than ensuring the
person would 24 hours after the safety of the
conclude needs incident or child.
treatment by a occurrence. [Medium-High]
medical [Medium-High]
professional or
hospitalization.
(3) Allegations of (A)(i) YES. (B)(i) YES. (C)(i) NO.
abuse, neglect, or (A)(ii) As soon as (B)(ii) (C)(ii) Not
exploitation of a the GRO becomes Immediately applicable.
child; or any aware of it. after ensuring
incident where [Medium-High] the safety of the
there are child.
indications that a [Medium-High]
child in care may
have been abused,
neglected, or
exploited.

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 Serious Incident (i) To Child Care (i) To Parents? (i) To Law
Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(4) Physical abuse (A)(i) YES. (B)(i) YES. (C)(i) NO.
committed by a (A)(ii) As soon as (B)(ii) (C)(ii) Not
child against the GRO becomes Immediately applicable.
another child. For become aware of after ensuring
the purpose of this it. the safety of the
subsection, [Medium-High] child.
physical abuse [Medium-High]
occurs when there
is substantial
physical injury,
excluding any
accident; or failure
to make a
reasonable effort
to prevent an
action by another
person that results
in substantial
physical injury to a
child.

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 Serious Incident (i) To Child Care (i) To Parents? (i) To Law
Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(5) Sexual abuse (A)(i) YES. (B)(i) YES. (C)(i) NO.
committed by a (A)(ii) As soon as (B)(ii) (C)(ii) Not
child against the GRO becomes Immediately applicable.
another child. aware of it. after ensuring
For the purpose [Medium-High] the safety of the
of this child.
subsection, [Medium-High]
sexual abuse is:
conduct harmful to
a child’s mental,
emotional or
physical welfare,
including
nonconsensual
sexual activity
between children
of any age, and
consensual sexual
activity between
children with more
than 24 months
difference in age
or when there is a
significant
difference in the
developmental
level of the
children; or failure
to make a
reasonable effort
to prevent sexual
conduct harmful to
a child.

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 Serious Incident (i) To Child Care (i) To Parents? (i) To Law
Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(6) A child is indicted, (A)(i) YES. (B)(i) YES. (C)(i) NO.
charged, or (A)(ii) As soon as (B)(ii) As soon as (C)(ii) Not
arrested for a possible, but no the GRO applicable.
crime; or when later than 24 becomes aware
law enforcement hours after the of it.
responds to an GRO becomes [Medium]
alleged incident at aware of it.
the GRO that could [Medium]
result in criminal
charges being filed
against the child.
(7) A child is issued a (A)(i) NO. (B)(i) YES. (C)(i) NO.
ticket at school by (A)(ii) Not (B)(ii) As soon as (C)(ii) Not
law enforcement applicable. possible, but no applicable.
or any other later than 24
citation that does hours after the
not result in the GRO becomes
child being aware of it.
detained. [Medium]
(8) The unauthorized (A)(i) YES. (B)(i) YES. (C)(i) YES.
absence of a child (A)(ii) Within 2 (B)(ii) Within 2 (C)(ii) Immediately
who is hours of notifying hours of notifying upon determining
developmentally or law enforcement. law enforcement. the child is not on
chronologically [Medium-High] [Medium] the premises and
under 6 years old. the child is still
missing.
[Medium-High]
(9) The unauthorized (A)(i) YES. (B)(i) YES. (C)(i) YES.
absence of a child (A)(ii) Within 2 (B)(ii) Within 2 (C)(ii) Within 2
who is hours of notifying hours of hours of
developmentally law enforcement, determining the determining the
or chronologically if the child is still child is not on the child is not on the
6 to 12 years old. missing. premises, if the premises, if the
[Medium-High] child is still child is still
missing. missing.
[Medium] [Medium-High]

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 Serious Incident (i) To Child Care (i) To Parents? (i) To Law
Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(10) The unauthorized (A)(i) YES. (B)(i) YES. (C)(i) YES.
absence of a child (A)(ii) No later (B)(ii) No later (C)(ii) No later than
who is 13 years than 6 hours from than 6 hours from 6 hours from when
old or older. when the child’s when the child’s the child’s absence
absence is absence is is discovered and
discovered and the discovered and the child is still
child is still the child is still missing. However,
missing. However, missing. However, the GRO must
the GRO must the GRO must report the child's
report the child's report the child's absence
absence absence immediately if the
immediately if the immediately if the child has previously
child has child has been alleged or
previously been previously been determined to be a
alleged or alleged or trafficking victim, or
determined to be a determined to be the GRO believes
trafficking victim, a trafficking the child has been
or the GRO victim, or the GRO abducted or has no
believes the child believes the child intention of
has been abducted has been returning to the
or has no intention abducted or has GRO.
of returning to the no intention of [Medium]
GRO. returning to the
[Medium] GRO.
[Medium]
(11) A child in the (A)(i) YES, unless (B)(i) YES, if their (C)(i) NO.
GRO's care the information is child contracted (C)(ii) Not
contracts a confidential. the communicable applicable.
communicable (A)(ii) As soon as disease or has
disease that the possible, but no been exposed to
law requires the later than 24 it.
GRO to report to hours after the (B)(ii) As soon as
the Department GRO becomes possible, but no
of State Health aware of the later than 24
Services (DSHS) communicable hours after the
as specified in 25 disease. GRO becomes
TAC Chapter 97, [Medium] aware of the
Subchapter A, communicable
(relating to disease.
Control of [Medium]
Communicable
Diseases).

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 Serious Incident (i) To Child Care (i) To Parents? (i) To Law
Regulation? (ii) If so, when? Enforcement?
(ii)If so, when? (ii) If so, when?
(12) A suicide attempt (A)(i) YES. (B)(i) YES. (C)(i) NO.
by a child. (A)(ii) As soon as (B)(ii) (C)(ii) Not
the GRO becomes Immediately applicable.
aware of the after ensuring
incident. the safety of the
[Medium-High] child.
[Medium]

(b) If there is a medically pertinent incident that does not rise to the level of a serious
incident, a GRO does not have to report the incident but the GRO must document the
incident in the same manner as a serious incident, as described in §748.311 of this
division (relating to How must I document a serious incident?). [Medium]
(c) If a child returns before the required reporting timeframe outlined in (a)(8) - (10) in
Figure: 26 TAC §748.303(a), the GRO is not required to report the absence as a
serious incident. Instead, the GRO must document within 24 hours after becoming
aware of the unauthorized absence in the same manner as for a serious incident, as
described in §748.311 of this division. [Medium]
(d) If there is a serious incident involving an allegation of abuse, neglect, or exploitation
of an elderly adult or an adult with a disability in a residential child-care operation, the
GRO must document the incident in the same manner as a serious incident. The GRO
must also report the incident to:
(1) The Department of Family and Protective and Services intake through:
(A) The Texas Abuse and Neglect Hotline (1-800-252-5400); or
(B) Online at [Link]
(2) Law enforcement, if there is a fatality; and
(3) The parent, if the adult resident is not capable of making decisions about the
resident’s own care.
(e) A GRO must report and document the following types of serious incidents involving
the GRO, an employee, a professional level service provider, contract staff, or a
volunteer to the following entities within the specified time frames:

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Figure: 26 TAC §748.303(e)

Serious Incident (i) To Child Care (i) To Parents?

Regulation? (ii) If so, when?
(ii) If so, when?
(1) Any incident that (A)(i) YES. (B)(i) YES.
renders all or part of the (A)(ii) As soon as possible, (B)(ii) As soon as possible,
GRO unsafe or but no later than 24 hours but no later than 24 hours
unsanitary for a child, after the incident. after the incident.
such as a fire or a flood. [Medium] [Medium]
(2) A disaster or emergency (A)(i) YES. (B)(i) YES.
that requires the GRO to (A)(ii) As soon as possible, (B)(ii) As soon as possible,
close. but no later than 24 hours but no later than 24 hours
after the incident. after the incident.
[Medium] [Medium]
(3) The GRO must (A)(i) YES. (B)(i) YES.
temporarily do the
following to comply with a (A)(ii) As soon as possible, (B)(ii) As soon as possible,
declared state of disaster but no later than 24 hours but no later than 24 hours
under Chapter 418, after temporarily moving to after temporarily moving to
Government Code: or providing care at any or providing care at any
location not noted on the location not noted on the
• Move the GRO to a new permit. permit.
location that is not [Medium-High] [Medium-High]
noted on the GRO’s
permit; or
• Provide care to any
child at a location not
noted on the permit (for
example providing care
to a child that needs to
be quarantined at a
different location from
other children).

(4) An adult who has (A)(i) YES, unless the (B)(i) YES, if their child has
contact with a child in information is confidential. contracted the
care contracts a (A)(ii) As soon as possible, communicable disease or
communicable disease but no later than 24 hours has been exposed to it.
noted in 25 TAC 97, after the GRO becomes (B)(ii) As soon as possible,
Subchapter A, (relating aware of the but no later than 24 hours
to Control of communicable disease. after the GRO becomes
Communicable [Medium] aware of the communicable
Diseases). disease.
[Medium]

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Serious Incident (i) To Child Care (i) To Parents?
Regulation? (ii) If so, when?
(ii) If so, when?
(5) An allegation that a (A)(i) YES. (B)(i) NO.
person under the (A)(ii) Within 24 (B)(ii) Not applicable.
auspices of the GRO who hours after learning
directly cares for or has of the allegation.
access to a child in the [Medium]
GRO has abused drugs
within the past seven
days.
(6) An investigation of (A)(i) YES. (B)(i) NO.
abuse or neglect by an (A)(ii) As soon as possible, (B)(ii) Not applicable.
entity (other than the but no later than 24 hours
Texas Department of after the GRO becomes
Family and Protective aware of the investigation.
Services Child Care [Medium]
Investigations division)
of an employee,
professional level
service provider,
contract staff, volunteer,
or other adult at the
GRO.

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Serious Incident (i) To Child Care (i) To Parents?
Regulation? (ii) If so, when?
(ii) If so, when?
(7) Any of the following (A)(i) YES. (B)(i) NO.
relating to an employee, (A)(ii) As soon as the GRO (B)(ii) Not applicable.
professional level service becomes aware of the
provider, contract staff, situation.
volunteer, or other adult [Medium]
at the GRO alleging
commission of any crime
as provided in §745.661
of this title (relating to
What types of criminal
convictions may affect a
subject’s ability to be
present at an
operation?):
• An arrest;
• An indictment;
• Information regarding
an official complaint
accepted by a county
or district attorney; or
• An arrest warrant
executed by law
enforcement.
(8) A search warrant is (A)(i) YES. (B)(i) NO.
executed by law (A)(ii) As soon as the GRO (B)(ii) Not applicable.
enforcement at the GRO. becomes aware of the
situation. [Medium]

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Serious Incident (i) To Child Care (i) To Parents?
Regulation? (ii) If so, when?
(ii) If so, when?
(9) An allegation that an (A)(i) YES. (B)(i) YES.
employee or caregiver: (A)(ii) As soon as possible (B)(ii) As soon as possible
• Used a prohibited but no later than 24 hours but no later than 24 hours
emergency behavior after the GRO becomes after the GRO becomes
intervention aware of the incident. aware of the incident.
technique, as outlined [Medium] [Medium]
in §748.2451(b) of
this chapter (relating
to What types of
emergency behavior
intervention may I
administer?);
• Used a prohibited
personal restraint
technique, as outlined
in §748.2605 of this
chapter (relating to
What personal
restraint techniques
are prohibited?); or
• Used an emergency
behavior intervention
inappropriately, as
outlined in §748.2463
of this chapter
(relating to Are there
any purposes for
which emergency
behavior intervention
cannot be used?),
§748.2705 of this
chapter (What
mechanical and other
restraint devices are
prohibited?), or
§748.2801 of this
chapter (relating to
What is the maximum
length of time that an
emergency behavior
intervention can be
administered to a
child?).

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Technical Assistance
Regarding subsection (a)(2), not every trip to a hospital or emergency clinic must be
reported as a serious incident. Only those incidents involving a “substantial physical injury
or critical illness” must be reported and documented as a serious incident. The definition of
“substantial physical injury” contains some examples of reportable serious incidents. Visits
to the emergency room or emergency clinic (that did not result in hospitalization) for a
common illness such as the flu, for a chronic illness such as an asthma attack, or for a
routine medical exam would not warrant reporting as a serious incident.
Also, it is the nature of the injury or illness that determines whether it is reportable as a
serious incident, not the venue in which it is treated. Taking a child to the emergency clinic
or doctor’s office for stitches is still reportable as a serious incident, even though the
treatment did not occur at an emergency room or hospital.
Regarding children receiving treatment services for primary medical needs, planned
admissions to the hospital are not reportable as serious incidents. If the child sustains a
substantial physical injury or contracts a critical illness, a serious incident report is required.
However, ongoing treatment for the child’s chronic illnesses or conditions is not reportable
as a serious incident.
In addition, admission to a psychiatric hospital only warrants a serious incident report if the
admission is precipitated by a reportable incident, such as a suicide attempt. The admission
itself is not reportable as a serious incident.
Regarding paragraph (e)(3), a disaster may be declared by the governor or the presiding
officer of the governing body of a political subdivision. The operation must be located in the
area impacted by the declared disaster before paragraph (e)(3) applies.
Regarding subsection (e)(7), see the Citizen’s Guide for the Texas Criminal Justice Process
for more information on criminal matters.

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§748.305. What constitutes a suicide attempt by a child?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
September 2010

A suicide attempt is a child’s attempt to take his own life using means or methods for causing his
death, including any act a child commits intending to cause his death, but excluding suicidal
gestures where it is clear that the act was unlikely to cause death. Suicidal thoughts are not
reportable as a suicide attempt.

§748.309. How do I make a report of a serious incident or

occurrence to Licensing?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
January 2017

All serious incident reports must be made directly to the Texas Abuse and Neglect Hotline.
[Medium]

§748.311. How must I document a serious incident?

Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
April 2022

A serious incident must be documented in a written report that includes the following
information [Medium]:
(1) The name of the operation, physical address, and telephone number [Medium];
(2) The time and date of the incident [Medium];
(3) The name, age, gender, and date of admission of the child or children involved
[Medium];
(4) The names of all adults involved and their role in relation to the child(ren) [Medium];
(5) The names or other means of identifying witnesses to the incident, if any [Medium];
(6) The nature of the incident [Medium];
(7) The circumstances surrounding the incident [Medium];

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 (8) Interventions made during and after the incident, such as medical interventions,
contacts made, and other follow-up actions [Medium];
(9) The treating licensed health-care professional’s name, findings, and treatment, if any
[Medium];
(10) The resolution of the incident [Medium]; and

(11) If the child returns to the operation after you complete the report for an unauthorized
absence, an update regarding the unauthorized absence and the child’s return.
[Medium]

Technical Assistance

Regarding subsection (3), this requirement is not intended to conflict with confidentiality
laws or rights. Identifying information for one child should not be placed in the record of
another child. You may choose to 1) write one incident report that is filed centrally (not in
each child’s record) and de-identified when released as part of a child’s record, 2) write one
incident report that is filed in each child’s record, with each copy de-identified to not show
the full name of other children involved in the incident, or 3) write a separate incident
report for each child, with only the first name or initials of each other child involved.
Regarding subsection (5), witnesses to the incident are persons who were present when the
incident occurred and can give a first-hand account of what they experienced during the
incident. A person is not automatically a witness because he lives in the same unit or
cottage as the child involved in the incident. Witnesses may also be persons unaffiliated
with the operation, such as a visitor to the operation who was present at the time of the
incident.

§748.313. What additional documentation must I include

with a written serious incident report?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
June 2020

You must include the following additional documentation with a written serious incident report,
as applicable:

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 Weight Serious Incident Documentation
[Medium] (1) Child death, substantial Any emergency behavior
physical injury, or a suicide interventions implemented on
attempt reportable under the child within 48 hours prior
§748.303(a)(1), (2), and (11) to the serious incident.
of this division (relating to
When must I report and
document a serious incident?).
[Medium-High] (2) Any substantial physical Documentation of the short
injury reportable under personal restraint, including
§748.303(a)(2) of this the precipitating
division that resulted from a circumstances and specific
short personal restraint. behaviors that led to the
emergency behavior
intervention.
[Medium] (3) Unauthorized absence of a (A) Any efforts made to locate
child. the child;
(B) The date and time you
notified the parent(s) and
the appropriate law
enforcement agency and
the names of the persons
with whom you spoke
regarding the child’s
absence and subsequent
location or return to the
operation;
(C)If the parent cannot be
located, dates and times of
all efforts made to notify
the parent regarding the
child’s absence and
subsequent location or
return to the operation;
(D) Whether the child has
returned to the operation,
and if so, the length of
time the child was gone
from the operation; and
(E) If the child returns to the
operation after 24 hours,
an addendum to the
report that documents the
child’s return.

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 Weight Serious Incident Documentation
[Medium] (4) Any physical or sexual The difference in size, age,
abuse committed by a and developmental level of the
child against another child children involved in the
reportable under physical or sexual abuse.
§748.303(a)(4) or (5) of
this division.

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§748.315. How long must I keep incident reports?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
January 2017

You must keep the incident reports on file at the operation for two years. The reports must be
easily accessible to Licensing upon request. [Medium-Low]

§748.317. What are the notification requirements when

Licensing finds my operation deficient in a standard related
to safe sleeping or the abuse, neglect, or exploitation of a
child?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
April 2021

(a) You must notify the parent of each child residing at your child-care operation of a
deficiency in:

(1) A safe sleeping standard noted in subsection (b) of this section [Medium-High]; or

(2) The abuse, neglect, or exploitation standard in §748.1101(b)(1)(B) of this chapter

(relating to What rights does a child in care have?). [Medium-High]

(b) The following are safe sleeping standards requiring notification:

(1) §748.1751(a)(1) of this chapter (relating to What specific safety requirements must
my cribs meet?);

(2) §748.1753(a)(2)(A) of this chapter (relating to Are play yards allowed?);

(3) §748.1757(a)(5) and (b) of this chapter (relating to What types of equipment are
not allowed for use with infants?);

(4) §748.1763 of this chapter (relating to What are the specific sleeping requirements
for infants?);

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 (5) §748.1765 of this chapter (relating to May I allow infants to sleep in a restrictive
device?); and

(6) §748.1767 of this chapter (relating to May I swaddle an infant to help the infant
sleep?).

§748.319. How must I notify parents of a safe sleeping

deficiency or an abuse, neglect, or exploitation deficiency?
Subchapter D, Reports and Record Keeping
Division 1, Reporting Serious Incidents and Other Occurrences
April 2021

(a) Within five days after you receive notification of a deficiency described in §748.317 of this
division (relating to What are the notification requirements when Licensing finds my
operation deficient in a standard related to safe sleeping or the abuse, neglect, or
exploitation of a child in care?), you must notify the parents of each child residing at your
child-care operation at the time of notification, including a child who may not have been in
care on the day of the actual incident. [Medium-High]

(b) If the deficiency is for a safe sleeping standard, you must notify the parents using Form
2970, Notification of Safe Sleeping Deficiency, located on the Licensing provider website.
[Medium]

(c) If the deficiency is for the standard related to the abuse, neglect, or exploitation of a child
in care, you must notify the parents using Form 7266, Notification of
Abuse/Neglect/Exploitation Deficiency, located on the Licensing provider website.
[Medium]

(d) You must maintain and make available for our review, upon request, proof that you have
notified parents in writing of deficiencies in safe sleeping and abuse, neglect, or
exploitation, as required by subsection (a) of this section. [Medium-High]

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Technical Assistance

● Regarding paragraph (a), “parent” refers to a person who has legal responsibility for a
child, as defined in 748.43(43) of this chapter (relating to What do certain words and
terms mean in this chapter?). For example, if you are caring for children in the
conservatorship of DFPS, you must notify each child’s DFPS caseworker.
● Regarding paragraph (d), you may maintain the documentation in a manner that is
consistent with your policies for record keeping, as long as you can verify that you have
notified each parent as required. Possible ways to maintain proof of notification include:
o Keeping a copy of the notification in each child’s individual file;
o Keeping a single file of all notifications, with a list of the parents whom you
notified attached to each notification form; or
o Maintaining a copy of any notification sent to a parent electronically, including
the date and address to which you sent the notification.

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Division 2, Operation Records

§748.341. What are the retention requirements for my

operation’s policies?
Subchapter D, Reports and Record Keeping
Division 2, Operation Records
January 2017

(a) You must maintain a copy of your policies and procedures at the operation. They must
be available for review by employees, contract staff, caregivers, Licensing, or your
clients, upon request. [Medium]
(b) You must maintain copies of all current and previous policies for at least two years.
[Medium-Low]

§748.343. What policies and procedures must I have for

protecting records?
Subchapter D, Reports and Record Keeping
Division 2, Operation Records
January 2017

You must have policies and procedures for:

(1) Protecting paper and electronic records from destruction and loss [Medium-Low]; and

(2) Clarifying the persons:

(A) Within your operation who are authorized to access records [Medium-Low]; and
(B) Outside of your operation who are authorized by law to have access to records.
[Medium-Low]

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§748.345. What additional policies and procedures must I
have for electronic records?
Subchapter D, Reports and Record Keeping
Division 2, Operation Records
January 2017

If you keep electronic records, you must develop policies and procedures in addition to the
requirements in §748.343 of this title (relating to What policies and procedures must I have for
protecting records?). These policies and procedures must address:

(1) What records must be in the external paper file and what records can be stored in
the electronic file [Low];

(2) Computer security systems, including confidentiality, passwords, and employee

procedures to ensure the security of the system [Medium-Low];

(3) Requirements for routine back-up of data [Medium-Low];

(4) Anti-virus protection systems [Medium-Low]; and

(5) Limit access to your electronic files to persons within your operation authorized to
see specific information in an electronic file. [Low]

748.347. Are electronic signatures allowed?

Subchapter D, Reports and Record Keeping
Division 2, Operation Records
January 2017

Yes, you may use electronic and digital signatures, including approvals by e-mail and electronic
approvals.

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Division 3, Personnel Records

§748.361. Where must I maintain personnel records?

Subchapter D, Reports and Record Keeping
Division 3, Personnel Records
January 2017

(a) You must maintain all active personnel records at the operation. [Medium-Low]

(b) You must maintain archived personnel records at the operation and/or in a designated
location, as long as they are available for our review within 48 hours. [Medium-Low]
(c) You may archive entire closed personnel records electronically.
(d) Your system for maintaining all personnel records must be uniform throughout the
operation. [Medium-Low]
(e) You must maintain in the main office of the operation a master list of active and archived
personnel records with a notation of the location of those records. [Medium-Low]

§748.363. What information must the personnel record of

an employee include?
Subchapter D, Reports and Record Keeping
Division 3, Personnel Records
August 2024

For each employee, the personnel record must include:

(1) Documentation showing the date of employment [Medium];

(2) Documentation showing how the person meets the minimum age and qualifications for the
position [Medium];
(3) Documentation that your operation has [No weight]:
(A) Verified employment history as required by §748.751 of this chapter (relating to
What are the requirements for obtaining and verifying an applicant's employment
history?); and
(B) Conducted reference checks as required by §748.753 of this chapter (relating to
What are the requirements for completing an applicant's reference checks?);
(4) A current job description [Medium];

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(5) Evidence of any valid professional licensures, certifications, or registrations the person
must have to meet qualifications for the position, such as a current renewal card or a
letter from the credentialing entity verifying that the person has met the required renewal
criteria [Medium];
(6) A copy of the record of tuberculosis screening conducted prior to the person having
contact with children in care showing that the employee is free of contagious tuberculosis
as provided in §748.1583 of this title (relating to Who must have a tuberculosis (TB)
examination?) [Medium];
(7) A notarized Affidavit for Applicants for Employment with a Licensed Operation or
Registered Child-Care Home (Form 2985) as specified in Texas Human Resources Code
§42.059 [Medium];
(8) A Pre-Employment Affidavit for Applicants for Employment at Certain Child Care
Operations (Form 2912) as specified in Texas Human Resources Code §42.0563
[Medium];
(9) A statement signed and dated by the employee documenting that the employee has read
a copy of the operational policies required by §748.103 of this title (relating to What
policies and procedures must I submit for Licensing’s approval as part of the application
process?) [Medium]:
(10)A statement signed and dated by the employee indicating the employee must
immediately report any suspected incident of child abuse, neglect, or exploitation to the
Texas Abuse and Neglect Hotline and to the operation’s administrator or administrator’s
designee [Medium];
(11) Proof of request for background checks required by Chapter 745, Subchapter F of this
title (relating to Background Checks) [High];
(12) For each person who transports a child, a copy of:
(A) The person’s valid driver’s license [Medium]; or
(B) A driver’s license check conducted through the Texas Department of Public Safety
within the last 12 months [Medium];
(13) A record of training, including the date of the training, the number of training hours,
and the curriculum covered [Medium];
(14) Any documentation of the person’s performance with the operation [Medium-Low];
and
(15) The date and reason for the person’s separation, if applicable. [Medium-Low]

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 Technical Assistance

Regarding §748.363(7) and (8), the affidavits are only required for volunteers and
contractors that perform employee functions discussed in §748.723 (relating to Are there
additional requirements for a volunteer or contractor that performs employee functions?)
and require initial background checks through CCR.

§748.365. What information regarding personnel must be

kept confidential?
Subchapter D, Reports and Record Keeping
Division 3, Personnel Records
September 2010

All background check results must be kept confidential, in accordance with HRC §40.005,
subsections (d) and (e). Background check results must be protected from unauthorized access
or release. [Low]

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Division 4, Child Records

§748.391. What is an active child record?

Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2007

An active child record consists of the child’s record for the most recent 12 months of service.
[Medium]

§748.393. How must I maintain an active child record?

Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2017

(a) You must keep active child records at the operation where the child is receiving services.
This may include electronic records. [Medium-Low]
(b) On an on-going basis, you must ensure that each child’s record:
(1) Includes the child’s full name and another method of identifying the child, such as a
client number [Medium];
(2) Includes documentation of known allergies and chronic health conditions on the
exterior of the child’s record or in another place where the information is clearly
visible to persons with access to the record, including a notation of “no known
allergies” when applicable [Medium-High];
(3) Is kept accurate and current [Medium];
(4) Is locked and kept in a safe location [Medium]; and
(5) Is kept confidential as required by law. [Medium]

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§748.395. How current must a child’s record be?
Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2017

All documentation must be in the record:

(1) No later than 30 days after the occurrence or event [Low]; or
(2) As otherwise specified in this chapter. [Low]

§748.397. Who must consent to the release of a child’s

record?
Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2007

Unless you are releasing the record to the parents, to us, or as required by law, you may not
release any portion of a child’s record to any agency, organization, or individual without the
written consent of the person legally authorized to consent to the release. [Medium-Low]

§748.399. Must I make records available for Licensing to

review?
Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2007
(a) You must make all active records available for our immediate review and reproduction.
[Medium]
(b) We must have reasonable access to your storage and file areas in order to monitor your
record keeping. [Medium]

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§748.401. How must I maintain a child’s record that is not
active?
Subchapter D, Reports and Record Keeping
Division 4, Child Records
January 2007

These records must be available for our review within 48 hours. Otherwise, the records may be
archived electronically or kept anywhere and in any manner, as long as they are safe from
damage or destruction. [Medium-Low]

Division 5, Record Retention

§748.431. How long must I maintain personnel records?

Subchapter D, Reports and Record Keeping
Division 5, Record Retention
January 2007

(a) You must maintain annual training records for current personnel for the last full
training year and current training year. [Medium-Low]
(b) With the exception of subsection (a) of this section, you must maintain personnel
records for a year after an employee’s last day of employment or until any
investigation involving the employee is resolved, whichever is longer. [Medium-Low]

§748.433. How long must I maintain child records?

Subchapter D, Reports and Record Keeping
Division 5, Record Retention
September 2010

You must maintain a child’s complete record from admittance to discharge for two years from
the date of discharge, or until the resolution of any investigation involving the child, whichever is
longer. [Medium-Low]

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Division 6, Unauthorized Absences

§748.451. What additional requirements are there for

unauthorized absences of children from my operation?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) For each unauthorized absence of a child, you must:

(1) Document the unauthorized absence in an annual summary log, as required by

§748.453 of this division (relating to What documentation must be included in an
annual summary log for a child who has an unauthorized absence?); and
(2) Debrief the child, as required by §748.455 of this division (relating to What are the
requirements for debriefing a child after an unauthorized absence?).
(b) If a child has three unauthorized absences within a 60-day timeframe, you must conduct a
triggered review of the child’s unauthorized absences that is consistent with the rules
in this division; and
(c) You must conduct an overall operation evaluation for unauthorized absences every six
months, as required by §748.463 of this division (relating to What is an overall
operation evaluation for unauthorized absences?).

§748.453. What documentation must be included in an

annual summary log for a child who has an unauthorized
absence?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) For each unauthorized absence during the relevant year, you must document the
following information in an annual summary log:
(1) The name, age, gender, and date of admission of the child who was absent
[Medium];
(2) The time and date the unauthorized absence was discovered [Medium];
(3) How long the child was gone or if the child did not return [Medium];

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 (4) The name of the caregiver responsible for the child at the time the child’s
absence was discovered [Medium];
(5) The intake report number, if a report was made to Licensing or the Department
of Family and Protective Services [Medium]; and
(6) Whether law enforcement was contacted, including the name of any law
enforcement agency that was contacted and the number of the police report, if
applicable. [Medium]

(b) You must maintain each annual summary log for five years. [Medium]

(c) You must make the annual summary logs available to Licensing for review
and reproduction, upon request. [Medium]

§748.455. What are the requirements for debriefing a child

after an unauthorized absence?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) After a child returns to an operation from an unauthorized absence, the caregiver,
or other appropriate person, must conduct a debriefing with the child as soon as
possible, but no later than 24 hours after the child’s return. The purpose of the
debriefing is for the child and the caregiver, or other appropriate person, to
discuss the following [Medium-High]:
(1) The circumstances that led to the child’s unauthorized absence [Medium];
(2) The trauma informed strategies the child can use to avoid future
unauthorized absences and how the operation can support those strategies
[Medium];
(3) The child’s condition [Medium]; and

(4) What occurred while the child was away from the operation, including
where the child went, who was with the child, the child’s activities, and any
other information that may be relevant to the child’s health and safety.
[Medium]
(b) The caregiver must allow the child to return to routine activities, excluding any
activity that the caregiver determines would be inappropriate because of the
child’s condition following the unauthorized absence or something that occurred
during the unauthorized absence. [Medium]

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 (c) The debriefing must be documented in the child’s record, including any routine
activity that would be inappropriate for the child to return to and the explanation
for why the activity is inappropriate. [Medium]
Technical Assistance
● While debriefing a child of any age, a caregiver or other person conducting the
debriefing should respect the wishes of the child and allow the child to decline the
debriefing or to ask for a different person to conduct the debriefing.
● Regarding Paragraph (a)(4), if a child discloses that abuse or neglect may have
occurred during an unauthorized absence, the caregiver or other person conducting
the debriefing must make a report to the Department of Family and Protective
Services and should not ask additional questions regarding the abuse or neglect. The
caregiver or other person conducting the debriefing must complete any other
remaining requirements of the debriefing.

§748.457. When must a triggered review of a child’s

unauthorized absences occur?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) A triggered review of a child’s unauthorized absences must occur as soon as possible,
but no later than 30 days after the child’s third unauthorized absence within a 60-
day timeframe. [Medium-High]
(b) A regularly scheduled review of the child’s service plan can serve as the triggered
review of a child’s unauthorized absences, if the regularly scheduled review
[Medium-High]:
(1) Meets the requirements in §748.461 of this division (relating to What must the
triggered review of a child’s unauthorized absences include?); and
(2) Takes place no later than 30 days after the child’s third unauthorized absence
within a 60-day timeframe.

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§748.459. Who must participate in a triggered review of a
child’s unauthorized absences?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) The triggered review of a child’s unauthorized absences must include the
following participants [Medium-High]:
(1) The child;
(2) An individual designated to make decisions regarding the child’s
participation in childhood activities, as described in §748.707 of this
chapter (relating to Who makes the decision regarding a foster child’s
participation in childhood activities?); and
(3) The child’s case manager.

(b) You must notify the child’s parent at least two weeks before the triggered review
of a child’s unauthorized absences, so the parent will have an opportunity to
participate in the review. [Medium-High]

§748.461. What must a triggered review of a child’s

unauthorized absences include?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

A triggered review of a child’s unauthorized absences must include the following [Medium-High]:

(1) A review of the child’s records documenting previous unauthorized absences,

including previous debriefings [Medium];
(2) A review of service plan elements identified in §748.1337(b)(1)(D) and (H) and,
as applicable, §748.1337(b)(2) and (3) of this chapter (relating to What must a
child’s initial service plan include?) [Medium];
(3) An examination of trauma informed alternatives to minimize the unauthorized
absences of the child [Medium-High]; and
(4) A written plan to reduce the unauthorized absences of the child, which you must
document in the child’s record. [Medium-High]

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§748.463. What is an overall operation evaluation for
unauthorized absences?
Subchapter D, Reports and Record Keeping
Division 6, Unauthorized Absences
June 2020

(a) Every six months, you must conduct an overall operation evaluation for
unauthorized absences that have occurred at your operation during that time
period. [Medium]
(b) The objectives of the evaluation are to:
(1) Develop and maintain a trauma informed environment that supports positive
and constructive behaviors by children in care [Medium]; and
(2) Ensure the overall safety and well-being of children in care. [Medium]
(c) The evaluation must include:
(1) The frequency and patterns of unauthorized absences of children in your
operation [Medium]; and
(2) Specific trauma informed strategies to reduce the number of unauthorized
absences in your operation. [Medium]
(d) You must maintain the results of each six-month overall operation evaluation for
unauthorized absences for five years. [Medium]
(e) You must make the results of each overall operation evaluation for unauthorized
absences available to Licensing for review and reproduction, upon request.
[Medium]

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Subchapter E, Personnel

Division 1, General Requirements

§748.503. Does education received outside of the United

States count toward educational qualifications?
Subchapter E, Personnel
Division 1, General Requirements
January 2007

Yes, however you must provide supporting information indicating that the education is
equivalent to the minimum educational qualifications for the position for which the person is
applying. Documents written in a foreign language must be translated into English. [Medium-
Low]

§748.505. What minimum qualifications must all

employees meet?
Subchapter E, Personnel
Division 1, General Requirements
August 2023

(a) An employee’s behavior or health status must not present a danger to children in care.
[Medium-High]
(b) Each employee must:
(1) Meet the requirements in Chapter 745, Subchapter F of this title (relating to
Background Checks) [High];
(2) Have a record of a tuberculosis screening showing the employee is free of
contagious TB as provided in §748.1583 of this title (relating to Who must have a
tuberculosis (TB) examination) [Medium];
(3) Be physically, mentally, and emotionally capable of performing assigned tasks and
have the skills necessary to perform assigned tasks [Medium]; and
(4) Complete a notarized Affidavit for Applicants for Employment with a Licensed
Operation or Registered Child-Care Home (Form 2985) before you hire the
employee, as specified in Texas Human Resources Code §42.059. [Medium]; and

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 (5) Complete a Pre-Employment Affidavit for Applicants for Employment at Certain
Child Care Operations (Form 2912) before you hire the employee, as specified in
Texas Human Resources Code §42.0563 [Medium]; and
(6) Have cleared a pre-employment screening assessment in which you determined the
employee's suitability for the employee's position. The screening must have
included [Medium-High]:
(A) Verification of employment history as required by §748.751 of this
subchapter (relating to What are the requirements for obtaining and
verifying an applicant's employment history?); and
(B) Reference checks, as required by §748.753 of this subchapter (relating to
What are the requirements for completing an applicant's reference checks?).

Technical Assistance

Regarding §748.505(b)(5), the affidavit is not a substitute for complying with CCR’s
background check requirements. Regardless of what information a person documents on the
affidavit about charges, convictions, or adjudications of a crime involving an inappropriate
relationship with a minor, CCR may determine the prospective employee ineligible to be
present at an operation due to a background check result. If CCR determines a person is
eligible to be present at an operation based on the person’s background check results, and
the person documents in the affidavit a charge of an inappropriate relationship with a minor,
the operation may choose to employ the person if the operation determines that the charge
was false based on the information disclosed in the affidavit. Moreover, an operation may
terminate an employee for failing to disclose the information required in the affidavit.

§748.507. What general responsibilities do all employees

have?
Subchapter E, Personnel
Division 1, General Requirements
September 2010

Regardless of whether the employee is counted in the child/caregiver ratio, each employee
must:

(1) In the absence of a more specific rule requirement, demonstrate competency,

prudent judgment, and self-control in the presence of children and when
performing assigned responsibilities [Medium-High];

(2) Report suspected abuse, neglect, and exploitation to the Child Abuse Hotline and to
the designated employee or administrator [Medium-High]; and

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 (3) Know and comply with rules of this chapter, Chapter 42 of the Human Resources
Code, Chapter 745 of this title (relating to Licensing), and any other laws which are
relevant to the person’s duties. [Medium-High]

Technical Assistance
Regarding subsection (1), this is only cited by Licensing when a more specific rule
requirement does not apply to the incident. For example, if a caregiver loses their temper
and inappropriately disciplines a child in care, this would be cited using §748.2301(b), or
another relevant standard in Subchapter M (relating to Discipline and Punishment).
This subsection is not cited when a more specific rule is cited regarding the incident.

§748.509. What are the requirements for tuberculosis

screening?
Subchapter E, Personnel
Division 1, General Requirements
January 2007

Before having contact with children in care, all caregivers, employees, volunteers, and contract
service providers must be screened for tuberculosis as provided in §748.1583 of this title
(relating to Who must have a tuberculosis (TB) examination?). [Medium]

§748.511. Is an employee, contract service provider, or

volunteer allowed to be in possession of a handgun?
Subchapter E, Personnel
Division 1, General Requirements
April 2022

An employee, contract service provider, or volunteer may not be in possession of a handgun

while at your operation or while caring for children. [High]

Technical Assistance
The intention of this standard is to prevent employees, caregivers, contract service
providers, and volunteers from having handguns on their person or anywhere on the
grounds of the operation, including vehicles that are parked on the property or vehicles
used to transport children. In addition to this standard, §748.103(b)(12) of this chapter

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Technical Assistance
requires you to submit a weapons, firearms, explosive materials, and projectiles policy
consistent with Subchapter Q, Division 6 of this chapter as part of the application process.

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Division 2, Child-Care Administrator

§748.531. What qualifications must a child-care

administrator meet?
Subchapter E, Personnel
Division 2, Child-Care Administrator
September 2010

(a) A child-care administrator must:

(1) Meet the qualifications established by the operation’s governing body [Medium-
Low];

(2) Be a Licensed Child-Care Administrator according to Chapter 43 of the Human

Resources Code and Subchapter N of this title (relating to Administrator’s Licensing)
[Medium]; and

(3) Be a full-time employee of the operation. [Medium]

(b) If acting as the administrator for two residential child-care operations under
§748.533 of this title (relating to Can a child-care administrator be an
administrator for two residential child-care operations?), the administrator must
split a full-time schedule between the two operations as described in the
professional staffing plans for each operation. [Medium]

§748.532. When can a child-care administrator with a

provisional license serve as the administrator for a general
residential operation?
Subchapter E, Personnel

Division 2, Child-Care Administrator

October 2023

A child-care administrator with a provisional license may serve as the child-care

administrator at a general residential operation if, at the time the administrator is hired,
the operation is not:
(1) On a voluntary plan of action [Medium];

(2) On corrective action [Medium];

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 (3) Subject to an adverse action [Medium]; or

(4) Pending due process for a corrective or an adverse action [Medium].

Technical Assistance

Regarding paragraphs 1 and 2, requiring administrators of operations on a voluntary plan of

action or corrective action to have a full Child-Care Administrator’s License ensures they can
focus their full attention improving their operation’s compliance in the areas of concern that
led to the basis of the action rather than splitting their attention between improving the
operation’s compliance and completing the requirements for a full administrator’s license.

§748.533. Can a child-care administrator be an

administrator for two residential child-care operations?
Subchapter E, Personnel
Division 2, Child-Care Administrator
October 2023

(a) Except as provided in subsection (b) and (c) of this section, a child-care
administrator can be an administrator for two residential child-care operations,
including a child-placing agency, if:
(1) Both operations are in good standing with Licensing [Medium];
(2) The size and scope of the operations are manageable by one person, which
is clarified in the written professional staffing plans [Medium];
(3) The child-placing agency, if applicable, is not managing more than 25 foster
homes [Medium];
(4) The person also holds a valid Child-Placing Agency Administrator License, if
the second operation is a child-placing agency [Medium]; and
(5) The general residential operations and/or RTCs are contiguous. A child-
placing agency does not have to be contiguous. [Medium-Low]
(b) An operation that provides emergency care services must designate an employee in
the staffing plan that is solely responsible for administering those services. This
employee must have the experience and background to be able to perform the child-
care administrator responsibilities. See §748.535 of this title (relating to What
responsibilities must the child-care administrator have?). A designated employee,
other than the child- care administrator for the operation, is not required if the
emergency care services program has a capacity of not more than 30 children.
[Medium]

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 (c) A child-care administrator with a provisional child-care administrator’s license may
only serve as a licensed administrator at one residential child-care operation
[Medium].

Technical Assistance

Regarding subsection (c), the purpose of this rule is to allow an individual with a
Provisional Child-Care Administrator’s License (PCCAL) to focus their full attention on
completing their management and supervisory experience requirements needed to
qualify for a Full Child-Care Administrator’s License before the expiration of the PCCAL.

§748.535. What responsibilities must the child-care

administrator have?
Subchapter E, Personnel
Division 2, Child-Care Administrator
April 2022

The child-care administrator must:

(1) Have daily supervision and on-site administrative responsibility for the overall
operation [Medium];
(2) Ensure that the operation complies with current heightened monitoring plans, if
applicable [Medium-High]; and
(3) Be responsible for or assign responsibility for:
(A) Overseeing staffing patterns to ensure the supervision and the provision of
child-care services that meet the needs of children in care [Medium-High];
(B) Ensuring the provision of planned but flexible program activities designed to
meet the developmental needs of children [Medium];
(C) Having a system in place to ensure an employee is available to handle
emergencies [Medium];
(D) Assigning tasks to caregivers that do not conflict or interfere with caregiver
responsibilities [Medium-High];
(E) Administering and managing the operation according to your policies
[Medium];
(F) Ensuring that the operation complies with applicable rules of this chapter,
Chapter 42 of the Human Resources Code, Chapter 745 of this title (relating
to Licensing), and other applicable laws [Medium];

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 (G) Ensuring a child in care is not assigned, utilized, or allowed to act as a
caregiver [Medium]; and
(H) Ensuring persons whose behavior or health status is known to present a
danger to children are not allowed at the operation. [Medium-High]

§748.537. What must the system for ensuring that an

employee is available to handle emergencies include?
Subchapter E, Personnel
Division 2, Child-Care Administrator
January 2007

(a) A person designated to handle emergencies must be on call and accessible to

your caregivers. [Medium-High]
(b) You must inform all caregivers and us of the system and how to contact the
person on call in case of an emergency. [Medium-High]
(c) The employee is not required to be a Licensed Child-Care Administrator.

§748.539. Who must have overall administrative

responsibility when the child-care administrator is absent
on a frequent and/or extended basis?
Subchapter E, Personnel
Division 2, Child-Care Administrator
January 2017

When the child-care administrator is absent on a frequent and/or extended basis, the
administrator must designate an employee that has a Child-Care Administrator’s License to be
responsible for the overall administration of the operation while the administrator is absent.
[Medium]

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Division 3, Professional Level Service Providers

§748.561. What professional level service activities must a

professional level service provider perform at my
operation?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2007

A professional level service provider must perform the following functions:

(1) Completing an admission assessment or any other evaluation of a child for

placement [Medium-Low];

(2) Developing, reviewing, and updating of service plans for a child in care [Medium];

(3) Completing a discharge or transfer summary for a child [Medium-Low];

(4) Approving any restrictions that will be imposed on a child for more than seven days
that have not been reviewed and approved by the treatment director or service
planning team, and any monthly re-evaluations of restrictions that continue for
more than 30 days [Medium-Low];

(5) Approving any restrictions to communication and visitation with the child’s family
that are imposed on a child, but have not been reviewed and approved by the
treatment director or service planning team, including monthly re-evaluations of
restrictions that continue for more than 30 days [Medium-Low]; and

(6) Approving any restrictions to a particular room or building for more than 24 hours
that are imposed on a child, but have not been reviewed and approved by the
treatment director or service planning team. [Medium-Low]

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§748.563. What professional qualifications must a
professional level service provider have in order to perform
professional level service activities?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2017

(a) If you provide treatment services to 25 or more children with emotional disorders,
or if more than 30% of the children in your care receive treatment services for
emotional disorders, a professional level service provider must have the following
qualifications [Medium]:

Educational qualifications Professional qualifications

A master’s degree or higher from an One year of documented full-time work
accredited college or university in social work experience in a treatment setting serving
or other human services field and nine credit children, including RTCs, child-placing
hours in graduate level courses that focus on agencies providing treatment services,
family and individual function and psychiatric hospitals serving children, etc.
interaction.
(b) If you provide treatment services to 25 or more children with primary medical needs,
or if more than 30% of the children in your care receive treatment services for
primary medical needs, a professional level service provider must have the following
qualifications [Medium]:

Educational qualifications Professional qualifications

A nurse’s degree or higher. One year of documented full-time work
experience in a medical or residential setting
serving children with primary medical needs.
(c) To provide services for any other children, a professional level service provider
must have the following qualifications [Medium]:

Options Educational qualifications Professional qualifications

Option 1 A master’s degree or higher One year of documented
from an accredited college or full-time work experience in
university; or a bachelor’s a residential child-care
degree from an accredited operation, or related field of
college or university in social child and family services.
work or other human
services field.

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 Options Educational qualifications Professional qualifications
Option 2 A bachelor’s degree from an Two years of documented
accredited college or full-time work experience in
university. a residential child-care
operation, or related field of
child and family services.

§748.565. How must a professional level service provider

document approval of professional level service functions?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2007

A professional level service provider must sign and date the following documents to indicate
review and approval or disapproval:

(1) Admission assessments or any other evaluation of a child for placement [Medium-Low];

(2) Initial service plans, updates, and reviews [Medium-Low];

(3) Discharge or transfer summaries [Medium-Low];

(4) Any restrictions that will be imposed on a child for more than seven days that have not
been reviewed and approved by the treatment director or service planning team [Medium-
Low];

(5) Any restrictions to communication and visitation with the child’s family that are imposed
on a child, but have not been reviewed and approved by the treatment director or service
planning team [Medium-Low]; and

(6) Any restrictions to a particular room or building for more than 24 hours that are imposed
on a child, but have not been reviewed and approved by the treatment director or service
planning team. [Medium-Low]

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§748.567. What are the requirements for the caseloads of a
professional level service provider?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2007

There is not a maximum caseload for a professional level service provider; however, you must
ensure manageable caseloads that allow professional level service providers to meet the needs
of children on their caseload. [Medium]

§748.569. Must I have health-care professionals on staff or

on contract if I provide services to children with primary
medical needs?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
September 2010

If you provide treatment services to 25 or more children with primary medical needs or if more
than 30% of the children in your care receive treatment services for primary medical needs:
(1) You must have a licensed registered nurse on staff or on contract to respond to
emergencies, questions, or other medical issues. A registered nurse must work
full-time at the operation. A registered nurse in this position may be relieved on
days off by a licensed registered nurse or by a licensed vocational nurse with
appropriate supervision as defined in Tex. Occ. Code §301.353. [Medium-High]
(2) You must arrange for:
(A) 24-hour availability of nursing, medical, and psychiatric services [Medium-
High];
(B) Licensed nursing services, including 24-hour nursing direction or
supervision [Medium-High];
(C)Assistance with mobility [Medium-High];
(D) Routine adjustments or replacement of medical equipment [Medium-
High]; and
(E) As needed, caregiver supervision of children during the provision of
medical and dental services. [Medium-High]

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 (3) You must ensure that a physician on staff or on contract recommends and
approves services at each initial diagnosis and at each review. [Medium-High]

§748.571. What are the responsibilities of a registered

nurse at an operation that provides services to a child with
primary medical needs?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2017

The responsibilities of a registered nurse include:

(1) Performing a nursing assessment of the child to include documentation of the
child’s diagnosed medical needs and selection of placement [Medium];
(2) Leading or participating in the service planning process for the child’s care
[Medium];
(3) Directing the health care training of unlicensed caregivers, such as care of a
permanently placed feeding tube [Medium-High];
(4) Ensuring non-mobile children are turned every two hours to increase circulation
and to prevent bedsores or contractures, unless medical orders are to the
contrary. This procedure must be documented in the child’s record [Medium-
High];
(5) Reviewing medical records [Medium];
(6) Contacting other professionals, as needed, for the child’s care [Medium];
(7) On-site visits for nursing assessments and child record reviews, including
compliance with written physician orders [Medium];
(8) Monitoring the implementation of the child’s service plan [Medium]; and
(9) Documenting outcomes for interventions used in the child’s care. [Medium]

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§748.573. What are the requirements for other nursing
personnel for an operation that provides treatment services
to 25 or more children with primary medical needs, or for
an operation in which more than 30% of the children in
care receive treatment services for primary medical needs?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2007

Your nursing personnel must:

(1) Be awake and available at the operation on a 24-hour basis [Medium-High];
(2) Be under the direction of a registered nurse who is licensed to practice in Texas [Medium-
High]; and
(3) Include a licensed vocational nurse or registered nurse. [Medium-High]

§748.575. In what circumstances may a physician or

registered nurse (including an advanced practice registered
nurse) delegate nursing tasks to unlicensed caregivers?
Subchapter E, Personnel
Division 3, Professional Level Service Providers
January 2017

The physician or registered nurse may delegate nursing tasks to unlicensed caregivers only if all
delegation criteria are met for the task to be delegated, including, but not limited to [Medium]:

(1) The nursing task is one that a reasonable and prudent physician or registered
nurse would find is within the scope of sound nursing judgment to delegate
[Medium];

(2) The physician or registered nurse determines that the nursing task can be
properly and safely performed by the unlicensed caregiver without
jeopardizing the child’s welfare [Medium];

(3) The operation employing or contracting with the unlicensed caregivers

develops and follows a protocol, with input from a physician or registered
nurse, for the instruction and training of unlicensed caregivers performing
nursing tasks. The protocol must address [Medium]:

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 (A) An established mechanism for identifying those individuals to whom
nursing tasks may be designated [Medium];

(B) The manner in which the instruction addresses the complexity of the
delegated task [Medium];

(C)The manner in which the unlicensed caregivers demonstrate the

competency of the delegated task [Medium]; and

(D) The mechanism for re-evaluation of the competency [Medium];

(4) The training protocol recognizes that the final decision as to what nursing
tasks can be safely delegated in any specific situation is within the specific
scope of the physician’s or registered nurse’s judgment [Medium]; and

(5) A physician or registered nurse must instruct unlicensed caregivers in

performing nursing tasks. [Medium]

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Division 4, Treatment Director

§748.601. Must I have a treatment director?

Subchapter E, Personnel
Division 4, Treatment Director
January 2007

You must have a treatment director if you provide treatment services to 25 or more children, or
to more than 30% of the children in your care. Your treatment director must be a full-time
employee of your operation. [Medium-High]

§748.603. What are the responsibilities of a treatment

director?
Subchapter E, Personnel
Division 4, Treatment Director
January 2007
(a) The treatment director:
(1) Is responsible for the overall treatment program, including clinical responsibility
for the management of your operation’s therapeutic interventions [Medium];
and
(2) Provides direction and overall management of your treatment program.
[Medium]

(b) When assigning responsibilities to your treatment director, you must ensure that the
treatment director can oversee the treatment of all children receiving treatment
services. [Medium]

§748.605. What qualifications must a treatment director

have?
Subchapter E, Personnel
Division 4, Treatment Director
January 2017

(a) A treatment director that provides or oversees treatment services for children
with intellectual disabilities or children with autism spectrum disorder must be
[Medium]:

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 (1) Licensed as a psychiatrist, psychologist, professional counselor, clinical
social worker, marriage and family therapist, or registered nurse; or
(2) Certified by the Texas Education Agency as an education diagnostician,
have a master’s degree in special education or a human services field,
and have three years of experience working with children with intellectual
disabilities or autism spectrum disorder.
(b) A treatment director that provides or oversees treatment services for children
with primary medical needs must be a physician or a licensed registered nurse.
[Medium]
(c) A treatment director that provides or oversees treatment services for children
with emotional disorders must [Medium]:
(1) Be a psychiatrist or psychologist;
(2) Have a master’s degree in a human services field from an accredited
college or university and three years of experience providing treatment
services for children with an emotional disorder, including one year in a
residential setting; or
(3) Be a licensed master social worker, a licensed clinical social worker, a
licensed professional counselor, or a licensed marriage and family
therapist, and have three years of experience providing treatment
services for children with an emotional disorder, including one year in a
residential setting.

§748.607. If I provide more than one type of treatment

service, can I have one treatment director?
Subchapter E, Personnel
Division 4, Treatment Director
January 2007

Yes, you can have one treatment director if he meets the required qualifications for the most
prevalent treatment services your operation offers. [Medium]

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Technical Assistance
If you provide multiple treatment services, you may want to consider hiring more than one
treatment director. Otherwise, your treatment director must either meet minimum
qualifications for all treatment services that you provide or must meet minimum qualifications
for your most prevalent treatment service. If there is no clear prevalence, you will need to
base the qualifications for this position on the treatment service that your operation intends
or predicts to be the most prevalent (and manage your admissions accordingly), or manage
your admissions based on the qualifications of your treatment director.

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Division 5, Caregivers

§748.681. What minimum qualifications must a caregiver

meet?
Subchapter E, Personnel
Division 5, Caregivers
January 2017

Each employee must meet the following qualifications before you can count the employee in the
child/caregiver ratio [Medium]:

(1) Be at least:
(A) 18 years old if all the children in the group the caregiver serves are under 13 years
old [Medium]; or
(B) 21 years old if at least one child in the group the caregiver serves is 13 years old or
older [Medium-Low];
(2) Have either [Medium]:
(A) A high school diploma or high school equivalency, such as a General Educational
Development (GED) from a program recognized by the Texas Education Agency
(TEA), the Texas Private School Accreditation Commission (TPSAC), or other similar
educational entity from another state; or
(B) Documentation to verify high school equivalency from home schooling. The
documentation must adequately address basic competencies that would be
otherwise met by a high-school diploma or a GED, including basic reading, writing,
and math skills; and

(3) Be able to read, write, and communicate with co-workers, medical personnel,
and other persons necessary to care for the child’s needs. [Medium]

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§748.683. What are the general requirements for
supervising caregivers?
Subchapter E, Personnel
Division 5, Caregivers
January 2007

You must provide oversight of caregivers, including volunteers to:

(1) Protect children’s health, safety, and well-being [Medium]; and

(2) Ensure that assigned duties are performed adequately. [Medium]

§748.685. What responsibilities does a caregiver have

when supervising a child or children?
Subchapter E, Personnel
Division 5, Caregivers
January 2017
(a) The caregiver is responsible for:
(1) Knowing which children they are responsible for [Medium];
(2) Child care services for each assigned child [Medium];
(3) Being aware of and accountable for each child’s on-going activity [High];
(4) Providing the level of supervision necessary to ensure each child’s safety and
well being, including auditory and/or visual awareness of each child’s on-going
activity as appropriate [High]; and
(5) Being able to intervene when necessary to ensure each child’s safety. [High]
(b) In deciding how closely to supervise a child, the caregiver must take into account:
(1) The child’s age [Medium-High];
(2) The child’s individual differences and abilities [Medium-High];
(3) The indoor and outdoor layout of the operation [Medium-High];
(4) Surrounding circumstances, hazards, and risks [Medium-High]; and
(5) The child’s physical, mental, emotional, and social needs. [Medium-High]
(c) Caregivers must:
(1) Be aware of the children’s habits, interests, and any special needs, including any
special supervision needs [Medium-High];
(2) Provide a safe environment [High];

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 (3) Cultivate developmentally appropriate independence in children through planned
but flexible program activities [Medium];
(4) Positively reinforce children’s efforts and accomplishments [Medium];
(5) Ensure continuity of care for children by sharing with incoming caregivers
information about each child’s activities during the previous shift and any verbal or
written information or instructions given by the parent or other professionals
[Medium-High]; and
(6) Implement and follow the children’s service plans. [Medium]
(d) If a child is participating in an unsupervised childhood activity, the caregiver must:
(1) Know where the child will be [Medium-High];
(2) Give the child a specific time to return to the operation or the caregiver’s location
[Medium-High];
(3) Provide, arrange, or confirm an appropriate method of transportation to and from
the activity [Medium-High];
(4) Give the child a way to contact the caregiver in an emergency [Medium-High]; and
(5) Be available to respond if the child contacts the caregiver and needs immediate
assistance. [Medium-High]
(e) Caregivers that supervise a child receiving treatment services for an emotional disorder
must maintain daily progress notes for the child. Caregivers must sign and date each
progress note at the time the progress note is completed. [Medium]
(f) If a child or children are allowed overnight visits with staff, the child(ren) must be
properly fed, lodged, and supervised, and their health, safety, and well-being protected.
The person(s) responsible for the child(ren) must be given information about obtaining
emergency medical care. [Medium-High]

Technical Assistance
Regarding subsection (d), children may also be away from the operation and caregivers in
order to participate in an activity supervised by adults not affiliated with the operation, such
as an event sponsored by a religious youth group, Boy Scout or similar event, school-
sponsored social event (like a dance), etc. The same expectations outlined in subsection (d)
of this rule apply to these types of activities.

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Division 6, Normalcy

§748.701. What is “normalcy”?

Subchapter E, Personnel
Division 6, Normalcy
January 2017

Normalcy is the ability of a child in care to live as normal a life as possible, including engaging in
childhood activities that are suitable for children of the same age, level of maturity, and
developmental level as determined by a reasonable and prudent parent standard.

§748.703. Are children in care required to participate in

childhood activities?
Subchapter E, Personnel
Division 6, Normalcy
January 2017

(a) Children in care must participate in childhood activities, including unsupervised

childhood activities, as much as possible. [Medium-High]
(b) Service planning meetings, and any decision making regarding the child’s need for
supervision, must include discussions on how normalcy for the child can be
achieved, and discussions, if applicable, regarding a child’s refusal to participate in
childhood activities. The child’s service plan must specify whether there are any
restrictions on the child’s participation in these activities and whether the activities
may extend into sleeping hours. [Medium-High]

§748.705. What is the “reasonable and prudent parent

standard”?
Subchapter E, Personnel
Division 6, Normalcy
January 2017

(a) The reasonable and prudent parent standard is the standard of care that a parent of
reasonable judgment, skill, and caution would use to maintain the health, safety, and
best interest of the child and encourage the emotional and social growth and
development of the child.

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 (b) When using the reasonable and prudent parent standard, a person must take into
consideration the following when deciding whether a child may participate in childhood
activities:
(1) The child’s age and level of maturity [Medium];
(2) The child’s cognitive, social, emotional, and physical development level
[Medium];
(3) The child’s behavioral history and ability to safely participate in a proposed
activity [Medium];
(4) The child’s overall abilities [Medium];

(5) Whether the activity is a normal childhood activity for a child of that age and
level of maturity [Medium];
(6) The child’s desires [Medium];
(7) The surrounding circumstances, hazards, and risks of the activity [Medium];
(8) Outside supervision of the activity, if available and appropriate [Medium];
(9) The supervision instructions in the child’s service plan [Medium]; and
(10) The importance of providing the child with the most normal family-like living
experience possible. [Medium]

§748.707. Who makes the decision regarding a foster

child’s participation in childhood activities?
Subchapter E, Personnel
Division 6, Normalcy
January 2017

(a) A General Residential Operation (GRO) must designate one or more persons to
make decisions regarding a child’s participation in childhood activities, except as
otherwise provided in subsection (c) of this section. [Medium-High]
(b) When making decisions regarding a child’s participation in childhood activities, a
designated person must follow the reasonable and prudent parent standard.
[Medium-High]
(c) The service plan may not require the prior approval of the parent before a
designated person may consent to a child’s participation in childhood activities.
However, if the parent provides notice in advance that the child is prohibited from
participating in a specific activity, a designated person must follow the parent’s
decision. [Medium-High]

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§748.709. Are there any restrictions on who can be a
designated person that makes decisions regarding a child’s
participation in childhood activities?
Subchapter E, Personnel
Division 6, Normalcy
January 2017

(a) Caregivers hired after August 31, 2016 may not be a designated person that
makes decisions regarding a child’s participation in childhood activities until the
caregiver completes either a two hour pre-service training regarding normalcy or
the annual training specific to normalcy. [Medium-High]
(b) A designated person that makes decisions regarding a child’s participation in
childhood activities must:
(1) Work at the location where the child resides [Medium-High]; and
(2) Be knowledgeable about the child’s current needs and history. [Medium-
High]
(c) The name of each designated person must be documented on the face sheet of the
child’s record. [Medium]

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Division 7, Contract Staff and Volunteers

§748.721. What are the requirements for a volunteer?

Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
April 2022

(a) You must maintain a personnel record for each volunteer. [Medium-Low]
(b) The personnel record must include a statement signed and dated by the volunteer
indicating the volunteer must immediately report any suspected incident of abuse,
neglect, or exploitation to the Texas Abuse and Neglect Hotline and the operation’s
administrator or administrator’s designee. An internal reporting policy may not require or
allow a person to delegate the person’s responsibility or require a person to obtain
approval to report suspected abuse, neglect, or exploitation. [Medium]

§748.723. Are there additional requirements for a

volunteer or contractor that performs employee functions?
Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
January 2007

(a) A volunteer or contractor that performs any employee function must meet the
same requirements as an employee who performs that function. [Medium]
(b) You must maintain records documenting how these requirements are met.
[Medium]

§748.724. When is a volunteer or contractor who is a part

of another organization subject to my policies and
procedures?
Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
January 2017

(a) A volunteer or contractor who is part of another organization is subject to your

policies and procedures unless that organization provides screening, training, and
supervision to the volunteer/contractor that are adequate to protect the health and

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 safety of children. Before the volunteer/contractor can have contact with children
[Medium-Low]:
(1) The volunteer/contractor must meet the relevant requirements of your policies
and procedures; or
(2) You must confirm the organization provides adequate screening, training, and
supervision.

(b) An organization may be another licensed operation.

§748.725. Can a volunteer or a volunteer’s family take a

child in care for an overnight or weekend visit?
Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
April 2022

(a) Yes, but when a volunteer or a volunteer’s family takes a child who is in care for an
overnight or weekend visit, this is a volunteer activity.
(b) Neither the volunteer nor the family would have to comply with employee or
caregiver requirements, but:
(1) The volunteer or the family would have to meet the relevant background
checks [High]; and
(2) You must get written approval from the parent. [Medium]

§748.729. What must I do when a child in care visits a

volunteer or a volunteer’s family for a day or overnight?
Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
April 2022

If a child has a day or overnight visit with a volunteer or a volunteer’s family, you must ensure
that:
(1) The child is properly supervised, properly fed and hydrated, and provided with
safe housing accommodations, if applicable [Medium-High];
(2) The child’s health, safety, and well-being are protected [Medium-High]; and

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 (3) Prior to the visit, the person responsible for the child during the visit has to
receive the same information that you as a respite child-care services provider
would receive, as specified in §748.4265 of this title (relating to What
information regarding a child must I receive prior to providing respite child-care
services to that child?). [Medium-High]

§748.731. May a person perform community service hours

at my operation?
Subchapter E, Personnel
Division 7, Contract Staff and Volunteers
January 2017

A person may not perform community service hours at your operation. For the purposes of this
rule, community service includes service a person must perform because the person is on
probation, parole, or otherwise required to perform the service through the courts because of
criminal activity. [Medium-High]

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Division 8, Pre-Employment Screening

§748.751. What are the requirements for obtaining and

verifying an applicant's employment history?
Subchapter E, Personnel
Division 8, Pre-Employment Screening

August 2023

(a) Before hiring an applicant for a position, you must:

(1) Obtain in writing the applicant's employment history for the last five years, which
may include [Medium]:

(A) Any history for an applicant who has not continuously been employed during
the last five years; or

(B) A statement that the applicant has no employment history during the last five
years; and

(2) When the applicant's employment history indicates the applicant has been
employed within the last five years, verify whether the applicant was employed as
described in the applicant's employment history by contacting [Medium]:

(A) Each employer included in the five-year employment history; or

(B) The applicant's three most recent employers, at a minimum, if the five-year
employment history includes more than three employers; and

(b) If you hire the applicant, you must maintain documentation of the following in the
applicant's personnel file:

(1) The applicant's employment history required by subsection (a)(1) of this section
[Medium-Low]; and

(2) If the applicant has been employed in the last five years, the results of any contact
with an applicant's previous employers related to employment verification. If you
are unable to contact an employer or obtain the information described in subsection
(a)(2) of this section from an employer [Medium-Low]:

(A) Any refusal by the employer to provide the information; or

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 (B) Your diligent efforts to contact the employer, which must include more than
one attempt to contact an employer who is not permanently unreachable. If
the employer is permanently unreachable, your documentation must include
the reason why you made that determination. Examples of an employer being
unreachable include:

(i) The employer is out of business and there is no alternative contact

information to obtain information from the employer; or

(ii) The employer is deceased.

(c) This rule applies only to applicants who seek employment with your operation on or after
August 9, 2023 [No weight].

Technical Assistance

• Regarding subsection (a)(1), job applications and resumes often capture employment
history. If you collect employment history for the last five years through either of
these methods, you do not need to maintain a separate written record of an
applicant’s employment history.

• Regarding subsection (a)(1), the operation may request a variance for this
requirement if disclosing employment would present a risk to an applicant’s safety.
For example, if an applicant is a survivor of human trafficking or domestic violence
contacting the reference could alert others to the survivor’s location.

• Regarding subsection (b)(2)(B), examples of diligent efforts include calling an

employer on separate days, reaching out via different methods (email, telephone,
virtually), etc.

• The CCR TA Library has additional resources for conducting employment verification.

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§748.753. What are the requirements for completing an
applicant's reference checks?
Subchapter E, Personnel

Division 8, Pre-Employment Screening

August 2023

(a) Before hiring an applicant for a position, you must complete the applicant's reference
checks by:

(1) Obtaining from the applicant the name and contact information of at least two
individuals unrelated to the applicant who can serve as references by answering
questions related to the applicant's suitability to work with or around children
[Medium]; and

(2) Contacting each of the two required references to verify that the applicant is
suitable to work with or around children. You may contact the reference through an
interview or in writing [Medium-High].

(b) For an applicant who is currently or was previously employed in a position responsible for
providing care or services to children within the past five years, at least one of the
reference checks required in subsection (a) of this section must be a current or prior
employer who has supervised or is otherwise familiar with the history and performance of
the applicant in that capacity [Medium].

(c) For any reference check you are unsuccessful in completing as required by subsection (a)
or (b) of this section, you must document:

(1) Any refusal by the reference to provide the information [Medium-Low]; or

(2) Your diligent efforts to contact the reference, which must include more than one
attempt to contact a reference who is not permanently unreachable. If the
reference is permanently unreachable, your documentation must include the reason
why you made that determination. Examples of a reference being unreachable
include [Medium-Low]:

(A) The reference is out of business and there is no alternative contact

information to obtain information from the employer; or

(B) The reference is deceased; and

(3) Your assessment of the applicant's suitability to work with or around children
[Medium-High].

(d) For each person you hire, you must maintain in the employee's personnel file:

(1) Documentation of each reference check that includes [Medium-Low]:

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 (A) The reference's name;

(B) The relation of the reference to the applicant;

(C)The reference's contact information;

(D)The date you completed the check;

(E) Information you obtained from the check, documented as:

(i) A summary of the interview; or

(ii) A copy of the written information provided by the reference; and

(F) If you conducted the check through an interview, the name of the person
who interviewed the reference; and

(2) If you were unsuccessful in completing a reference check, documentation required

by subsection (c) of this section [No weight].

(e) This rule applies only to applicants who seek employment with your operation on or after
August 9, 2023 [No weight].

Technical Assistance
• Regarding subsection (a), when possible, the operation should require and check
professional references from individuals the applicant has actually worked with on a
day-to-day basis for at least six months within the last five years. If the applicant is
unable to produce recent professional references in a setting that provides care or
services for children, the operation may accept and check other professional or
unrelated personal references who are able to answer questions about the applicant’s
suitability to work with or around children.

• Regarding subsection (a), if it is not possible to obtain a professional reference,

personal references should come from a variety of sources and should not be limited
to friends. Neighbors, clergy, or any other member of the applicant’s community who
can provide a description of the applicant’s suitability to work with or around children
are all appropriate sources for providing personal references.

• Regarding subsection (a), when conducting a reference check to verify an applicant’s

suitability to work with or around children, consider gathering information about the
applicant’s:

o Appropriateness to have contact with children; and

o Ability to care for and meet the needs of children.

• While not required, additional resources that may assist in determining suitability for
employment include the publicly accessible Employee Misconduct Registry and Nurse
Aid Registry. Both registries provide information about unlicensed personnel who
commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against:

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Technical Assistance
o Residents and individuals receiving services in Intermediate Care Facilities for
Individuals with an Intellectual Disability licensed by HHSC;
o Adult foster care providers that contract with HHSC;
o Home and community support services agencies licensed by HHSC; or
o Prescribed pediatric extended care centers licensed by HHSC.

The HHSC Employee Misconduct Registry webpage has additional information about
these registries.

• To meet the requirements in subsection (a)(1), a reference’s contact information must

include a working telephone number or valid email address. If an applicant provides
invalid contact information for a reference, you must obtain updated information from
the applicant.

• Regarding subsections (a)(1) and (b), the operation may request a variance for this
requirement if contacting a reference would present a risk to an applicant’s safety. For
example, if an applicant is a survivor of human trafficking or domestic violence
contacting the reference could alert others to the survivor’s location.

• Regarding subsection (b), you are responsible for conducting a reference check with a
child care employer only when the applicant has provided the name of the employer
as one of individuals under subsection (a)(1) during the application process.

• You are considered unsuccessful in completing a reference check for the purposes of
subsection (c) if you are unable to contact a reference or if a reference refuses to
provide the required information. Attempts to contact a reference via a non-working
telephone number or invalid email address do not count as diligent attempts to
contact the reference.

• An individual who verifies employment history as required by §748.751 may also be

utilized as a reference if the individual meets the requirements in subsection (a)(1) or
(b) of this rule.

• The CCR TA Library and Safe Kids Thrive have additional resources for conducting
reference checks.

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Subchapter F, Training and Professional Development

Division 1, Definitions

§748.801. What do certain words and terms mean in this

subchapter?
Subchapter F, Training and Professional Development
Division 1, Definitions
April 2022

The words and terms used in this subchapter have the following meanings:
(1) CPR – Cardiopulmonary resuscitation.
(2) Hours – Clock hours.
(3) Instructor-led training – Training that is characterized by the communication and
interaction that takes place between the student and the instructor. Instructor-led training
does not have to be in person, but it must include an opportunity for the student to
interact with the instructor to obtain clarifications and information beyond the scope of the
training material. For such an opportunity to exist, the instructor must be able to answer
questions, provide feedback on skills practice, provide guidance or information on
additional resources, and proactively interact with students. Examples of this type of
training include classroom training, online distance learning, blended learning, video-
conferencing, or other group learning experiences.
(4) Self-instructional training – Training designed to be used by one individual working alone
and at the individual’s own pace to complete lessons or modules. Lessons or modules
commonly include questions with clear right and wrong answers. An example of this type
of training is web-based training. Self-study training is also a type of self-instructional
training.
(5) Self-study training – Non-standardized training where an individual reads written
materials, watches a training video, or listens to a recording to obtain certain knowledge
that is required for annual training. Self-study training is limited to three hours of annual
training per year. See 748.937(d) of this subchapter (relating to What types of hours or
instruction can be used to complete the annual training requirements?).

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Division 2, Overview of Training and Experience
Requirements

§748.811. What are the training and experience

requirements for a caregiver?
Subchapter F, Training and Professional Development
Division 2, Overview of Training and Experience Requirements
April 2022

(a) A caregiver must complete the following training requirements, unless the caregiver
meets the requirements of an exemption or a waiver for the training that is provided in
this subchapter:

Type of training for When must the training be completed?

caregivers:
(1) Orientation, as required by Prior to having contact with children.
§748.831 of this subchapter
(relating to What is the
orientation requirement for
caregivers and employees?).
(2) Pre-service training, as Varies with the type of training. See §748.863 of this
required by §748.863 of this subchapter.
subchapter (relating to What
are the pre-service training
requirements for a
caregiver?).
(3) First-aid and CPR, as required (A) A caregiver must be certified in CPR prior to being
by §748.911 of this subchapter the only caregiver counted in the child to caregiver ratio;
(relating to Who must have first and
aid and CPR training?)
(B) Each caregiver must be certified in first aid within 90
days of the caregiver’s employment.

(4) Annual training, as required by (A) Within 12 months of employment; and

§748.930 of this subchapter
(relating to What are the annual (B) As further required by §748.935 of this subchapter
training requirements for a (relating to When must an employee or caregiver
caregiver?). complete annual training?) and §748.936 of this
subchapter (relating to When must a caregiver complete
emergency behavior intervention training?).

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 (b) You must ensure that a caregiver who provides care to a child receiving treatment
services meets the pre-service experience requirements specified in §748.861 of this
subchapter (relating to What are the pre-service experience requirements for a
caregiver?).

§748.813. What are the training requirements for an

employee?
Subchapter F, Training and Professional Development
Division 2, Overview of Training and Experience Requirements
April 2022

An employee must complete the following training requirements, unless the employee meets the
requirements of an exemption for the training that is provided in this subchapter:

Type of training for When must the training be completed?

employees
(1) Orientation, as required by Prior to beginning job duties.
§748.831 of this subchapter
(relating to What is the
orientation requirement for
caregivers and employees?).
(2) Pre-service training, as Within 90 days of beginning job duties.
required by §748.864 of this
subchapter (relating to What
are the pre-service training
requirements for an
employee?).
(3) Annual training, as required (A) Within 12 months of employment; and
by §748.931 of this
subchapter (relating to What (B) As further required by §748.935 of this subchapter
are the annual training (relating to When must an employee or caregiver
requirements for an complete annual training?).
employee?).

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Division 3, Orientation

§748.831. What is the orientation requirement for

caregivers and employees?
Subchapter F, Training and Professional Development
Division 3, Orientation
April 2022

(a) Prior to beginning job duties or having contact with children in care, each caregiver or
employee must have orientation that includes [Medium]:
(1) An overview of the relevant and applicable rules of this chapter [Medium];
(2) Your philosophy, organizational structure, policies, and a description of the
services and programs you offer [Medium]; and
(3) The needs and characteristics of children that you serve. [Medium]
(b) You must document the completion of the orientation in the appropriate personnel
record. [Medium-Low]

§748.833. When may a caregiver or employee be exempt

from orientation?
Subchapter F, Training and Professional Development
Division 3, Orientation
April 2022

(a) A person who was a caregiver or employee at your operation during the past 12
months may be exempt from orientation if you meet the following requirements:
(1) You discuss with the person any changes in your services or programs that
have occurred since the person was previously a caregiver or employee
[Medium];
(2) If the person is an employee, you ensure the employee received training
during the past 12 months from your operation on prevention, recognition,
and reporting on child abuse, neglect, and exploitation [Medium];
(3) If the person is acting as a caregiver, you do not allow the person to be the
only caregiver for a group of children before you meet the requirement in
paragraph (1) of this section. [Medium]

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 (b) You must document this discussion and previous training in the person’s
personnel record. [Medium-Low]

Division 4, Pre-Service Experience and Training

§748.861. What are the pre-service experience

requirements for a caregiver?
Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
January 2017

(a) If less than 25 children and less than 30% of your total population of children in
care are receiving treatment services, then there are no pre-service experience
requirements.
(b) If 25 or more children or 30% or more of your total population of children in care
are receiving treatment services, then a caregiver must have 40 hours of
supervised child-care experience in your operation and/or another operation that
provides the same treatment services. Until the caregiver has met this 40-hour
experience requirement, the caregiver [Medium-High]:
(1) May not be assigned as the only caregiver responsible for a group of
children [Medium];
(2) Must be supervised at all times by another caregiver who has already
satisfied the 40-hour experience requirement [Medium]; and
(3) The supervised child-care experience must be documented in the
appropriate personnel record. [Medium]

§748.863. What are the pre-service training requirements

for a caregiver?
Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
April 2022

(a) A caregiver must complete the following applicable types of pre-service training
within the noted time frame:

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 What type of What How many When must the
pre-service caregivers hours of training be
Weight training is must training completed?
required? receive the are
training? required?
[Medium] (1) General pre- (A) All (B) 8 hours (C) At least 4 hours
service training. caregivers. of training before the
caregiver may be
counted in the child
to caregiver ratio,
and the remaining
hours within 30 days
of becoming a
caregiver.
[Medium- (2) (A) (B) 8 hours (C) At least 4 hours
High] Emergency Caregivers of training before the
behavior who care for caregiver may be
intervention children counted in the child
(EBI), if you receiving: to caregiver ratio,
do not allow and the remaining
the use of (i) Only child hours within 90 days
EBI. care services of becoming a
or caregiver.
programmatic
services; or

(ii) Treatment
services for
emotional
disorders,
intellectual
disabilities, or
autism
spectrum
disorder.

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 What type of What How many When must the
pre-service caregivers hours of training be
Weight training is must training completed?
required? receive the are
training? required?
[Medium- (3) EBI, if you (A) (B)(i) 8 (C)(i) At least half of
High] allow the use of Caregivers hours for the hours of training
EBI. who care for caregivers before the caregiver
children who only may be counted in
receiving: care for the child to caregiver
children ratio, and the
(i) Only child described in remaining hours
care services subsection within 90 days of
or (a)(3))A)(i) becoming a
programmatic or this caregiver; and
services; or section; or
(ii) A caregiver may
(ii) Treatment (ii) 16 hours not administer any
services for for caregivers form of EBI before
emotional who care for completing all the
disorders, children required training
intellectual described in hours for EBI,
disabilities, or subsection except for
autism (a)(3)(A)(ii) administering a
spectrum of this short personal
disorder. section. restraint.

[Medium- (4) Safe (A) Caregivers (B) No (C) A caregiver must

High] sleeping. who care for specified complete the
children hours. training before the
younger than 2 caregiver may be
years of age. counted in the child
to caregiver ratio for
children younger
than 2 years of age.
[Medium- (5) (A) Caregivers (B) No (C) A caregiver must
High] Administering who administer specified complete the training
psychotropic psychotropic hours. before administering
medication. medication. a psychotropic
medication.

(b) A caregiver who has not completed all of the pre-service training
requirements in subsection (a) of this section may not be counted in the child
to caregiver ratio unless there is a fully qualified caregiver counted in ratio at
the same time. [Medium-High]

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 (c) A caregiver who cares exclusively for children receiving treatment services
for primary medical needs is exempt from the pre-service EBI training
requirement.

(d) To meet the pre-service training requirements, the training must comply with
the applicable curriculum requirements in Division 5 of this subchapter
(relating to Curriculum Components for Pre-Service Training).

(e) You must document the completion of each training requirement in the
appropriate personnel record [Medium-Low].

Technical Assistance
● Regarding subsections (a) and (b) of this section, “caregiver” refers to a person counted
in the child to caregiver ratio, whose duties include the direct care, supervision,
guidance, and protection of the child, as defined in §748.43(5) of this chapter.
● The Department of Family and Protective Services or your general residential operation
may require additional pre-service training.

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§748.864 What are the pre-service training requirements
for an employee?
Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
April 2022

(a) An employee must complete the following applicable training types and hours within
the noted time frames:

What type Who is required to How many When must

of pre- receive the hours of the training
Weight service training? training be
training is are completed?
required? required?
[Medium] (1) Normalcy. Child care 2 hours (C) Before the
administrators, person can be the
professional level designated person
service providers, that makes
treatment directors, decisions
and case managers. regarding a child
participating in
childhood
activities, or
within 90 days of
beginning job
duties, whichever
occurs earlier.
[Medium] (2) Child care 8 hours Within 90 days of
Emergency administrators, beginning job
behavior professional level duties.
intervention. service providers,
treatment directors,
and case managers
excluding any
employee who is
exclusively assigned
to the care of
children receiving
treatment services
for primary medical
needs.

(b) To meet the pre-service training requirements, the training must comply with
the applicable curriculum requirements in Division 5 of this subchapter
(relating to Curriculum Components for Pre-Service Training). [Medium]

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 (c) You must document the completion of each training requirement in the
appropriate personnel record. [Medium-Low]

Technical Assistance
The Department of Family and Protective Services or your general residential operation may
require additional pre-service training.

§748.865. Can time spent in orientation training count

towards pre-service training?
Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
January 2007

No, the orientation training must be separate from the pre-service training requirement.
[Medium-Low]

Technical Assistance
Orientation is focused on providing new employees with information about your organization
and how it operates. Pre-service training is focused on preparing new employees to do their
job competently. This is the reason that these requirements are separate in the minimum
standards and that orientation may not be counted toward pre-service or annual training
requirements.

§748.867. What caregivers or employees are exempt from

certain pre-service training requirements?
Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
April 2022

(a) A caregiver is exempt from completing the eight hours of general pre-service training
if the caregiver has been employed as a caregiver in a general residential operation
during the past 12 months.
(b) An employee is exempt from completing the two hours of normalcy training if the
employee has:
(1) Been employed by a general residential operation during the past 12 months;
(2) Received training on normalcy during the past 12 months; and

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 (3) Can document that the training was received. [Medium-Low]
(c) A caregiver or an employee is exempt from completing the pre-service training for
emergency behavior intervention if the caregiver or employee:
(1) Has been employed in a general residential operation during the past 12
months;
(2) Has received emergency behavior intervention training during the past 12
months that meets the required curriculum components of the following
applicable rule:
(A)§748.887 of this subchapter (relating to If I do not allow the use of
emergency behavior intervention, what curriculum components must be
included in the pre-service training for emergency behavior
intervention?); or
(B)§748.889 of this subchapter (relating to If I allow the use of
emergency behavior intervention, what curriculum components must be
included in the pre-service training for emergency behavior
intervention?); and
(3) Can demonstrate knowledge and competency of the training material in writing
and, if the general residential operation allows the use of emergency behavior
intervention, in physical techniques.
(d) You must document the exemption factors in the appropriate personnel record.
[Medium-Low]

§748.869. How must pre-service training be conducted?

Subchapter F, Training and Professional Development
Division 4, Pre-Service Experience and Training
April 2022

(a) Instructor-led training and self-instructional training must include:

(1) Specifically stated learning objectives [Medium-Low];

(2) An evaluation or assessment tool to determine whether the person has obtained the
information necessary to meet the stated objectives [Medium]; and
(3) A certificate, letter, or a signed and dated statement of successful completion from
the training source. [Medium-Low]
(b) Pre-service training must be provided by an instructor who [Medium]:
(1) Holds a generally recognized credential; or

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 (2) Possesses documented knowledge or experience relevant to the training the
instructor will provide.
(c) Training on administering psychotropic medication must be instructor-led, as defined in
§748.801(3) of this subchapter (relating to What do certain words and terms mean in this
subchapter?). The instructor must be a health-care professional or pharmacist. [Medium-
High]
(d) Training on emergency behavior intervention must:
(1) Be instructor-led with each instructor certified in a recognized method of
emergency behavior intervention [Medium-High] or otherwise able to document
knowledge of:
(A) Emergency behavior intervention [Medium-High];
(B) The course material [Medium-High];
(C)Methods for delivering the training, including physical techniques for
restraints, if applicable [Medium-High]; and
(D) Methods for evaluating and assessing a participant’s knowledge and
competency of the training material and physical techniques, if applicable
[Medium-High];

(2) Be competency-based [Medium-High]; and

(3) At the end of the training, require each participant to demonstrate

knowledge and competency of the training material:

(A)In writing [Medium-High]; and

(B)If the general residential operation allows the use of behavior

intervention, by demonstrating the physical technique the participant
is allowed to use. [Medium-High]

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Division 5, Curriculum Components for Pre-Service
Training

§748.881. What curriculum components must be included

in the general pre-service training?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

The general pre-service training must include the following curriculum components:

(1) Topics appropriate to the needs of children for whom the caregiver will be
providing care, such as developmental stages of children, fostering children’s self-
esteem, constructive guidance and discipline of children, water safety, strategies
and techniques for monitoring and working with these children, and age-
appropriate activities for the children [Medium];
(2) Measures to prevent, recognize, and report suspected occurrences of child abuse
(including sexual abuse), neglect, and exploitation [Medium-High];
(3) Procedures to follow in emergencies, such as weather-related emergencies, volatile
persons, and severe injury or illness of a child or adult [Medium-High];

(4) Preventing the spread of communicable diseases [Medium-High];

(5) The location and use of fire extinguishers and first-aid equipment [Medium-High];

(6) Trauma-informed care [Medium]; and

(7) Normalcy. [Medium]

§748.882. What curriculum components must be included

in the pre-service training for normalcy?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

The pre-service training for normalcy must include the following curriculum components:

(1) A discussion of the definitions of normalcy and the reasonable and prudent
parent standard [Medium-High];
(2) The developmental stages of children, including a discussion of the cognitive,
social, emotional, and physical development of children [Medium];

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 (3) Age appropriate activities for children, including unsupervised childhood
activities [Medium];

(4) The benefits of childhood activities to a child’s well-being, mental health, and
social, emotional, and developmental growth [Medium];
(5) How to apply the reasonable and prudent parent standard to make decisions
[Medium-High]; and
(6) The child’s and the caregiver’s responsibilities when participating in childhood
activities. [Medium-High]

Technical Assistance
A caregiver’s specific responsibilities for a child that participates in unsupervised activities are
listed at §748.685(d) of this chapter (relating to What responsibilities does a caregiver have
when supervising a child or children?).

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§748.883. What curriculum components must be included
in the pre-service training for safe sleeping?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

The pre-service training for safe sleeping must include the following curriculum components:
(1) Recognizing and preventing shaken baby syndrome and abusive head trauma [Medium-
High];
(2) Understanding safe sleeping practices and preventing sudden infant death syndrome
[Medium-High]; and
(3) Understanding early childhood brain development. [Medium]

§748.885. What curriculum components must be included

in the pre-service training for administering psychotropic
medication?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

The pre-service training for administering psychotropic medication must include the following
curriculum components:
(1) Identification of psychotropic medications [High];
(2) Basic pharmacology (the actions and side effects of, and possible adverse reactions to,
various psychotropic medications) [Medium-High];
(3) Techniques and methods of administering medications [Medium-High];
(4) Who is legally authorized to provide consent for the psychotropic medication [Medium];
and
(5) Any related policies and procedures, including how to document when a medication is
administered. [High]

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 Technical Assistance
The online psychotropic medication training of the Child Protective Services Division of
DFPS satisfies this general pre-service training requirement as long as caregivers also get
instructor-led training that covers:
● Policies and procedures on administering medication; and
● Who may consent to using psychotropic medications for children who are not in the
conservatorship of DFPS.

§748.887. If I do not allow the use of emergency behavior

intervention, what curriculum components must be
included in the pre-service training for emergency behavior
intervention?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

If you do not allow the use of emergency behavior intervention, the pre-service training
curriculum regarding emergency behavior intervention must focus on early identification of
potential problem behaviors and strategies and techniques for less restrictive interventions,
including the following curriculum components [Medium]:

(1) Developing and maintaining an environment that supports positive and

constructive behaviors [Medium];

(2) The causes of behaviors potentially harmful to children, including aspects of

the environment [Medium];

(3) Early signs of behaviors that may become dangerous to the child or others
[Medium-High];

(4) Strategies and techniques the child can use to avoid harmful behaviors
[Medium-High];

(5) Teaching a child to use the strategies and techniques of your operation’s de-
escalation protocols to avoid harmful behavior, and supporting the child’s
efforts to progress into a state of self-control [Medium-High];

(6) Less restrictive strategies caregivers can use to intervene in potentially

harmful behaviors [Medium-High];

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 (7) Less restrictive strategies caregivers can use to engage a child and de-
escalate a situation [Medium];

(8) Addressing circumstances when all de-escalation strategies fail [Medium]; and

(9) The risks associated with the use of prone or supine restraints, including
positional, compression, or restraint asphyxia. [Medium-High]

§748.889. If I allow the use of emergency behavior

intervention, what curriculum components must be
included in the pre-service training for emergency behavior
intervention?
Subchapter F, Training and Professional Development
Division 5, Curriculum Components for Pre-Service Training
April 2022

(a) If you allow the use of emergency behavior intervention, at least 75 percent of the pre-
service training for emergency behavior intervention must focus on early identification of
potential problem behaviors and strategies and techniques of less restrictive interventions,
including the curriculum components listed in §748.887 of this division (relating to If I do
not allow the use of emergency behavior intervention, what curriculum components must
be included in the pre-service training for emergency behavior intervention?). [Medium-
High]
(b) The training does not have to address the use of any emergency behavior intervention
that your policies do not allow.
(c) The other 25 percent of the pre-service training for emergency behavior intervention must
include the following components:
(1) Different roles and responsibilities of caregivers qualified in emergency behavior
intervention versus employees or volunteers who are not qualified in emergency
behavior intervention [Medium-High];
(2) Escape and evasion techniques to prevent harm to the child and caregiver without
requiring the use of an emergency behavior intervention [Medium-High];
(3) Safe implementation of the restraints and seclusion techniques and procedures that
are appropriate for the age and weight of children served and permitted by the
rules in this chapter and your policies and procedures [Medium-High];
(4) The physiological impact of emergency behavior intervention [Medium-High];
(5) The psychological impact of emergency behavior intervention, such as flashbacks
from prior abuse [Medium-High];

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 (6) How to adequately monitor the child during the administration of an emergency
behavior intervention to prevent injury or death [High];
(7) Monitoring physical signs of distress and obtaining medical assistance [High];
(8) Health risks for children associated with the use of specific techniques and
procedures [Medium-High];
(9) Drawings, photographs, or videos of each personal or mechanical restraint
permitted by your policy; for mechanical restraints, this must include the
manufacturer’s complete specifications for each device permitted, an explanation of
modifications to the manufacturer’s specifications, and a copy of the approval of the
modification from a licensed psychiatrist [Medium-High]; and
(10) Strategies for re-integration of children into the environment after the use of
emergency behavior intervention, including the debriefing of caregivers and the
child. [Medium]

Division 6, First-Aid and CPR Certification

§748.911. Who must have first-aid and CPR training?

Subchapter F, Training and Professional Development
Division 6, First-Aid and CPR Certification
April 2022

(a) Each caregiver must have a current certificate of training with an expiration or renewal
date in first-aid with rescue breathing and choking. This training may be through
instructor-led training or self-instructional training. [High]

(b) At least one caregiver counted in the child to caregiver ratio must have a current
certificate of training with an expiration or renewal date in:

(1) Pediatric CPR, if your operation only serves children under 12 years of age
[Medium-High];

(2) Adult CPR, if your operation only serves children 12 years of age and older
[Medium-High]; or

(3) Pediatric and Adult CPR, if your operation serves children between the ages of birth
through 17 You may meet this requirement if:

(A) One caregiver counted in the child to caregiver ratio has a current
certificate of training in both types of CPR; or

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 (B) One caregiver counted in the child to caregiver ratio has a current
certificate of training in Pediatric CPR, and another caregiver counted in
the child to caregiver ratio has a current certificate of training in Adult
CPR. [Medium-High]

(c) Each caregiver must:

(1) Be certified in first-aid within 90 days of employment [Medium-High]; and

(2) Be certified in CPR and able to respond to emergencies prior to being the
only caregiver counted in the child to caregiver ratio. [Medium-High]

Technical Assistance
Regarding subsection (b)(3) of this section, a caregiver may take a class that combines
Pediatric and Adult CPR to meet the requirement, as long as the class meets the
requirements in §748.913 of this division.

§748.913. What are the requirements for CPR training?

Subchapter F, Training and Professional Development
Division 6, First-Aid and CPR Certification
April 2022

CPR training:
(1) Must adhere to the guidelines for CPR for a layperson established by the American
Heart Association, and consist of a curriculum that includes use of a CPR manikin and
both written and hands-on skill-based instruction, practice, and testing [Medium-
High]; and
(2) May be provided through blended learning that utilizes online technology, including
self-instructional training, as long as the learning meets the criteria in paragraph (1) of
this section.

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§748.915. What documentation must I maintain for first-
aid and CPR certifications?
Subchapter F, Training and Professional Development
Division 6, First-Aid and CPR Certification
April 2022

(a) You must document the caregiver’s completion of each training requirement in the
appropriate personnel record. The documentation may be a certificate, letter, or a signed
and dated statement of successful completion from the training source. You may maintain
a photocopy of the original first-aid or CPR certificate or letter in the personnel record, as
long as the caregiver can provide an original document upon request by Licensing.
[Medium-Low]

(b) The documentation must include:

(1) The participant’s name [Medium-Low];

(2) Date of the training [Medium-Low];

(3) Title of subject of the training [Medium-Low];

(4) The trainer’s name and qualifications [Medium-Low];

(5) The expiration date of the certification as determined by the organization providing
the certification [Medium-Low]; and

(6) Length of the training in hours. [Medium-Low]

Division 7, Annual Training

§748.930. What are the annual training requirements for a

caregiver?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

(a) A caregiver must complete the number of annual training hours described in the following
chart:

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 Weight A caregiver who cares for children Must complete the
at: following number of
annual training
hours:
[Medium-High] (1) An operation that has: 20 hours.
(A) Less than 25 children in care who
are receiving treatment services;
and
(B) Less than 30% of their total
population of children in care are
receiving treatment services.
[Medium-High] (2) An operation that has: 50 hours.
(A) 25 or more children in care that
are receiving treatment services;
or
(B) 30% or more of their total
population of children in care are
receiving treatment services.
[Medium-High] (3) A cottage home 20 hours.

(b) For the annual training hours described in subsection (a) of this section, each
caregiver must complete the following specific types of training and hours:

Weight Type of Training Hours

[Medium-High] (1) Emergency Behavior (A) 4 hours, every 6 months, for a
Intervention. caregiver identified in subsection
(a)(1) or (a)(2) of this section;
(B) 4 hours for a caregiver identified in
subsection (a)(3) of this section; or
(C) No hours for a caregiver who cares
exclusively for children receiving
treatment services for primary
medical needs.
[Medium-High] (2) Trauma Informed 2 hours.
Care.
[Medium-High] (3) Normalcy. 1 hour.
[Medium-High] (4) Transportation Safety, 2 hours.
if the caregiver
transports a child in
care who chronological
or developmental age is
younger than 9 years
old.

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 Weight Type of Training Hours
[Medium-High] (5) Administering No specified hours.
Psychotropic
Medication, if the
caregiver administers
psychotropic
medication.
(c) To meet the mandated annual training requirements in subsection (b) of this section,
the training must comply with the applicable curriculum requirements in Division 8 of
this subchapter (relating to Topics and Curriculum Components for Annual Training.
(d) After completing the type of annual training required in subsection (b) of this
section, any remaining number of annual training hours must be in areas appropriate
to the needs of children for whom the caregiver provides care, as required by
§748.943 of this subchapter (relating to What areas or topics are appropriate for
annual training?).

Technical Assistance
● Regarding subsections (a) and (b) of this section, “caregiver” refers to a person counted
in the child to caregiver ratio whose duties include the direct care, supervision,
guidance, and protection of the child, as defined in §748.43(5) of this chapter.
● The Department of Family and Protective Services or your general residential operation
may require additional annual training.

§748.931. What are the annual training requirements for

an employee?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

(a) Each type of employee in the chart must complete the following number of annual training
hours:

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 Weight Type of Employee Hours of Annual Training
[Medium] (1) Child-care 20 hours.
administrators,
professional level
service providers,
treatment directors, and
case managers who do
not hold a relevant
professional license.
[Medium] (2) Child-care 15 hours.
administrators,
professional level
service providers,
treatment directors, and
case managers who
hold a relevant
professional license.
(b) For the annual training requirements in subsection (a)(1) of this section, each
employee must complete the following specific types of training and hours:

Weight Type of Training Hours

[Medium-High] (1) Trauma Informed 2 hours.
Care.
[Medium-High] (2) Normalcy. 1 hour.
[Medium-High] (3) Transportation Safety, 2 hours.
if the employee transports
a child in care whose
chronological or
developmental age is
younger than 9 years old.
(c) For the annual training hours described in subsection (a)(2) of this section, each
employee must complete the following specific types of training and hours:

Weight Type of Training Hours

[Medium-High] (1) Normalcy, if the 1 hour.
employee is a
designated person who
makes decisions
regarding any child’s
participation in
childhood activities.

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 Weight Type of Training Hours
[Medium-High] (2) Transportation Safety, 2 hours.
if the employee
transports a child in
care whose
chronological or
developmental age is
younger than 9 years
old.
(d) An employee described in (a)(2) of this section may use annual training hours that
the employee completes to maintain a relevant professional license, if the hours
include the necessary components of subsection (c) of this section or completes the
components separately.
(e) There are no annual training requirements for emergency behavior intervention.
However, the employee must be retrained whenever there is a substantial change in
techniques, types of interventions, or agency policies for emergency behavior
intervention. [Medium-High]

Technical Assistance
Your general residential operation may require additional annual training.

§748.935. When must an employee or caregiver complete

the annual training?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

(a) With the exception of emergency behavior intervention training, each person must
complete the annual training:
(1) Within 12 months from the when you hire the person [Medium]; and
(2) During each subsequent 12-month period after the anniversary date of hire.
[Medium]

(b) Alternately, you have the option of prorating the person’s annual training
requirements from the date of hire to the end of the calendar year or the end of
the operation’s fiscal year and then beginning a new 12-month period that
coincides with the calendar or fiscal year.

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 (c) Whether you use subsection (a) or (b) of this section as your method for
completing annual training requirements, you must use the method consistently
throughout your operation. [Medium-Low]

§748.936. When must a caregiver complete emergency

behavior intervention training?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

Each caregiver must complete emergency behavior intervention training within:

(1) Six months from the date that the caregiver last received the training, if the
caregiver cares for children at an operation where children receive treatment services
[Medium-High]; or
(2) 12 months from the date the caregiver last received the training, if the caregiver cares
for children in a cottage home. [Medium-High]

§748.937. What types of hours or instruction can be used

to complete the annual training requirements?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

(a) If the training complies with the other rules in this division (relating to Annual Training),
annual training may include hours or Continuing Education Units earned through:

(1) Workshops or courses offered by local school districts, colleges or universities, or

Licensing;

(2) Conferences or seminars;

(3) Instructor-led training, as defined in §748.801(3) of this subchapter (relating to

What do certain words and terms mean in this subchapter?);

(4) Self-instructional training, as defined at §748.801(4) of this subchapter;

(5) Planned learning opportunities provided by child-care associations or Licensing;

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 (6) Planned learning opportunities provided by a professional contract service
provider, child-care administrator, professional level service provider, treatment
director, or caregiver who meets minimum qualifications in the rules of this
chapter; or

(7) Completed college courses for which a passing grade is earned, with three college
credit hours being equivalent to 50 clock hours of required training. College
courses do not substitute for required CPR or first-aid certification or required
annual training on emergency behavior intervention or psychotropic medication.

(b) For annual training hours, you may count:

(1) The hours of annual training that a person received at another residential child-
care operation, if the person [Medium]:

(A) Received the training within the time period you are using to calculate
the person’s annual training; and

(B) Provides documentation of the training;

(2) First-aid and CPR;

(3) Any hours of pre-service training that the person earned in addition to the
required pre-service hours, although you may not carry over more than 15 hours
of a person’s pre-service training hours for use as annual training hours during
the upcoming year [Medium];

(4) Half of the hours spent developing initial training curriculum that is relevant to the
population of children served. No additional credit hours for training curriculum
development are permitted for repeated training sessions [Medium]; and

(5) One-fourth of the hours spent updating and making revisions to training
curriculum that is relevant to the population of children served. [Medium]

(c) For annual training hours, you may not count:

(1) Orientation training [Medium-Low];
(2) Required pre-service training [Medium-Low];
(3) The hours involved in case staffings and conferences with the supervisor [Medium-
Low]; or
(4) The hours presenting training to others. [Medium-Low]

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 (d) No more than 80 percent of the required annual training hours may come from self-
instructional training, as defined at §748.801(4) of this subchapter. No more than three of
those self-instructional hours may come from self-study training, as defined at
§748.801(5) of this subchapter. [Medium-Low]
(e) If a person earns more than the minimum number of annual training hours required
during a particular year, the person can carry over to the next year a maximum of 15
annual training hours. [Medium-Low]

Technical Assistance
Here are two examples to clarify (b)(3): (1) if a person completes a total of 35 hours of pre-
service training and is required to complete a total of 18 hours of pre-service training, then
that person may only carry over a maximum of 15 of the hours toward annual training
requirements even though the person completed 17 extra hours of non-required, pre-service
training; and (2) if a person completes a total of 35 hours of pre-service training and is
required to complete a total of 26 hours of pre-service training, then that person may only
carry over 9 hours toward annual training requirements because the person completed 9
extra hours of non-required, pre-service training.

§748.939. Does Licensing approve training resources or

trainers for annual training hours?
Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

We do not approve or endorse training resources or trainers for training hours.

§748.941. How must annual training be conducted?

Subchapter F, Training and Professional Development
Division 7, Annual Training
April 2022

(a) Instructor-led training and self-instructional training, excluding self-study

training, must include:
(1) Specifically stated learning objectives [Medium-Low];

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 (2) A curriculum that includes experiential or applied activities [Medium-
Low];
(3) An evaluation or assessment tool to determine whether the person has
obtained the information necessary to meet the stated objectives
[Medium]; and
(4) A certificate, letter, or a signed and dated statement of successful
completion from the training source. [Medium-Low]
(b) Training on emergency behavior intervention and administering psychotropic
medication must be instructor-led, as defined in §748.801(3) of this subchapter
(relating to What do certain words and terms mean in this subchapter?).
[Medium]
(c) Training on emergency behavior intervention must:
(1) Be led by an instructor who is certified in a recognized method of
emergency behavior intervention or otherwise able to document
knowledge of [Medium-High]:
(A)Emergency behavior intervention [Medium-High];
(B)The course material [Medium-High];
(C)Methods for delivering the training, including physical techniques
for restraints, if applicable [Medium-High]; and
(D)The methods for evaluating and assessing a participant’s
knowledge and competency of the training material and physical
techniques, if applicable [Medium-High];
(2) Be competency-based [Medium-High]; and
(3) At the end of the training, require each participant to demonstrate
knowledge and competency of the training material:
(A)In writing [Medium-High]; and
(B)If the general residential operation allows the use of emergency
behavior intervention, by demonstrating the physical techniques
that the participant may use [Medium-High].
(d) A health-care professional or a pharmacist must lead the training in
administering psychotropic medication. The trainer must assess each
participant after the training to ensure that the participant has learned the
course content. [Medium-High]
(e) Training on transportation safety must be instructor led and provided by
[Medium-High]:

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 (1) A training provider registered with the Texas Early Care and Education
Career Development System’s Texas Trainer Registry, maintained by the
Texas Head Start Collaboration Office;
(2) An instructor who teaches early childhood development or another
relevant course at a secondary school or institution of higher education
accredited by a recognized accrediting agency;
(3) An employee of a state agency with relevant expertise;
(4) A physician, psychologist, licensed professional counselor, social worker,
or registered nurse;
(5) A person who holds a generally recognized credential or possesses
documented knowledge relevant to the training the person will provide;
or
(6) A person who has at least two years of experience working in child
development, a child development program, early childhood education, a
childhood education program, or a Head Start or Early Head Start
program and:
(A)Has been awarded a Child Development Associate Credential; or

(B)Holds at least an Associate’s Degree in child development, early

childhood education, or a related field.

Technical Assistance
As noted in §748.939, Licensing does not approve or endorse trainers.

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Division 8, Topics and Curriculum Components for Annual
Training

§748.943. What areas or topics are appropriate for annual

training?
Subchapter F, Training and Professional Development
Division 8, Topics and Curriculum Components for Annual Training
April 2022

(a) Other than the mandated topics, annual training for caregivers must be in areas appropriate
to the needs of children for whom the operation or employee will be providing care, which may
include [Medium]:

(1) Developmental stages of children;

(2) Constructive guidance and discipline of children;
(3) Fostering children’s self-esteem;
(4) Positive interaction with children;
(5) Strategies and techniques for working with the population of children served;
(6) Supervision and safety practices for children in care;
(7) Preventing the spread of communicable diseases;
(8) Water safety;
(9) Administration of medication;
(10)Medical-related training to help children receiving treatment services for primary medical
needs;
(11)Helping children experience grief or loss;
(12)Prevention, recognition, and reporting of child abuse, neglect, and exploitation; or
(13)Safe sleeping as specified in §748.883 of this subchapter (relating to What curriculum
components must be included in the additional general pre-service training for safe
sleeping?).

(b) Other than mandated topics, annual training for employees must be in areas appropriate to
the needs of children for whom the general residential operation provides care, which may
include [Medium]:

(1) The areas listed in subsection (a) of this section; and

(2) Emergency behavior intervention.

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Technical Assistance
● A person should attempt to attend trainings in new topic areas every year or attend
topics where the person believes there is a need for improvement or need for additional
knowledge. A person should avoid attending the same training every year, unless there
is a specific need for information regarding that topic.
● Examples of annual training topics:
o Helping children cope with separation, such as from parents, family, and
placement;
o Helping or preparing children for re-integration into a family, community, or
subsequent placement;
o Stages of child development, including normal behavioral reactions to stress
at the various ages of children served by the program;
o Healthy personal boundaries and professional relationship boundaries;
o Protecting self and others from false allegations;
o Training to perform special tasks such as the care of gastric tubes or lifeguard
certification training, if applicable;
o For a caregiver who provides care to children receiving treatment services for
emotional disorders, training on cognitive distortions and how they apply to
the children; or
o Special needs of children in care, which may include areas such as sexualized
behavior, trauma, medical needs, and/or Autism Spectrum Disorder.

§748.944. What curriculum components must be included

in the annual training for normalcy?
Subchapter F, Training and Professional Development
Division 8, Topics and Curriculum Components for Annual Training
April 2022

(a) The annual training for normalcy must include the curriculum components covered in
the pre-service training for normalcy, see §748.882 of this subchapter (relating to
What curriculum components must be included in the pre-service training for
normalcy?). [Medium-High]

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 (b) Subsequent annual training for normalcy should include curriculum that further
develops and refines an employee’s knowledge and understanding of normalcy,
including how to implement normalcy. [Medium]

§748.945. What curriculum components must be included

in the annual training for administering psychotropic
medication?
Subchapter F, Training and Professional Development
Division 8, Topics and Curriculum Components for Annual Training
April 2022

The annual training for administering psychotropic medication must include the curriculum
components identified in §748.885 of this subchapter (relating to What curriculum components
must be included in the pre-service training for administering psychotropic medication?).

Technical Assistance
● The online psychotropic medication training for the Child Protective Services Division of
DFPS satisfies this annual training requirement as long as caregivers also get instructor-
led training that covers:
o Policies and procedures on administering medication; and
o Who may consent to using psychotropic medications for children who are not
in the conservatorship of DFPS.

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§748.947. What curriculum components must be included
in the annual training for emergency behavior
intervention?
Subchapter F, Training and Professional Development
Division 8, Topics and Curriculum Components for Annual Training
April 2022

(a) The annual training for emergency behavior intervention must include curriculum
components that:
(1) Reinforce basic principles covered in the pre-service training identified in
§748.887 of this subchapter (relating to If I do not allow the use of
emergency behavior intervention, what curriculum components must be
included in the pre-service training for emergency behavior intervention?)
and §748.889 of this subchapter (relating to If I allow the use of
emergency behavior intervention, what curriculum components must be
included in the pre-service training for emergency behavior intervention?)
[Medium-High]; and
(2) Develop and refine the caregiver’s skills. [Medium-High]
(b) You may determine the content of the training based on your evaluation of your
emergency behavior interventions.
(c) The training may repeat pre-service training components, including training in the
proper use and implementation of emergency behavior intervention.

Technical Assistance
Annual emergency behavior intervention training is not intended to be an exact replica of
pre-service emergency behavior intervention training. While some review of previous content
may be needed to ensure that caregivers retain necessary skills, you are expected and
encouraged to use your emergency behavior intervention data to craft annual training that
can most effectively improve the use of de-escalation techniques and emergency behavior
interventions at your operation. This must include techniques caregivers can use to
proactively avoid crisis situations and any necessary actions once all de-escalation attempts
have failed.

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§748.949. What documentation must I maintain for annual
training?
Subchapter F, Training and Professional Development
Division 8, Topics and Curriculum Components for Annual Training
September 2010

(a) You must keep documentation verifying completion of annual training in the
appropriate personnel record. The documentation may be a certificate, letter, or a
signed and dated statement of successful completion from the training source. The
documentation may also be a transcript from an accredited college or university.
[Medium-Low]
(b) The documentation for training other than college courses must include the following
information:
(1) The participant’s name [Medium-Low];
(2) Date of the training [Medium-Low];
(3) Title or subject of the training [Medium-Low];
(4) The trainer’s name and qualifications, or the source of the training for self-
instructional training [Medium-Low]; and
(5) Length of the training in hours. [Medium-Low]

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Subchapter G, Child/Caregiver Ratios

§748.1001. What is the child/caregiver ratio?

Subchapter G, Child/Caregiver Ratios
January 2007

The child/caregiver ratio is the maximum number of children for whom one caregiver can be
responsible.

§748.1003. For purposes of the child/caregiver ratio, how

many children can a single caregiver care for during the
children’s waking hours?
Subchapter G, Child/Caregiver Ratios
January 2017

(a) The number of children that a single caregiver may care for during waking hours
depends on the ages and treatment service needs of the children in the group. A
single caregiver may care for five children if at least one child in the group requires
treatment services, or eight children if none of the children in the group require
treatment services. Children younger than five years old count as two children.
[Medium-High]
(b) You may separate children into groups based on age and/or treatment services in
order to vary the child/caregiver ratio required for each group, as long as [Medium]:
(1) The groups remain easily distinguishable and separated, such as by cottage or
unit; and
(2) The child/caregiver ratio is re-calculated any time groups intermingle, such as
on a field trip or in the dining room.
(c) A cottage home may be out of ratio during waking hours for short periods to enable
a normal home-like routine as long as the care and supervision needs of the
children continue to be met. Staff or other caregivers must be on the premises and
available to respond in an emergency. These additional staff or caregivers must be
specifically addressed in the written professional staffing plan. [Medium]
(d) A child does not count in the child/caregiver ratio while participating in an approved
unsupervised childhood activity.

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 Technical Assistance
Examples of how to calculate ratio:
Children in the group are 4, 6, 7, 8, 9, and 11 years old. None of the children require
treatment services, so the ratio is 1:8. Even though the 4-year-old counts as two children,
only one staff person is needed.

If you added another 4-year-old to this group, two staff would be needed:

● 4-year-old counts as 2 children

● 4-year-old counts as 2 children
● 6-year-old counts as 1 child
● 7-year-old counts as 1 child
● 7-year-old counts as 1 child
● 9-year-old counts as 1 child
● 11-year-old counts as 1 child

This is a total of 9 children, so a second caregiver is needed to comply with the 1:8 ratio.

Children in the group are 4, 6, 7, 8, and 9 years old. One of the children requires
treatment services, so the ratio is 1:5. Since the 4-year-old counts as two children, two
staff are needed.

A group of children is determined largely by the layout of the building and/or campus. For
example, the children in a cottage home are counted as one group. Since building structures
vary greatly, each facility is assessed on a case-by-case basis.

§748.1005. Can child/caregiver ratios be averaged on an

operation-wide basis?
Subchapter G, Child/Caregiver Ratios
September 2010

Each group of children must have sufficient caregivers to meet the required child/caregiver ratio
for that group of children. A person may not be counted in the ratio for a group of children if he
is caring for children outside the group or working in an administrative capacity. [Medium-High]

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§748.1007. For purposes of the child/caregiver ratio, how
many children can a single caregiver care for when children
are asleep at night?
Subchapter G, Child/Caregiver Ratios
September 2010

(a) The number of children that a single caregiver may care for during night-time
sleeping hours depends on whether the caregiver stays awake or sleeps during
these hours and on the ages and treatment service needs of the children in
the group. Children younger than five years old count as two children.
[Medium-High]
(b) If the caregiver stays awake, the caregiver may care for:
(1) 15 children if at least one child in the group requires treatment services
[Medium-High]; or
(2) 24 children if none of the children in the group require treatment
services. [Medium-High]
(c) If the caregiver sleeps, the caregiver may care for:
(1) 10 children if at least one child in the group requires treatment services
[Medium-High]; or
(2) 16 children if none of the children in the group require treatment services.
[Medium-High]
(d) You may separate children into groups based on age and/or treatment services in order
to vary the child/caregiver ratio required for each group, as long as [Medium]:
(1) The groups remain easily distinguishable and separated, such as by cottage or
unit; and
(2) The child/caregiver ratio is re-calculated any time groups intermingle, such as on
a field trip.

(e) A cottage home may be out of ratio during night-time sleeping hours for short
periods to enable a normal home-like routine as long as the care and supervision
needs of the children continue to be met. Staff or other caregivers must be on the
premises and available to respond in an emergency. These additional staff or
caregivers must be specifically addressed in the written professional staffing plan.
[Medium]

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 Technical Assistance
Here is a chart depicting the night-time sleeping ratios:

Supervising Staff: No treatment services Treatment Services

Awake 1:24 1:15

Asleep 1:16 1:10

HOWEVER, remember that children younger than five years old always count as two
children.

§748.1009. How many caregivers must I employ?

Subchapter G, Child/Caregiver Ratios
January 2017

You must employ an adequate number of qualified caregivers to meet the needs of children,
taking into account each child’s age, medical, physical, and mental condition and other factors
that affect the amount of supervision the child requires, including enough caregivers to meet
[High]:
(1) Child/caregiver ratios [High]; and
(2) All of their responsibilities required in §748.685 of this title (relating to What
responsibilities does a caregiver have when supervising a child or children?). [High]

§748.1011. What employees can be counted as a caregiver

in the child/caregiver ratio?
Subchapter G, Child/Caregiver Ratios
January 2007

The child/caregiver ratio only includes qualified caregivers who are working directly with a child
or group of children. [Medium-High]

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§748.1013. How does a caregiver care for a child needing
constant supervision during sleeping hours?
Subchapter G, Child/Caregiver Ratios
January 2017

(a) A caregiver must always be awake when caring for a child needing constant
supervision, such as a medically fragile child or a child that is an immediate
danger to self or others. [High]
(b) To facilitate continuous care for a child, the caregiver may move a child to a
location where the caregiver can directly and continuously supervise a child until
there is no longer an immediate danger to self or others. The caregiver must
provide comfortable sleeping arrangements for the child. [Low]

§748.1015. How does the child/caregiver ratio apply if I

provide care for both children in care and children of
caregivers, or for both children and adult residents?
Subchapter G, Child/Caregiver Ratios
January 2007

(a) The child/caregiver ratio applies to the children of caregivers who are
present with children in care. [Medium-High]
(b) For both children and adult residents, you must maintain the ratio as
outlined in §748.1935 of this title (relating to How does the child/caregiver
ratio apply if I provide care to both children and adults?). [Medium-High]

§748.1017. How does the child/caregiver ratio apply to

activities that occur away from my operation?
Subchapter G, Child/Caregiver Ratios
January 2007

(a) The child/caregiver ratio applies to activities sponsored or conducted by the

operation, including field trips, higher risk recreational activities, and
appointments that occur away from the operation. [Medium-High]

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 (b) You must have additional caregivers to meet the special needs of children when
there are activities away from your operation, for example a non-ambulatory
child. [Medium-High]

§748.1019. What are the supervision requirements for a

transitional living program?
Subchapter G, Child/Caregiver Ratios
January 2007

A caregiver counted in the child/caregiver ratio who is responsible for supervising children of the
same gender in a transitional living program must:

(1) Reside in or within close physical proximity of the children’s living quarters [Medium];
(2) Be onsite at the operation during times when children are awake, but the caregiver is not
physically present with the children [Medium];
(3) Be physically available to the children at all times [Medium-High];

(4) Be capable of responding quickly in an emergency [Medium-High]; and

(5) Be capable of monitoring the comings and goings of the children in the program.
[Medium]

Technical Assistance
In this rule, “same gender” means that the children and young adults in care are all the same
gender. This language is not related to the gender of the caregiver. See §748.1023 for
expectations regarding children of both genders sharing living quarters.

§748.1021. When does a child who is in a transitional living

program not need supervision?
Subchapter G, Child/Caregiver Ratios
January 2017

(a) The child must be 16 years old or older. [Medium]

(b) You must evaluate each child in a transitional living program to determine whether
the child needs supervision. The evaluation must [Medium]:
(1) Include a written plan defining the periods of time the child may be left
unsupervised [Medium-Low];

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 (2) Include a written plan for addressing behavioral problems that a child may
have while in the transitional living program [Medium-Low]; and
(3) Identify how the child may contact the caregivers when caregivers are not
physically present with the child, such as being available to the child by
telephone or other means of contact. [Medium]

(c) The child’s service planning team must approve the evaluation. [Medium-Low]
(d) You must document the evaluation of the child and the approval in the child’s record. You
must review and update the evaluation during the child’s service planning meetings.
[Medium-Low]

§748.1023. Is my operation permitted to have a

transitional living program with living quarters, a cottage,
or a house with both male and female residents?
Subchapter G, Child/Caregiver Ratios
January 2007

You must not have living quarters, a cottage, or a house with both male and female residents,
unless caregivers are always present when children are at the living quarters, cottage, or house
of the transitional living program. [Medium-High]

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Subchapter H, Child Rights

§748.1101. What rights does a child in care have?

Subchapter H, Child Rights
January 2017

(a) A child’s rights are cumulative of any other rights granted by law or other Licensing rules.
[Medium-Low]
(b) The following categories include the child’s rights that you must adhere to:
(1) Safety and care, including:
(A) The right to good care and treatment that meets the child’s needs in the
most family-like setting possible [Medium-High];
(B) The right to be free from abuse, neglect, and exploitation [High]; and
(C) The right to fair treatment [Medium-High];
(2) Family contacts, including the right to maintain regular contact with the child’s
parents and siblings, unless restrictions are necessary because of the child’s best
interest, the decision of an appropriate professional, or a court order [Medium];
(3) Living a normal life, including:
(A) The right to be able to communicate in a language or any other means
that is understandable to the child at admission or within a reasonable time
after an emergency admission, if applicable, such as having a plan for an
interpreter, having at least one person at the operation at all times who can
communicate with the child in the child’s own language, or other means to
communicate with the child in the child’s own language [Medium];
(B) The right to receive educational services appropriate to the child’s age and
developmental level [Medium-Low];
(C) The right to have the child’s religious needs met [Medium-High];
(D) The right to participate in childhood activities, including unsupervised
childhood activities away from the operation and the caregivers, that are
appropriate for the child’s age, maturity, and developmental level [Medium];
(E) The right to privacy, including sending and receiving unopened mail,
making and receiving phone calls, keeping a personal journal, and having
visitors, unless the child’s best interest, appropriate professionals, or court
order necessitates restrictions [Medium];

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 (F) The right to personal care, hygiene, and grooming equipment and supplies
and training in how to use them [Medium];
(G) The right to have comfortable clothing, which is suitable to the child’s age
and size and similar to the clothing of other children in the community.
Teenagers should have reasonable opportunities to select the clothing
[Medium];
(H) The right to clothing that protects the child against the weather [Medium-
High];
(I) The right to have personal items in the child’s room and to get additional
items within reasonable limits [Medium-Low];
(J) The right to personal space in the child’s bedroom to store the child’s
clothes and belongings [Medium-Low];
(K) The right to be informed of search policies and be free of unreasonable
searches and unreasonable removal of personal items [Medium-Low];
(L) Depending on the child’s age and maturity, the right to seek employment,
keep the child’s own money, have a bank account in the child’s name, and
get paid for any work done for the operation as part of the child’s service
plan or vocational training, with the exception of assigned routine duties that
relate to the child’s living environment, such as cleaning the child’s room, or
other chores, or work assigned as a disciplinary measure [Medium-Low];
(M) The right to consent in writing before taking part in any publicity or fund
raising activity for the operation, including the use of the child’s photograph
[Medium-Low];
(N) The right to refuse to make public statements showing gratitude to the
operation [Medium-Low]; and
(O) The right to not be pressured to get an abortion, give up her child for
adoption, or parent her child, if applicable [High];
(4) Discipline, including:
(A) The right to be free from any harsh, cruel, unusual, unnecessary,
demeaning, or humiliating treatment or punishment. This means the child
must not be [High]:
(i) Shaken [High];
(ii) Subjected to or threatened with corporal punishment, including
spanking or hitting the child [High];
(iii) Forced to do unproductive work that serves no purpose except to
demean the child, such as moving rocks from one pile to another or
digging a hole and then filling it in [Medium];

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 (iv) Denied food, sleep, a bathroom, mail, or family visits as punishment
[High];
(v) Subjected to remarks that belittle or ridicule the child or the child’s
family [Medium-High];
(vi) Threatened with the loss of placement or shelter as punishment
[Medium]; and
(vii) Subjected to demeaning behavior to embarrass, control, harm,
intimidate, or isolate the child. “Demeaning behavior” may include
using physical force, rumors, threats, or inappropriate comments
[Medium-High];
(B) The right to discipline that is appropriate to the child’s age, maturity, and
developmental level [Medium-High]; and
(C) The right to have restrictions or disciplinary policies explained to the child
at admittance and when the measures are imposed [Medium];
(5) Plans for the child while in care, including:
(A) The right to have a comprehensive service plan that addresses the child’s
needs, including transitional and discharge planning [Medium]; and
(B) The right to actively participate in the development of the child’s service
plan within the limits of the child’s comprehension and ability to manage the
information. The child has the right to a copy or summary of the plan. A child
14 years of age or older has the right to review and sign the service plan,
unless there is a reason not to provide the plan [Medium];
(6) Medical care and records, including:
(A) The right to medical, dental, vision, and mental health care and
developmental services that adequately meet the child’s needs. The right to
request that the care or services be separate from adults (other than young
adults) who are receiving services [Medium];
(B) The right to be free of unnecessary or excessive medication [Medium-
High]; and
(C)The right to confidential care and treatment, including keeping medical
records and operation records private and only discussing them when it is
about the child’s care [Medium-Low]; and
(7) Complaints, including the right to make calls, reports, or complaints without
interference, coercion, punishment, retaliation, or threats of punishment or
retaliation. The child may make these calls, reports, or complaints anonymously.
Depending upon the nature of the complaint, the child has the right to call, report,
or complain to [High]:
(a) The DFPS Texas Abuse/Neglect Hotline at 1-800-252-5400;
(b) The HHSC Ombudsman for Children and Youth Currently in Foster Care at
1- 844-286-0769;
(c) The DFPS Office of Consumer Affairs at 1-800-720-7777; or
(d) Disability Rights of Texas at 1-800-252-9108.

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§748.1103. How must I inform a child and the child’s
parents of their rights?
Subchapter H, Child Rights
January 2017

(a) Within seven days after you admit a child into your operation, you must review the
child’s rights with the child and a child’s parent, unless the parent’s consent is not
required. You must also provide the child and a child’s parent with a written copy of the
child’s rights. [Medium]
(b) Child rights must be written in:
(1) Simple, non-technical terms [Medium]; and
(2) English, unless the person does not understand English. The child’s rights must
be written in the person’s primary language, if possible. [Medium]
(c) If the person you are informing has a visual or auditory impairment, you must explain
the child’s rights in a manner that is understandable to the person. [Medium]
(d) The person you are informing of the child’s rights must sign a statement indicating that
the person has read and understands these rights. A copy of a timely signed “CPS
Rights of Children and Youth in Foster Care” will meet this standard. You must put the
signed copy in the child’s record. [Medium]

§748.1107. What right does a child have regarding contact

with his parent(s)?
Subchapter H, Child Rights
January 2007

(a) You must allow contact between a child and his parent(s) whose parental rights
have not been terminated according to [Medium]:
(1) Your policies [Medium-Low]; and
(2) The provisions of a court order or any visitation agreements. [Medium]

(b) You must document in the child’s record:

(1) Any plans for contact between the child and a parent [Medium-Low]; and
(2) Any decision to limit contact with a parent. [Medium]

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 (c) Before the service planning team, treatment director, or professional level
service provider can temporarily restrict ongoing contacts or communication
between the child and a parent, you must:
(1) Explain the reasons for the restrictions to the child and the child’s parent
[Medium-Low]; and
(2) Document the reasons in the child’s record. [Medium-Low]

(d) Restrictions imposed by you that continue for more than 30 days must be re-
evaluated monthly by a professional level service provider, who also must
[Medium]:
(1) Explain the reasons for the continued restrictions to the child and the
child’s parents [Medium-Low]; and
(2) Document the reasons in the child’s record. [Medium-Low]
(e) If you limit communications or visits with a parent for practical reasons, such
as geographical distance or expense, you must discuss the limits with the child
and the child’s parents. You must document the limits in the child’s record.
[Medium-Low]

§748.1109. What right does a child have regarding contact

with siblings?
Subchapter H, Child Rights
January 2017

(a) A child must have a reasonable opportunity for sibling visits and contacts in an
effort to preserve sibling relationships. [Medium]
(b) You must address plans for sibling visits and contacts in the child’s record.
[Medium-Low]
(c) When you restrict sibling contact, you must include justification in the child’s
record. Restrictions imposed by you that continue for more than 60 days must
be re-evaluated every 60 days by a professional level service provider, who also
must [Medium]:
(1) Explain the reasons for the continued restrictions to the child [Medium];
and
(2) Document the reasons in the child’s record. [Medium-Low]

(d) If barriers to visits exist, such as unavoidable geographic distance and expense
issues, the operation must make provisions for sibling contact through letters,
telephone calls, or some other means. [Medium]

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§748.1111. What right to privacy does a child have in his
contact with others?
Subchapter H, Child Rights
September 2010

(a) Except as determined by the child’s service planning team, treatment

director, professional level service provider, or parent, you may not:
(1) Open or read the child’s incoming or outgoing mail, including
electronic mail, unless necessary to assist the child with reading or
writing [Medium]; or
(2) Listen to or screen the child’s telephone calls unless the child needs
assistance with using the telephone. [Medium]
(b) You must document in the child’s record:
(1) Any reason for restrictions on the child’s mail or telephone calls that you impose
[Medium-Low]; and
(2) A list of the mail or telephone calls that you restrict. [Medium-Low]

(c) You must inform the child and his parent about restrictions you place on the child.
[Medium-Low]

(d) Restrictions imposed by you that continue for more than 30 days must be re-evaluated
monthly by a professional level service provider, who also must [Medium]:

(1) Explain the reasons for the continued restrictions to the child [Medium-Low]; and

(2) Document the reasons in the child’s record. [Medium-Low]

Technical Assistance

Minimum standards §§748.1107, 748.1109, and 748.1111 apply only to contact restrictions
imposed by you. Limitations or restrictions on contact imposed by the court or by the child’s
parent(s) are not subject to the explanation, documentation, and re-evaluation
requirements in these rules. However, it is recommended that you retain written notice of
any contact restrictions imposed by the court or parent(s), so that you will have
documentation of who imposed the restrictions.

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§748.1113. Under what circumstances may I conduct a
search for prohibited items or items that endanger a child’s
safety?
Subchapter H, Child Rights
September 2010

(a) A child’s possessions must be free of unreasonable searches and unreasonable

removal of personal items. [Medium-Low]
(b) You may search a child, his possessions, or his room when you have reasonable
suspicion [Medium-Low]:
(1) Of the presence of a prohibited item or an item that endangers the child’s
safety;
(2) That the child made suicidal threats or threatened to hurt himself or others; or
(3) That the child was involved in theft.
(c) Residential treatment centers and emergency care services programs may conduct
routine searches (such as upon return from a home visit or return from school) as
long as the routine searches are:
(1) Justified in your policies [Medium-Low];
(2) Conducted uniformly [Medium-Low]; and
(3) Do not involve the removal of clothing, other than outer clothing, such as
coats, jackets, hats, gloves, shoes, or socks. [Medium-High]
(d) Only a caregiver of the same gender as the child may conduct a search that
involves the removal of clothing, other than outer clothing, such as coats, jackets,
hats, gloves, shoes, or socks. [Medium-High]
(e) If a search involves the removal of clothing (other than outer clothing), a second
caregiver must witness the search. [Medium-High]
(f) The caregiver must ensure that other children do not witness a search that
involves the removal of clothing, other than outer clothing. [Medium-High]

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§748.1115. May a caregiver conduct a body cavity search of
a child in care?
Subchapter H, Child Rights
January 2007

With the exception of a child’s mouth, a caregiver may not conduct a body cavity search of a
child in care. [High]

§748.1117. What must I document regarding a search?

Subchapter H, Child Rights
January 2017

You must document the following in the child’s record when you conduct a search under
§748.1113(b) of this title (relating to Under what circumstances may I conduct a search for
prohibited items or items that endanger a child’s safety?) [Medium-Low]:
(1) The date of the search [Medium-Low];
(2) The name of the child [Medium-Low];
(3) Reason for the search [Low];
(4) A description of what you searched [Low];
(5) The clothing removed, if applicable [Medium-Low];
(6) The name of the caregivers conducting the search [Medium-Low];
(7) The name of the witness, if applicable [Medium-Low];
(8) The results of the search [Low]; and
(9) The resolution of the issue with the child, including increased supervision, additional
counseling, or disciplinary consequences. [Medium-Low]

§748.1119. What techniques am I prohibited from using on

a child?
Subchapter H, Child Rights
January 2017

Certain techniques must not be used on a child, including:

(1) Chemical restraints. For more information on emergency behavior intervention,
see Subchapter N of this chapter (relating to Emergency Behavior Intervention)
[High];

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(2) Aversive conditioning, which includes, but is not limited to, any technique
designed to or likely to cause a child physical pain, the application of startling
stimuli, and the release of noxious stimuli or toxic sprays, mists, or substances in
proximity to the child’s face [High];

(3) Pressure points [High];

(4) Rebirthing therapy [High];

(5) Hug and/or holding therapy [High]; and

(6) Tazor or stun guns. [High]

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Subchapter I, Admission, Service Planning, and Discharge

Technical Assistance
The admission information and admission assessment requirements vary based on the
circumstances of the child’s admission. Here are the applicable minimum standards based on
the type of admission:

1. Regular Admission:
a. Admission information per 748.1205
b. Admission assessment per
748.1217
i. Subsection (b) prior to admission
ii. Subsection (c) within 40 days
2. Emergency Admission:
a. Admission information per 748.1271
b. Admission assessment per 748.1217
i. Subsection (b) within 40 days
ii. Subsection (c) within 40 days
3. Emergency Care Services
Admission:
a. Admission information per 748.1205
b. Admission assessment per 748.4231.

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Division 1, Admission

§748.1201. May children receiving different types of

service live in the same living quarters?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
September 2010

(a) Except as provided by subsection (c) of this section, children receiving different types
of service may reside in the same living quarters as long as:
(1) A professional level service provider completes an evaluation of the living
quarters for each child that you place in the living quarters [Medium]; and
(2) In each evaluation, the professional level service provider ensures that:
(A) There is no conflict of care with the best interests of any of the children
placed in the living quarters [Medium];
(B) Placing the child with different service or treatment needs in the living
quarters will not adversely impact the other children in the living
quarters [Medium];
(C)The number of children in the living quarters is appropriate at all times
based on the needs of all children in the living quarters [Medium];
(D) Caregivers can appropriately supervise all children in the living
quarters at all times [Medium]; and
(E) You can meet the needs of all children in the living quarters. [Medium]

(b) If the treatment or service needs of any children in the living quarters changes,
the professional level service provider must evaluate the needs of each child in
the living quarters to ensure there is no conflict of care. [Medium-Low]

(c) Children admitted for emergency care services must receive any therapeutic
services (such as group therapy or art therapy) separate from children
admitted for non- emergency care and must have separate living quarters,
such as a separate wing of an operation, or a separate cottage. Children
admitted for emergency care services may be combined with children in non-
emergency care for meals, recreation, and transportation. [Medium-Low]

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 Technical Assistance
Examples of conflicts in care are placements that:
● Place one child at serious risk for harm by another child;
● Significantly compromise the care and supervision of any child in care;
● Require a level of expertise from the caregivers that they do not possess; or
● Create an environment that is appropriately restrictive for one child but inappropriate
for another.

§748.1203. Who may I admit?

Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
September 2010

(a) You may only admit children or young adults who meet your admission policy
guidelines and whose needs you can meet. If you adopt a change in your
admission policies that requires a change in the conditions of your permit, you
must request an amendment to your permit with us. [Medium]

(b) Each placement must meet the child’s physical, medical, recreational,
educational, and emotional needs as identified in the child’s admission
assessment. [Medium-High]

§748.1205. What information must I document in the

child’s record at the time of admission?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) You must include the following in the child’s record at the time of admission:
(1) The child’s name, gender, race, religion, and date of birth [Medium-Low];
(2) The name, address, and telephone number of the managing conservator, the
primary caregivers for the child, any person with whom the child is allowed to leave
the operation, and any other individual who has the legal authority to consent to
the child’s medical care [Medium-Low];
(3) The names, addresses, and telephone numbers of biological or adoptive parents,
unless parental rights have been terminated [Low];

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 (4) The names, addresses, and telephone numbers of siblings [Low];
(5) The date of admission [Low];
(6) Medication the child is taking [Medium-High];
(7) The child’s immunization record [Medium-Low];
(8) Allergies, such as food, medication, sting, and skin allergies [Medium-High];
(9) Chronic health conditions, such as asthma or diabetes [Medium-High];
(10) Known contraindications to the use of restraint [Medium];
(11) Identification of the child’s treatment needs, if applicable, and any additional
treatment services or programmatic services the child is receiving [Medium];
(12) Identification of the child’s high-risk behaviors, if applicable, and the safety plan
staff and caregivers will implement related to the behaviors [High];
(13) If a suicide risk screening is required at admission and the child is screened as
having a high or potential risk of suicide [High]:
(A) The identification of any risk factors or warning signs of suicide, if
applicable and not already identified in paragraph (12) of this subsection;
and
(B) The safety plan staff and caregivers will implement related to the risk
factors and warning signs;
(14) The results of the suicide screening at admission, if required [Medium];
(15) A copy of the placement agreement, if applicable [Low]; and
(16) Documentation of the attempt to notify the parent of the child’s location as
required by §748.1211(c)(3) of this title (relating to What information must I
share with the parent at the time of placement?), if applicable. [Medium]
(b) If you admit a child for emergency care services, you must document the information:
(1) Regarding the reason for admission in the child’s record upon admission [Low]; and
(2) In subsection (a) of this section within 72 hours after you admit the child. If any
information is not available within that time frame, you must document in the
child’s record reasonable efforts made to obtain the information. [Medium-Low]
(c) For emergency admissions, as opposed to a child receiving emergency care services, you
must meet the requirements in Division 2 of this subchapter (relating to Emergency
Admission).

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§748.1207. What is a placement agreement?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) A placement agreement is your agreement with a child’s parent or the child that
defines your roles and responsibilities and authorizes you to obtain or provide
services for the child. The placement agreement must include:
(1) Authorization permitting you to care for the child [Medium-Low];
(2) A medical consent form signed by a person legally authorized by the Texas
Family Code to provide consent [High]; and
(3) The reason for placement and anticipated length of time in care. [Low]
(b) A placement agreement must be signed by the child’s parent, except as provided
in subsection (c). [Medium]
(c) For a transitional living program, a child 16 years of age or older may sign the
placement agreement on the child’s own behalf, as provided in the Texas Family
Code §32.203, without the consent of the child’s parent if the child [Medium]:
(1) Resides separate and apart from the child’s parent and manages the child’s
own financial affairs;
(2) Is unmarried and pregnant; or
(3) Is unmarried and a parent.

§748.1209. What orientation must I provide a child?

Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) Within seven days of admission, you must provide orientation to each newly
admitted child who is five years old or older. You must gear orientation to the
intellectual level of the child. [Medium-Low]

(b) Orientation must include information about your policies on the following:
(1) Visitation, including family visitation and overnight visitation [Medium-Low];
(2) Mail [Medium-Low];
(3) Telephone calls [Medium-Low];

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 (4) Gifts [Low];
(5) Personal possessions, including any limits placed on the possessions the child may
or may not have [Low];
(6) Emergency behavior intervention, including your policies and practices on the use
of personal restraint and the child’s input on preferred de-escalation techniques
that caregivers can use to assist the child in the de-escalation process [Medium-
High];
(7) Discipline [Medium-High];
(8) The religious program and practices [Low];
(9) The educational program [Low];
(10) Trips away from the operation [Low];
(11) Program expectations and rules [Medium-Low];
(12) A general daily schedule for routine activities for children in care [Medium-Low];
and
(13) Internal grievance procedures. [Medium-Low]
(c) Orientation must include information on how to:
(1) Make complaints to outside agencies [Medium-High]; and
(2) Contact parties to a child’s case (i.e. caseworker, attorney ad litem, guardian ad
litem, CASA worker, etc.). [Medium]

(d) You must document in the child’s record when the orientation occurred, any items
that the orientation did not include, and the reason that the orientation did not
include that item. [Low]

§748.1211. What information must I share with the parent

at the time of placement?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
April 2022

(a) At admission, you must provide the following policies to the parent placing the child
[Medium]:
(1) Fee policies [Low];
(2) Emergency behavior intervention policies [Medium-Low];

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 (3) Discipline policies [Medium-Low]; and
(4) Any other policies required by us, upon request of the parent. [Medium-Low]
(b) At admission, you must provide and explain the following written information and
policies to the parent placing the child:
(1) Information about the policies that you would present a child during orientation
Medium-Low;
(2) Your policies regarding the:
(A) Use of volunteers, if applicable [Low];
(B) Type and frequency of notifications made to parents [Medium-Low];
and
(C) Involvement of the child in any publicity or fundraising activity for the
operation [Low]; and
(3) Information about the parent’s right to refuse to or withdraw consent for a
child to participate in:
(A) Research programs [Medium-Low]; or
(B) Publicity or fundraising activities for the operation. [Low]
(c) If you sign a placement agreement for a transitional living program with a child
as specified in §748.1207 of this title (relating to What is a placement
agreement?), then you:
(1) Must share the policies noted in subsection (a) of this section with the
child, instead of the parent [Medium-Low];
(2) Do not have to comply with subsection (b) of this section, but you must
provide and explain to the child your policies regarding the:
(A) Use of volunteers, if applicable Low;
(B) Involvement of the child in any publicity or fundraising activity
for the operation [Low]; and
(C) Child’s right to refuse to or withdraw consent to participate in:
(i) Research programs [Medium-Low]; or
(ii) Publicity or fundraising activities for the operation [Low];
and
(3) Must attempt to notify the child’s parent of the child’s location, if the
child was admitted without the consent of the parent. [Medium-High]

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§748.1213. What information must I provide caregivers
when I admit a child?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) By the day you admit the child for care, you must provide caregivers responsible
for the child’s care with information about the child’s immediate needs such as
enrolling the child in school or obtaining needed medical care or clothing. [Medium]
(b) You must inform appropriate caregivers of any special needs, such as medical or
dietary needs or conditions or supervision needs, and document that you shared
the information with the caregiver. [Medium-High]

§748.1215. When must I complete the admission

assessment?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) You must complete a non-emergency admission assessment prior to admission.

(b) A professional level service provider must sign and date each assessment, which must be
in the child’s record. [Low]

§748.1217. What information must an admission

assessment include?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
April 2022

(a) An admission assessment must provide an initial evaluation of the appropriate

placement for a child and ensure that you obtain the information necessary for you to
facilitate service planning. [Medium]
(b) Prior to a child’s non-emergency admission, an admission assessment must be
completed which includes:
(1) The child’s legal status [Low];

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 (2) A description of the circumstances that led to the child’s referral for substitute
care [Medium];
(3) A description of the child’s behavior, including appropriate and maladaptive
behavior, and any high-risk behavior [Medium-High];
(4) Any history of physical, sexual, or emotional abuse or neglect [Medium-High];
(5) Any history of trauma [Medium-High];
(6) Current medical and dental status, including the available results of any
medical and dental examinations [Medium];
(7) Current mental health and substance abuse status, including available results
of any psychiatric evaluation, psychological evaluation, or psychosocial
assessment [Medium];
(8) The child’s current developmental, educational, and behavioral level of
functioning [Medium-High];
(9) The child’s current educational level and any school problems [Medium-Low];
(10) Any applicable requirements of §748.1219 of this title (relating to What
are the additional admission requirements when I admit a child for treatment
services?) [Medium];
(11) Documentation indicating efforts made to obtain any of the information in
paragraphs (1)-(10) of this subsection, if any information is not obtainable
[Medium-Low];
(12) The services you plan to provide to the child [Medium-Low];
(13) Immediate goals of placement [Medium-Low];
(14) The parent’s expectations for placement, duration of the placement, and
family involvement [Low];
(15) The child’s understanding of the placement [Low]; and
(16) A determination of whether and how you can meet the needs of the child.
[Medium-Low]

(c) Prior to completing a child’s initial service plan, the following information must be
added to the admission assessment:
(1) The child’s social history. The history must include information about past and
existing relationships with the child’s birth parents, siblings, extended family
members, and other significant adults and children, and the quality of those
relationships with the child [Low];
(2) A description of the child’s home environment and family functioning Low;

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 (3) The child’s birth and neonatal history [Low];
(4) The child’s developmental history [Medium-Low];
(5) The child’s mental health and substance abuse history [Medium-Low];
(6) The child’s school history, including the names of previous schools attended
and the dates the schools were attended, grades earned, and special
achievements [Low];
(7) The child’s history of any other placements outside the child’s home, including
the admission and discharge dates and reasons for placement [Medium-Low];
(8) The child’s criminal history, if applicable [Medium-Low];
(9) The child’s skills and special interests [Medium-Low];
(10) Documentation indicating efforts made to obtain any of the information in
paragraphs (1)-(9) of this subsection, if any information is not obtainable
[Low];
(11) The services you plan to provide to the child, including long-range goals of
placement [Medium-Low];
(12) Recommendations for any further assessments and testing [Medium-Low];
(13) A recommended behavior management plan [Medium]; and
(14) A determination of whether and how you can meet the needs of the child,
based on an evaluation of the child’s special strengths and needs. [Medium-
Low]
(d) You must attempt to obtain a signed authorization, so you can subsequently request
in writing materials from the child’s current or most recent placement, such as the
admission assessment, professional assessments, and the discharge summary. You
must consider information from these materials when you complete your admission
assessment if they are made available to you. [Medium-Low]
(e) This rule does not apply to children receiving emergency care services. See
§748.4231 of this chapter (relating to What information must an admission
assessment include for a child needing emergency care services, including respite
child-care services?).

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§748.1219. What are the additional admission assessment
requirements when I admit a child for treatment services?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
September 2022

When you admit a child for treatment services, you must do the following, as applicable:

If: Then:
(1) You intend to provide treatment (A) The admission assessment must include a
services for a child with an emotional written, dated, and signed [Medium-
disorder or autism spectrum disorder High]:
(i) Psychiatric evaluation or
psychological evaluation
including the child’s diagnosis
[Medium-High]; or
(ii) Psychosocial assessment as defined in
§748.43 of this title (relating to What do
certain words and terms mean in this
chapter?). [Medium-High]
(B) The psychiatric evaluation,
psychological evaluation, or
psychosocial assessment must have
been completed within [Medium]:
(i) 14 months of the date of admission,
if the child is coming from another
regulated residential child care
operation [Medium]; or
(ii) Six months of the date of admission, if
the child is not coming from another
regulated residential child care
operation. [Medium]
(C) The admission assessment must include
the reasons for choosing treatment
services for the child. [Medium]
(D) The admission assessment must include
consideration given to any history of
inpatient or outpatient treatment.
[Medium-Low]

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 If: Then:
(2) You intend to provide treatment (A) The admission assessment must include a
services for a child with an intellectual written, dated, and signed [Medium-
disability High]:
(i) Psychological evaluation with
psychometric testing, including the
child’s diagnosis [Medium-High]; or
(ii) Psychosocial assessment as defined in
§748.43 of this title. [Medium-High]
(B) The psychological evaluation or
psychosocial assessment must be
completed within 14 months of the date
of admission. [Medium]
(C) The psychological evaluation must:
(i) Be performed by a licensed
psychologist who has experience with
intellectual disabilities or published
scales [Medium];
(ii) Include the use of standardized tests to
determine the intellectual functioning of a
child. The test results must be
documented in the evaluation [Medium];
(iii) Determine and document the child’s level
of adaptive functioning [Medium]; and
(iv) Indicate manifestations of an
intellectual disability as defined in the
Diagnostic and Statistical Manual of
Mental Disorders 5 (DSM-5). [Medium-
Low]
(D) The admission assessment must include
the reasons for choosing treatment
services for the child. [Medium-Low]
(E) The admission assessment must include
consideration given to any history of
inpatient or outpatient treatment.
[Medium-Low]

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 If: Then:
(3) You intend to provide treatment (A) The admission assessment must have a
services for a child with primary medical licensed physician’s signed, written orders
needs as the basis for the child’s admission. An
evaluation from a health care professional
must confirm that the child can be cared
for appropriately in a general residential
operation. [Medium-High]
(B) The written orders or hospital discharge
must include orders for [Medium-High]:
(i) Medications [Medium-High];
(ii) Treatments [Medium-High];
(iii) Diet [Medium-High];
(iv) Range-of-motion program at stated
intervals [Medium-High];
(v) Habilitation, as appropriate [Medium-
High]; and
(vi) Any special medical or
developmental procedures.
[Medium-High]
(C)The admission assessment must
include the reasons for choosing
treatment services for the child.
[Medium]
(D) The admission assessment must include
consideration given to any history of
inpatient or outpatient treatment.
[Medium-High]

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 If: Then:
(4) You intend to provide services to a (A) The admission assessment must include
child that is determined to be an a written, dated, and signed [Medium-
immediate danger to others based on the High]:
child’s behavior and history within the last (i) Psychiatric evaluation or
two months, or a child is screened as a psychological evaluation,
high or potential risk of suicide based on including the child’s diagnosis
the results of a suicide risk screening at [Medium-High]; or
admission.
(ii) Psychosocial assessment as defined in
§748.43 of this title. [Medium-High]
(B) The psychiatric evaluation or psychological
evaluation must include:
(i) The child’s diagnosis, if applicable
[Medium-High];
(ii) An assessment of the child’s needs and
potential danger to self or others
[Medium-High]; and
(iii) Recommendations for care,
treatment, and further evaluation. If
the child is admitted, the
recommendations must become part
of the child’s service plan and must
be implemented. [Medium-High]
(C) The psychiatric evaluation,
psychological evaluation, or
psychosocial assessment must have
been completed within [Medium]:
(i) 14 months of the date of admission,
if the child is coming from another
regulated residential child care
operation [Medium]; or
(ii) Six months of the date of admission, if
the child is not coming from another
regulated residential child care
operation. [Medium]

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§748.1221. What must I do if I cannot obtain the required
information for an admission assessment?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2007

(a) You must make reasonable efforts to obtain all required information. [Medium]

(b) If you and the child’s parent determine that attempting to get information at the time of
placement would not be in the child’s best interests, you may postpone attempting to
acquire the information. [Medium]

(c) In the child’s admission assessment, you must document why a:

(1) Particular piece of information is unavailable [Medium]; or

(2) Delay in obtaining a piece of information is necessary, including efforts made to

obtain the information. [Medium]

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 Technical Assistance

Regarding subsection (a), Licensing expects documentation of at least three attempts to

comply with a minimum standard requiring “reasonable effort” to obtain information.
Efforts should be reasonably spaced, allowing enough time for a person to respond yet not
unreasonably delaying the acquisition of the requested information.

Example: Calling a CPS caseworker or parent three times in one day would not be considered
three separate “reasonable efforts” to obtain needed information, as this does not allow the
person reasonable time to respond to each of the requests.

Example: Calling a CPS caseworker or parent once every three months to obtain information
needed for an admission assessment would not be considered reasonable effort to obtain the
information, as the third attempt would be made at least six months after the child was
placed.

Example: Calling a CPS caseworker or parent once a week for three weeks to obtain
information needed for an admission assessment would be considered reasonable effort to
obtain the information, as this gives ample time for the person to respond to each call, and
also seeks to obtain the information within one month of admission. No further attempts
would be expected if the information was not obtained after these three attempts.

§748.1223. What are the medical requirements when I

admit a child into care?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) You must ensure that the child has a medical examination by a health-care
professional within 30 days after the date of admission. This exam is not required if
you have documentation that the child has had a medical examination within the
past year, including documentation in the child’s health passport if the child is in the
department’s conservatorship. [Medium]
(b) If you admit a child with primary medical needs, you must provide the child with a
medical examination by a health-care professional within seven days before or three
days after the date of admission. [High]
(c) If a child admitted shows symptoms of abuse or illness, a health-care professional
must examine the child immediately. [Medium-High]

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 (d) The report and findings of any medical examination must be documented in the
child’s record, according to §748.1531(b) and (c) of this title (relating to What
general medical requirements must my operation meet?). [Medium-Low]

Technical Assistance
Regarding subsection (a), there is one exception for those operations that contract with Child
Protective Services. A child new to state conservatorship must receive a medical exam (Texas
Health Steps Checkup) within 30 days after the date of admission into the foster care system.
This must occur even if the child’s health passport indicates that the child received a medical
exam prior to entering the foster care system.

§748.1225. What are the dental requirements when I admit

a child into care?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2017

(a) If the child is younger than three years old and a health-care professional
recommends a dental examination, then you must ensure that a dentist examines
the child. [Medium-Low]
(b) A child three years old or older must have a dental appointment scheduled with a
dentist within 30 days after the date of admission, and the examination must
occur within 90 days after the date of admission. A dental examination is not
required if you have documentation that the child has had a dental examination
within the past year, including documentation in the child’s health passport if the
child is in the department’s conservatorship. [Medium-Low]
(c) The report and findings of the dental examination must be documented in the
child’s record, according to §748.1501(b) and (c) of this title (relating to What
general dental requirements must my operation meet?). [Medium-Low]

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§748.1227. What must I document when I re-admit a child
for care?
Subchapter I, Admission, Service Planning, and Discharge
Division 1, Admission
January 2007

For re-admission, you must complete the admission documentation as if the child was never in
your care; or for children that were discharged from your operation within the last 12 months,
you may update the previous admission documentation. [Medium-Low]

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Division 2, Emergency Admission

§748.1261. For which of my programs may I accept

emergency admissions?
Subchapter I, Admission, Service Planning, and Discharge
Division 2, Emergency Admission
January 2007

Neither a transitional living program nor a therapeutic camp program may accept emergency
admissions. All other programs may accept emergency admissions. [Medium]

§748.1263. What constitutes an emergency admission to

my operation?
Subchapter I, Admission, Service Planning, and Discharge
Division 2, Emergency Admission
July 26, 2018

It is an emergency admission if:

(1) You must place the child within 72 hours;
(2) The child was removed from a situation involving alleged abuse or neglect;
(3) The child is an alleged perpetrator of abuse and cannot be served in the child’s current
placement due to the child’s perpetrating behaviors;
(4) The child displays behavior that is an immediate danger to self or others and cannot
function or be served in his current setting;
(5) The child was abandoned and after exercising reasonable efforts, the child’s identity
cannot be immediately determined. You must document the efforts made to obtain
information on the child’s identity in the child’s record;
(6) The child was removed from the child’s home or placement, and there is an immediate
need to find a residence for the child;
(7) A law enforcement officer released the child to your operation that is licensed to provide
emergency care services; or
(8) The child is otherwise without adult care.

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§748.1265. May I take possession of a child from a law
enforcement officer?
Subchapter I, Admission, Service Planning, and Discharge
Division 2, Emergency Admission
July 26, 2018

You may take possession of a child from a law enforcement officer only if you meet the
requirements of 40 TAC Chapter 745, Subchapter H, Division 2 (relating to Taking Possession of
a Child Directly from a Law Enforcement Officer). [Medium-Low]

§748.1269. For an emergency admission, when must I

complete all of the requirements for an admission
assessment?
Subchapter I, Admission, Service Planning, and Discharge
Division 2, Emergency Admission
January 2017

(1) For an emergency admission, you must complete all of the requirements (see
Division 1 of this subchapter (relating to Admission)) for an admission
assessment within 40 days from the date of the child’s admission. [Medium]

(2) In an emergency admission of a child receiving treatment services, the child must
not continue in care for more than 30 days after the date of admission or 10 days
after the date of admission for a residential treatment center, unless the child has
received the psychiatric evaluation, psychological evaluation, psychosocial
assessment, or medical evaluation that is required by §748.1219 of this title
(relating to What are the additional admission assessment requirements when I
admit a child for treatment services?), and the evaluation or assessment indicates
manifestations of the disorder requiring treatment services. All evaluations and
assessments must be signed, dated, and documented in the child’s record.
[Medium]

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§748.1271. At the time of an emergency admission, what
information must I document in the child’s record?
Subchapter I, Admission, Service Planning, and Discharge
Division 2, Emergency Admission
September 2010

At the time of the emergency admission you must document in the child’s record:

(1) A brief description of the circumstances necessitating the emergency admission

[Medium-Low];
(2) The date of admission [Low];
(3) Allergies, such as food, medication, sting, and skin allergies [Medium-High];

(4) Chronic health conditions, such as asthma or diabetes [Medium-High];

(5) Known contraindications to the use of restraint [High];
(6) Identification of the child’s high-risk behaviors, if applicable, and the safety plan staff and
caregivers will implement related to the behaviors [High]; and
(7) If a suicide risk screening is required at admission and the child is screened as having a
high or potential risk of suicide [High]:

(A) The identification of any risk factors or warning signs of suicide, if applicable and
not already identified in paragraph (6) of this section; and
(B) The safety plan staff and caregivers will implement related to the risk factors and
warning signs;
(8) The results of the suicide screening at admission, if required [Medium]; and
(9) For the purpose of providing treatment services:
(A) A brief description of the child’s history [Medium];

(B) The child’s current behavior [Medium]; and

(C)Your evaluation of how the placement will meet the child’s needs and best interests.
[Medium-Low]

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Division 3, Educational Services

§748.1301. What responsibilities do I have for the

education of a child in care?
Subchapter I, Admission, Service Planning, and Discharge
Division 3, Educational Services
January 2007

(a) You must arrange an appropriate education for each child, including [Low]:
(1) Ensuring the child in care attends an educational facility or program that is
approved or accredited by the Texas Education Agency, the Southern Association of
Colleges and Schools, the Texas Private School Accreditation Commission or by the
out-of- state school district funding the child [Medium-Low];
(2) Ensuring a school-age child has the training and education in the least restrictive
setting necessary to meet the child’s needs and abilities [Medium-Low];
(3) Ensuring a child in care attends an educational facility or program that implements
a special education student’s individual education plan (IEP) [Medium-Low]; and
(4) Advocating that a school-age child receives the educational and related services to
which he is entitled under provisions of federal and state law and regulations.
[Medium-Low]
(b) For children receiving treatment services you must designate a liaison between the
agency and the child’s school. [Medium-Low]

§748.1303. What responsibilities do I have for a child’s

individual educational needs?
Subchapter I, Admission, Service Planning, and Discharge
Division 3, Educational Services
April 2022

You must:
(1) Review report cards and other information received from teachers or school
authorities with the child and provide necessary information to caregivers [Low];
(2) Counsel and assist the child regarding adequate classroom performance [Low];

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 (3) Permit, encourage, and make reasonable efforts to involve the child in
extracurricular activities to the extent of the child’s interests and abilities and in
accordance with the child’s service plan [Low];
(4) Provide a quiet, well-lighted space for the child to study and allow regular times for
homework and study [Medium-Low];
(5) Know what emergency behavior interventions are permitted and being used with
the child [Medium-High];
(6) Let the parent know that an ARD (Admission, Review, and Dismissal), IEP
(Individual Education Plan), or ITP (Individual Transitional Planning) meeting should
be requested if you are concerned with the child’s educational program or if the
child does not appear to be making progress [Medium-Low];
(7) Attend ARD, IEP, and ITP meetings and other school staffings and conferences, if
requested by the parent, to represent the child’s educational best interests,
including the child being evaluated for and provided with related services needed to
benefit from educational services, and positive behavior supports designed to
decrease the need for negative disciplinary techniques or interventions [Medium-
Low]; and
(8) Know what is in the child’s IEP and support the school’s efforts to implement the
IEP, if applicable. [Medium-Low]

§748.1305. If I have an educational program, what

information must I provide to a child’s parent about that
program?
Subchapter I, Admission, Service Planning, and Discharge
Division 3, Educational Services
January 2007

If you have an educational program, you must include the following information in the discussion
and in the written material you give to parents when you admit the child:

(1) The name of any educational program operated on the premises of your operation [Low];

(2) Whether the program is accredited [Low];

(3) Whether the Texas Education Agency has approved the program [Low];
(4) Whether the educational course work is transferable to public schools [Low]; and

(5) The credentials of the teachers, if the teachers are not approved and regulated by the
State Board of Educator Certification (SBEC). [Low]

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 Division 4, Service Plans
Technical Assistance
You may combine admission and service plan documentation, as long as the
documentation meets the content requirements and time frames required by the applicable
minimum standards. For example, you may combine an admission assessment and initial
service plan for a child admitted as an emergency admission, as long as the content of the
document complies with both §748.1217 and §748.1337 and the document is complete
within 40 days of admission. A preliminary service plan would still be needed within 72
hours of admission, per §748.1331.

§748.1331. What are the requirements for a preliminary

service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

(a) You must complete a preliminary service plan that addresses the immediate needs
of a child within 72 hours, such as supervision requirements, enrolling the child in
school, or obtaining needed medical care or clothing. [Medium-Low]

(b) In addition, for a child receiving treatment services the preliminary service plan
must include:

(1) A description of the child’s immediate treatment and care needs [Medium-
Low];

(2) A description of the child’s immediate educational, medical, and dental

needs, including possible side effects of medications or treatment prescribed
to the child [Medium-Low];

(3) A description of how you will meet the child’s needs, including any necessary
increased supervision or follow-up actions of possible side effects of
medication or treatment provided to the child [Medium-Low];

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 (4) The identification of any issues or concerns the child may have that could
escalate a child’s behavior. Identification of a child’s issues or concerns must
serve to avoid the use of unnecessary emergency behavior interventions
with the child. Child concerns may include issues with food, eye contact,
physical touch, personal property, or certain topics [Medium]; and

(5) A designation of who will be responsible for meeting each of the child’s
needs. [Medium-Low]

(c) The plan must be compatible with the information included in the child’s
admission assessment. [Medium-Low]

(d) You must document the plan in the child’s record. [Low]

(e) You must inform each professional level service provider and caregiver working
with a child about the child’s preliminary service plan. [Medium]

(f) You must implement and follow the preliminary service plan. [Medium]

Technical Assistance
It is a good idea to include in service plans specific information about the situations that
trigger significant emotional responses for the child (e.g., enclosed spaces, darkness,
bedtime), successful intervention strategies to effectively de-escalate those responses, anger
and anxiety management options to assist the child in calming, techniques for self-
management, and specific goals that address the targeted behaviors that most often lead to
emergency behavior interventions for the child.

§748.1333. Who must be involved in developing the

preliminary service plan for children receiving treatment
services?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2007

The treatment director or a professional level service provider must develop, sign, and date the
preliminary service plan for children receiving treatment services. [Medium]

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§748.1335. When must I complete an initial service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

You must complete the initial service plan within 45 days after you admit the child. [Medium-
Low]

§748.1337. What must a child’s initial service plan include?

Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
September 2022

(a) You must base the child’s initial service plan on the child’s needs identified in the
child’s admission assessment and integrate trauma informed care in the care,
treatment, and management of each child. The service planning team may prioritize
the child’s service planning goals and objectives based on the child’s admission
assessment. However, any required service plan components not initially addressed
must have a justification for the delay in addressing the needs. [Medium-Low]

(b) The child’s initial service plan must be documented in the child’s record and include
those items that a preliminary plan must include (see §748.1331 of this title (relating
to What are the requirements for a preliminary service plan?)), and the items noted
below for each specific type of service that you provide the child [Medium-Low]:

Type of Items that must be included:

Service
(1) Child-care (A) The child’s needs identified in the admission assessment, in addition
services to basic needs related to day-to-day care and development,
including [Medium-Low]:
(i) Medical needs, including scheduled medical exams and plans for
recommended follow-up treatment [Medium-Low];
(ii) Dental needs, including scheduled dental exams and plans for
recommended follow-up treatment [Medium-Low];
(iii) Intellectual functioning, including any testing and plans for
recommended follow-up [Medium-Low];

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Type of Items that must be included:
Service
(iv) Developmental functioning, including any developmental delays
and plans to improve or remediate developmental functioning
[Medium-Low];
(v) Educational needs and how those needs will be met, including
planning for high school completion and post-secondary
education and training, if appropriate, and any school
evaluations or recommendations [Medium-Low];
(vi) Plans for normalcy, including:
(I) Social, extracurricular, recreation, and leisure activities
[Medium]; and
(II) Integrating the child into the community and
community activities, as appropriate [Medium];
(vii) Therapeutic needs, including plans for psychiatric evaluation,
psychological evaluation, psychosocial assessment or follow-up
treatment, testing, and the use of psychotropic medications
[Medium]; and
(viii) Cultural identity needs, including assisting children in connecting
with their culture in the community [Low];

(B) Plans for maintaining and improving the child’s relationship with family
members, including recommendations for visitation and contacts
between the child and the child’s parents, the child and the child’s
siblings, and the child and the child’s extended family [Low];
(C)Recent information from the current caregiver’s evaluation of the
child’s behavior and level of functioning [Medium-Low];
(D)Specific goals and strategies to meet the child’s needs, including
instructions to caregivers responsible for the care of the child.
Instructions must include specific information about [Medium]:
(i) The child’s personal trauma history [Medium];
(ii) Level of supervision required [Medium-High];
(iii) The child’s trauma triggers [Medium];

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Type of Items that must be included:
Service
(iv) Methods of responding that improve a child’s ability to trust, to
feel safe, and to adapt to changes in the child’s environment
[Medium];
(v) Discipline techniques [Medium-High];
(vi) Behavior intervention techniques [Medium-High];
(vii) Plans for trips and visits away from the operation [Medium-Low];
and
(viii) Any actions the caregivers must take or conditions the caregivers
must be aware of to meet the child’s special needs, such as
medications, medical care, dietary needs, therapeutic care, how
to communicate with the child, and reward systems [Medium];
(E) If the child is 13 years old or older, a plan for educating the child in
the following areas:
(i) Healthy interpersonal relationships [Low];
(ii) Healthy boundaries [Low];
(iii) Pro-social communication skills [Low];
(iv) Sexually transmitted diseases [Medium-Low]; and
(v) Human reproduction [Medium-Low];
(F) If the child is 14 years old or older, plans for the caregivers to assist
the child in obtaining experiential life-skills training to improve the
child’s transition to independent living. Plans must [Medium]:
(i) Be tailored to a child’s skills and abilities [Medium]; and
(ii) Include training in practical activities that include, but are not
limited to, grocery shopping, meal preparation, cooking, using
public transportation, performing basic household tasks, and
money management, including balancing a checkbook [Medium];
(G) For children 16 years old and older, preparation for independent
living, including employment opportunities, if appropriate [Medium];
(H) For children who exhibit high-risk behaviors or have a suicide risk
screening that indicates a high or potential risk of suicide:

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 Type of Items that must be included:
Service
(i) Plans to minimize the risk of harm to the child or others, such as
special instructions for caregivers, sleeping arrangements, or
bathroom arrangements [High]; and
(ii) A specific safety contract developed between the child and staff
that addresses how the child’s safety needs will be maintained
[High];
(I) Expected outcomes of placement for the child and estimated length
of stay in care [Low];
(J) Plans for discharge [Low];
(K) The names and roles of persons who participated in the development
of the child’s service plan [Low];
(L) The date the service plan was developed and completed [Low];
(M) The effective date of the service plan [Low]; and
(N) The signatures of the service planning team members that were
involved in the development of the service plan. [Low]

(2) Treatment For children receiving treatment services, the plan must address all
services of the child’s waking hours and include:
(A) The child-care services planning requirements noted in
paragraph (1) of this subsection [weight is the weight of the
missing element, if any, noted in paragraph (1)];
(B) A description of the emotional, behavioral, and physical conditions
that require treatment services [Medium-Low];
(C)A description of the emotional, behavioral, and physical conditions
the child must achieve and maintain to function in a less
restrictive setting, including any special treatment program or
other services and activities that are planned to help the child
achieve and to function in a less restrictive setting [Medium-Low];
and
(D) A list of emotional, physical, and social needs that require
specific professional expertise, and plans to obtain the

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 Type of Items that must be included:
Service
appropriate professional consultation and treatment for those
needs. Any specialized testing, recommendations, or
treatment must be documented in the child’s record.
[Medium-Low]

(3) Treatment (A) The child-care and treatment services planning requirements noted
services for in paragraphs (1) and (2) of this subsection weight is the weight of
children with an the missing element, if any, noted in paragraphs (1) and (2);
intellectual (B) A minimum of one hour per day of visual, auditory and tactile
disability stimulation to enhance the child’s physical, neurological, and
emotional development [Medium-Low];
(C)An educational or training plan encouraging normalization
appropriate to the child’s functioning [Medium-Low]; and
(D) Career planning for older adolescents who are not receiving
treatment services for a severe or profound intellectual disability.
[Medium-Low]

(4) Transitional (A) Child-care service planning requirements noted in paragraph (1) of
living program this subsection weight is the weight of the missing element, if any,
noted in paragraph (1);
(B) Plans for encouraging the child to participate in community life and
to form interpersonal relationships or friendships outside the
transitional living program, such as extra-curricular recreational
activities [Low];
(C)Plans for education related to meal planning, meal preparation,
grocery shopping, public transportation, searching for an apartment,
and obtaining utility services [Low];
(D) Career planning, including assisting the child in enrolling in an
educational or vocational job training program [Medium];
(E) Money management and assisting the child in establishing a
personal bank account [Low];

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 Type of Items that must be included:
Service
(F) Assisting the child with how to access resources, such as medical
and dental care, counseling, mental health care, an attorney, the
police, and other emergency assistance [Medium];
(G) Assisting the child in obtaining the child’s social security number,
birth certificate, and a driver’s license or a Department of Public
Safety identification card, as needed [Medium]; and
(H) Problem-solving, such as assessing personal strengths and needs,
stress management, reviewing options, assessing consequences for
actions taken and possible short-term and long-term results, and
establishing goals and planning for the future. [Medium]

§748.1339. Who must be involved in developing an initial

service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

(a) A service planning team must develop the service plan. The team must consist of [Low]:
(1) At least one of the child’s current caregivers [Low];
(2) A person designated to make decisions regarding a child’s participation in childhood
activities [Low]; and
(3) At least one professional level service provider who provides direct services to the
child. [Low]
(b) If you are providing treatment services to the child, the team must also consist of two of
the following professions, which may or may not include additional members [Low]:
(1) A licensed professional counselor;
(2) A psychologist;

(3) A psychiatrist or physician;

(4) A licensed registered nurse;
(5) A licensed masters level social worker;
(6) A licensed or registered occupational therapist; or

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 (7) Any other person in a related discipline or profession that is licensed or regulated in
accordance with state law.
(c) The child, if verbal and developmentally able to participate, and the parents must be
invited to a service planning meeting and should participate and provide input into the
development of the service plan, including discussions regarding the child’s participation
in childhood activities. [Low]

§748.1340. Can the service planning team discuss to

develop a child’s service plan in separate meetings?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

Yes, the service planning team may meet in one meeting, two or more meetings, or in separate
meetings, provided that each service planning team member is informed of the discussions and
comments regarding the child’s service plan that were made in each meeting. [Medium-Low]

§748.1341. When must I inform the child’s parent(s) of an

initial service plan meeting?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

(a) The child’s parent must have at least two weeks advance notice of the initial service
plan meeting. [Low]
(b) The child’s record must include documentation of the notice and any responses from
the parents. [Low]

§748.1343. Must a professional level service provider or a

professional who must participate in a child’s service plan
be an employee of my operation?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2007

No. You may employ or contract with a professional level service provider or any other
professional who participates in a child’s service plan.

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§748.1345. What roles do professional level service
providers have in service planning?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

The roles of professional level service providers in service planning include:

Type of
Treatment
Service The roles of professional level service providers in service
planning include:
(1) Emotional (A) Reviewing the child’s diagnoses [Medium-Low];
disorder (B) Reviewing the identified needs and the plan for treatment based
and autism on the child’s diagnoses [Medium-Low];
spectrum (C)Reviewing the techniques, strategies, and therapeutic
disorder interventions that are planned for the child to improve adaptive
functioning [Medium-Low]; and
(D) Reviewing any medications prescribed for a child with special
review of psychotropic medications; the presence or absence of
medication side effects, including the effects of the medications on
the child’s behavior; laboratory findings; and any reason the child
should not use a medication. [Medium]

(2) Intellectual (A) Assessing the child’s educational needs and progress toward
disability meeting those needs [Medium-Low];
(B) Ensuring coordination between educators, caregivers, operation
employees, and other professionals involved in the child’s
treatment [Medium-Low]; and
(C)Providing information to the education system on the
strategies and techniques used with the child in the
operation. [Low]
(3) Primary (A) Reviewing any medications prescribed for a child [Medium];
medical (B) Recommending any special equipment needed by a child [Medium];
needs and
(C)Reviewing special instructions and training to caregivers for the
daily care of the child. [Medium]

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§748.1347. What must I document regarding a
professional level service provider’s participation in the
development of an initial service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2007

(a) You must document the professional level service provider’s:

(1) Name [Low]; and
(2) Date of participation. [Low]

(b) The professional level service provider must sign and date the document. If the
provider disagrees with any portion of the plan, the provider must document the
issue(s) of contention before signing it. [Low]

§748.1349. To whom do I provide a copy of the child’s

initial service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

(a) You must give a copy or summary of the initial service plan to the:
(1) Child, when appropriate. At a minimum, you must give a copy or summary of the
plant to a child 14 years of age or older, unless there is justification for not
providing the plan [Low];
(2) Child’s parents [Low]; and
(3) Child’s caregivers. [Medium-Low]
(b) If you provide a copy or summary of the initial service plan to a child:
(1) The child must review the plan [Low];
(2) The child must sign the plan, or you must document the child’s refusal to sign it
[Low]; and
(3) You must document if the child disagrees with the plan. [Low]
(c) If you do not provide a copy or summary of the initial service plan to a child, you must
document your justification for not sharing the plan in the child’s record. [Low]

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 (d) You must document in the child’s record that you provided a copy or summary of the
initial service plan to the child’s parents. [Low]

§748.1351. When must I implement a service plan?

Subchapter I, Admission, Service Planning, and Discharge
Division 4, Service Plans
January 2017

You must implement and follow an initial service plan as soon as all of the service planning team
members have reviewed and signed the plan, but no later than 15 days after the date of the
scheduled service-planning meeting involving the parents and the child. [Medium-Low]

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Division 5, Service Plan Reviews and Updates

§748.1381. How often must I review and update a service

plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2017

Except for when the child’s placement within your operation changes because of a change in the
child’s needs, you must review and update the service plan as follows:

Weight Type of Service Review and Update

[Medium- (1) Child-care services At least 180 days from the date of the
Low] child’s last service plan.
[Medium- (2) Treatment services for At least 90 days from the date of the
Low] emotional disorder, autism child’s last service plan.
spectrum disorder, or
primary medical needs
[Medium- (3) Treatment services for In the first year of care, the plan must
Low] intellectual disabilities be reviewed at least every 180 days
from the date of the child’s last service
plan. Thereafter, the plan must be
reviewed at least annually from the date
of the child’s last service plan review.

§748.1383. How does a child’s transfer affect the timing of

the review of a child’s service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2007

(a) You must review a child’s service plan whenever the child’s placement changes
because of a change in the child’s needs. [Medium-Low]
(b) If the child’s placement changes for another reason:
(1) The child’s service planning team must approve the decision not to review
the plan [Low]; and
(2) You must document the decision not to review the plan. [Low]

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§748.1385. How do I review and update a service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2017

To review and update a service plan, you must:

(1) Evaluate the child’s progress and the effectiveness of strategies and techniques used
toward meeting identified needs, including educational progress reports and medical
interventions [Medium-Low];

(2) Identify any new needs and strategies or techniques to meet these needs, including
instructions to appropriate employees [Medium-Low];
(3) Document any achieved or changed objectives [Medium-Low];
(4) If the review shows no progress towards meeting the identified needs of the child,
document reasons for continued placement [Medium-Low];
(5) Evaluate the possible effectiveness and side effects in the use of psychotropic medications
prescribed for the child, any change in psychotropic medications during the period since
the last review, and the behaviors and reactions of the child observed by caregivers,
professional level service providers, and parents, if applicable [Medium];
(6) Document visitation and contacts between the child and the child’s parents, the child and
the child’s siblings, and the child and the child’s extended family [Low];
(7) Update the estimated length-of-stay and discharge plans, if changed [Low];
(8) Evaluate the use and effectiveness of emergency behavior intervention techniques, if
used, since the last service plan. If applicable, this evaluation must focus on [Medium-
High]:
(A) The frequency, patterns, and effectiveness of types of emergency behavior
interventions [Medium];

(B) Strategies to reduce the need for emergency behavior interventions overall
[Medium]; and

(C)Specific strategies to reduce the need for use of personal and mechanical restraints,
emergency medication, and/or seclusion, where applicable [Medium];
(9) Document in the child’s record the review and update of the plan [Medium-Low]; and
(10) Document the names of the persons participating in the review and update. [Low]

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§748.1386. Can an operation continue to review and
update a child’s previous service plan without creating a
new service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2017

Yes, a single service plan that continues throughout the time a child is in residential child care is
acceptable, as long as you:
(1) Complete a preliminary service plan as required by §748.1331 of this title (relating to
What are the requirements for a preliminary service plan?) each time a child is admitted
into your care [Medium-Low]; and
(2) Continue to comply with the service plan review and update requirements in this division
of this subchapter (relating to Service Plan Reviews and Updates). [Medium-Low]

§748.1387. Are the notification, participation,

implementation, and documentation requirements for a
service plan review and update the same as for an initial
service plan?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2007

Yes, the same requirements found in Division 4 of this subchapter (relating to Service Plans)
apply to a service plan review and update. [Medium-Low]

§748.1389. How often must I re-evaluate the intellectual

functioning of a child receiving treatment services for
intellectual disabilities?
Subchapter I, Admission, Service Planning, and Discharge
Division 5, Service Plan Reviews and Updates
January 2017
(a) Each child’s intellectual functioning must be re-evaluated at least every three years
by a psychologist qualified to provide psychological testing [Medium-Low]; or

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 (b) A psychologist must determine the need and frequency for a specific child’s
intellectual functioning to be re-evaluated, such as a young child who may require
more frequent testing. This determination, including justification for the time frame,
must be documented in the child’s record annually by the service planning team.
[Medium-Low]

Division 6, Discharge and Transfer Planning

§748.1431. What does a “transfer” of a child in care mean?

Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
September 2010

A transfer refers to a child in care who is moved from one of your programs to another one of
your programs that you operate under the same permit or at the same location. For example,
you may transfer a child from your emergency care services program to your transitional living
services program, if the programs are under the same permit or at the same location. You may
also transfer a child from your general residential operation to your child-placing agency, if your
child-placing agency office is located on the same property as your general residential operation.

Technical Assistance
A transfer must comply with §§748.1433, 748.1435, and 748.1437. A transfer does not
require:

● A discharge summary
● An admission assessment
● A preliminary or initial service plan

See §748.1383 regarding service plan updates related to transfers.

§748.1433. Who must plan a child’s non-emergency

discharge or transfer?
Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
January 2017

(a) You must involve the following persons in planning the child’s non-emergency
discharge or transfer:
(1) At least one of the child’s current caregivers [Low]; and

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 (2) At least one professional level service provider involved in the child’s
service planning. [Low]
(b) You must invite the following persons to participate in planning the child’s non-
emergency discharge or transfer, if appropriate:
(1) The child [Low];
(2) The child’s parent(s) [Low]; and
(3) Any other person pertinent to the child’s care. [Low]

(c) If you are unable to plan the transfer or discharge with the persons as required
in subsections (a) and (b) of this section, you must document in the child’s
record the reason why. For example, an emergency transfer or discharge was
necessary or the child met the requirements to consent for emergency care
services and decided not to include his parents in planning for the child’s
transfer or discharge. [Low]
(d) If a child in your care is not receiving treatment services, you must inform the
child of the non-emergency discharge or transfer at least four days prior to the
date of the discharge or transfer, unless your licensed child-care administrator
or a professional level service provider has clear justification for not giving the
child such notice. The licensed child-care administrator or professional level
service provider who determines the justification for the child not having the
advance notice of the discharge or transfer, must put the justification in writing
and sign and date it. The justification must be in the child’s record. [Low]
(e) If a child in your care is receiving treatment services, you must inform the child
of the non-emergency discharge or transfer at least four days prior to the date
of the discharge or transfer, unless your treatment director, three members of
the child’s service planning team, or the child’s psychiatrist or psychologist has
justification for not giving the child such notice. Whoever determines the
justification for the child not having the advance notice of the discharge or
transfer must put the justification in writing and sign and date it. The
justification must be in the child’s record. [Low]

§748.1435. How do I discharge or transfer a child who is

an immediate danger to self or others?
Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
January 2017

An employee of your operation must accompany the child to the receiving operation, agency, or
person unless the child’s parent or law enforcement transports the child. [Medium-High]

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§748.1437. What must I document in the child’s record at
the time of a discharge or transfer?
Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
January 2017

At the time of a discharge or transfer, you must document the following:

(1) The date and circumstances of the discharge or transfer [Medium-Low];

(2) Date and time the child was informed of his discharge or transfer, if applicable [Low];

(3) For discharge, the name, address, telephone number, and relationship of the person to
whom you discharge the child, unless the child legally consents to a discharge. If the child
legally consents to a discharge and does not want to involve the child’s parent(s), you
must document this in the child’s record [Medium-Low];
(4) The child’s service plans while in your care for the past 12 months [Medium-Low];
(5) A list of medications the child is taking, the dosage, frequency, and reason the medication
was prescribed [Medium];
(6) Any treatment for a physical condition that is in progress and requires continuing or
follow-up medical care [Medium-High]; and

(7) For emergency discharge or transfer, the explanation given to the child regarding the
reason for the discharge or transfer and the child’s reaction to the discharge or transfer.
[Medium-Low]

§748.1439. When I discharge a child, what information

must I provide to the next placement or caregiver?
Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
September 2010

(a) On or before the child’s discharge, you must attempt to obtain legal consent to
release the information in subsection (b) of this section. If consent is not obtained,
your attempt to obtain consent must be documented in the child’s record. If
consent is obtained, the information must be provided to the receiving placement
or caregiver within 15 days of the date the child is discharged. [Medium-Low]

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 (b) If not already provided at the time of discharge, copies of the following
documentation must be provided to the next placement or caregiver:
(1) A written discharge summary, which must include [Medium-Low]:
(A) Services provided to the child while in your care [Medium-Low];
(B) Accomplishments of the child while in your care [Medium-Low];

(C) An assessment of the child’s remaining needs [Medium-Low];

(D) Recommendations about the services to meet the child’s remaining
needs [Medium-Low];
(E) Support resources for the child, including telephone numbers and
addresses [Medium-Low]; and
(F) Aftercare plans and recommendations for the child, including
medical, psychiatric, psychological, dental, educational, and social
appointments [Medium-Low];
(2) The child’s background information, including progress notes for the past 60
days, if applicable [Medium-Low];
(3) Any unresolved incidents or investigations involving the child, if applicable
[Medium-Low]; and
(4) Assessments and/or evaluations that you have performed for the child,
including the child’s admission assessment, diagnostic assessment,
educational assessment, neurological assessment, and psychiatric or
psychological evaluation. [Medium-Low]

§748.1443. What constitutes an emergency discharge or

transfer?
Subchapter I, Admission, Service Planning, and Discharge
Division 6, Discharge and Transfer Planning
January 2007

An emergency discharge or transfer occurs when:

(1) The parent withdraws a child unexpectedly from care;

(2) There is a medical emergency requiring inpatient care;

(3) The child is absent from your operation and cannot be located; or
(4) There is an immediate danger to the child or others and you determine that you cannot
serve the child.

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Division 7, Release of Child

§748.1481. To whom may I release a child?

Subchapter I, Admission, Service Planning, and Discharge
Division 7, Release of Child
January 2007

(a) Except in an emergency, you must only release a child to the child’s parent, a
person designated by the parent, law enforcement authorities, or a person
authorized by law to take possession of the child. [Medium-High]
(b) You must instruct all employees and service providers to follow your policies for:
(1) Releasing a child [Medium-High];
(2) Verifying the identity of a person authorized to pick up a child but whom the
caregiver does not know [Medium-High];
(3) Recording the identity of the person in a log or other designated location
[Medium-High]; and
(4) Retaining the identifying information at the operation until the child returns.
[Medium-High]

Technical Assistance

If you suspect the person picking up a child is under the influence of drugs or alcohol, you
have the option of contacting local law enforcement to request their assistance.

You may not legally prevent the child from being picked up by a parent or person designated
by the parent; however, you have the option of addressing this issue at admission by asking
parents what they would like for you to do if you do not feel comfortable releasing the child to
one of the parents or their designee and signing an agreement to this effect.

Law enforcement officers and DFPS Child Protective Services staff have the authority by law to
remove a child without a parent’s permission.

You may want to ask to see identification of persons you do not know.

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Subchapter J, Child Care

Division 1, Dental Care

§748.1501. What general dental requirements must my

operation meet?
Subchapter J, Child Care
Division 1, Dental Care
January 2017

(a) A child in your care must receive dental care:

(1) Initially, according to the requirements in §748.1225 of this title (relating to What
are the dental requirements when I admit a child into care?) [Medium];
(2) At as early an age as necessary [Medium];
(3) As needed for relief of pain and infections [Medium-High]; and
(4) As needed for ongoing maintenance of dental health. [Medium-High]

(b) The child’s record must include a written record of each dental examination that
consists of [Medium-Low]:

(1) A copy of the results of the dental examination [Medium-Low];

(2) Follow-up treatment recommended and any appointments scheduled [Medium-

Low]; and

(3) A notation of the child’s refusal to accept dental treatment, if applicable.

[Medium-Low]
(c) For a child in the conservatorship of the department, you must supplement any
information already documented in the child’s health passport in order to comply
with subsection (b) of this section. In your written record for the child, you are not
required to repeat information that is already in the child’s health passport.
[Medium-Low]
(d) You must obtain follow-up dental work recommended by the dentist, such as
treatment of cavities and cleaning. [Medium-High]

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§748.1503. Who must determine the need and frequency of
ongoing maintenance of dental health for a child?
Subchapter J, Child Care
Division 1, Dental Care
January 2007

A licensed dentist must determine the need and frequency of ongoing maintenance of dental
health. You must comply with dentist recommendations for examinations and treatment for each
child. [Medium]

§748.1505. Who must perform dental examinations and

provide dental treatment?
Subchapter J, Child Care
Division 1, Dental Care
January 2007

A health-care professional licensed in the United States to practice dentistry must provide dental
care. [Medium]

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Division 2, Medical Care

§748.1531. What general medical requirements must my

operation meet?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

(a) A child in your care must receive medical care:

(1) Initially, according to the requirements in §748.1223 of this title (relating to What
are the medical requirements when I admit a child into care?) [Medium-High];
(2) As needed for injury, illness, and pain [High]; and
(3) As needed for ongoing maintenance of medical health. [Medium-High]

(b) The child’s record must include a written record of each medical examination
that consists of [Medium]:
(1) A copy of the results of the medical examination Medium;

(2) Follow-up treatment recommended and any appointments scheduled

[Medium];
(3) A notation of the child’s refusal to accept medical treatment, if
applicable [Medium];
(4) If the medical examination is a result of an injury or illness, the
documentation of the date, time, and circumstances surrounding the
injury or illness [Medium]; and
(5) Any other documentation provided by the health-care professional
who performed the examination. [Medium]
(c) For a child in the conservatorship of the department, you must supplement any
information already documented in the child’s health passport in order to comply
with subsection (b) of this section. In your written record for the child, you are
not required to repeat information that is already in the child’s health passport.
[Medium]
(d) You must obtain follow-up medical treatment as recommended by the health-care
professional. [Medium-High]

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Technical Assistance
If there is no date by which to obtain follow-up treatment, then if necessary the follow-up
should be done as soon as practical and integrated into the next service plan review.

§748.1533. Who determines the need and frequency for

ongoing maintenance of medical care and treatment for a
child?
Subchapter J, Child Care
Division 2, Medical Care
January 2007

A health-care professional determines the need and frequency for ongoing maintenance of
medical care and treatment for a child. [Medium-High]

§748.1535. Who must perform medical examinations and

provide medical treatment for a child?
Subchapter J, Child Care
Division 2, Medical Care
January 2007

A health-care professional licensed in the United States to practice in an appropriate medical or

health-care discipline must perform medical examinations and provide medical treatment for a
child. [Medium-High]

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§748.1539. What immunizations must a child in my care
have?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

(a) Each child that you admit must meet and continue to meet the applicable
immunization requirements as specified by the Department of State Health
Services. [Medium-High]
(b) You must maintain current immunizations records for each child in your care,
including any immunization exemptions or exceptions. [Medium-Low]
(c) Unless the child is exempt from immunization requirements, all immunizations
required for the child’s age must [Medium-High]:
(1) Be completed by the date of admission; or
(2) A child that is homeless or a child in foster care shall be admitted temporarily
for 30 days if acceptable evidence of immunization is not available. You
should immediately refer the child to an appropriate health care professional
to obtain the required immunizations

Technical Assistance
The current immunization requirements can be found at [Link]
and:

● For children 0 through 43 months click on “School Requirements”, click on “Main Page”,
to the right of the page click on “Child-Care Facilities”, and click on “2015-2016 Texas
Minimum State Vaccine Requirements for Child-Care Facilities”;
● For children 44 months through 18 years click on “School Requirements”, click on “Main
Page”, to the right of the page click on “Schools”, and click on “2015-2016 Texas
Minimum State Vaccine Requirements for Students Grades K-12”.

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§748.1541. What exemptions or exceptions are there
concerning immunization requirements?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

(a) A child may be exempt from immunization requirements for a medical reason or
reason of conscience, including a religious belief. To claim an exemption, the
person applying for the child’s admission must meet criteria specified by [Medium]:
(1) §42.043(d) and (d-1) of the Human Resources Code; or
(2) The Department of State Health Services rule in 25 TAC §97.62 (relating to
Exclusions from Compliance).
(b) For some diseases, a child who previously had a disease and is accordingly
naturally immune from it may qualify for an exception to immunization
requirements for the disease. To claim this exception, the person applying for the
child’s admission must meet the criteria specified by the Department of State
Health Services rule in 25 TAC §97.65 (relating to Exceptions to Immunization
Requirements). [Medium]

Technical Assistance

● You can find more information regarding the Department of State Health Services’
exemptions at [Link] click on “School
Requirements”, click on “Main Page”, and to the right of the page click on “Exclusions
from Immunization Requirements”.
● While exemptions that comply with HRC §42.043(d) and (d-1) may be used by the
person applying for the child’s admission into an operation, these exemptions may not
comply with the school exemption requirements.

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§748.1543. What documentation is acceptable for an
immunization record?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

Acceptable documentation includes:

(1) An official immunization record generated from a state or local health authority,
including a record from another state. Examples include a registry, a copy of the
current immunization record that is on file at the pre-kindergarten program or
school, or the health passport for a child in the conservatorship of DFPS, so long
as the record includes [Medium]:
(A) The child's name and date of birth [Medium-Low];

(B) The type of vaccine and number of doses [Medium-Low]; and

(C)The month, day, and year the child received each vaccination [Medium-
Low]; or
(2) An official immunization record or photocopy, such as from a doctor's office, that
includes [Medium]:

(A) The child's name and date of birth [Medium-Low];

(B) The type of vaccine and number of doses [Medium-Low];

(C)The month, day, and year the child received each vaccination [Medium-
Low];
(D) The signature (including a rubber stamp or electronic signature) of the
health-care professional who administered the vaccine, or another health-
care professional's documentation of the immunization as long as the
name of the health-care professional that administered the vaccine is
documented [Medium-Low]; and

(E) Clinic contact information, if the immunization record is generated from an

electronic health record system. [Medium-Low]

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§748.1545. Must children in my care have a vision and
hearing screening?
Subchapter J, Child Care
Division 2, Medical Care
September 2010

(a) You must ensure that each child you admit is screened for possible vision and
hearing problems that meet the requirements of the Special Senses and
Communication Disorders Act, Health and Safety Code, Chapter 36. If problems are
detected, the child must have a professional vision and hearing examination.
[Medium-High]
(b) For each child required to be screened, you must keep one of the following in each
child’s record [Medium-Low]:
(1) The individual vision and hearing screening results; however, results found in
the child’s health passport if the child is in DFPS conservatorship are sufficient
to meet this requirement;
(2) A signed statement from the child’s parent that the child’s screening records
are current and on file at the program or school the child attends away from
the operation. The statement must be dated and include the name, address,
and telephone number of the program or school; or
(3) An affidavit from the child’s parent stating that the vision or hearing
screening and/or examination conflicts with the tenets or practices of a
church or religious denomination of the parents.
Technical Assistance
You can refer to the Health and Safety Code, §36.011, for specific information on vision and
hearing screening, including determining which children must be screened and the
timeframes for screening. This information may be accessed on the Department of State
Health Services’ website at: [Link]/vhs/.

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§748.1547. What must I do if a child in my care is
identified as needing a diagnostic vision or hearing
examination?
Subchapter J, Child Care
Division 2, Medical Care
January 2007

You must:

(1) Schedule the child for a professional examination and needed health services [Medium-
High];

(2) Ensure the professional and medical recommendations are carried out [Medium]; and

(3) Convey the information concerning the child’s visual and/or hearing difficulty to the
educational and operation caregivers, so the recommended adjustments can be made in
programs. [Medium]

§748.1549. What special equipment must I provide for a

child with a physical disability?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

When recommended by a health-care professional, you must ensure that a child with a physical
disability has any special equipment that can be reasonably obtained. [Medium-High]

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§748.1551. How often must the physician review a child
with primary medical needs?
Subchapter J, Child Care
Division 2, Medical Care
January 2017

(a) A licensed physician must review a child’s primary medical needs:

(1) At least every 90 days or on a schedule recommended by the child’s physician
[Medium-High]; and
(2) Whenever a medical or related problem occurs. [Medium-High]
(b) The review must address:
(1) Whether the child can continue to be cared for appropriately in the operation
[Medium-High]; and
(2) Any new or changed orders regarding the items outlined in §748.1219(3)(B) of this
title (relating to What are the additional admission assessment requirements when I
admit a child for treatment services?). [Medium-High]

(c) Documentation of each physician review must be filed in the child’s record. [Medium]

§748.1553. How must a caregiver respond when a child is

injured or ill and requires immediate treatment by a health-
care professional?
Subchapter J, Child Care
Division 2, Medical Care
April 2022

For an injury or illness that requires immediate treatment by a health-care professional, the
caregiver must immediately have the child treated by a healthcare professional, contact
emergency services, or take the child to the nearest emergency room after ensuring the
supervision of any other children present. The caregiver must not be required to seek approval
to contact emergency services or to take the child to the nearest emergency room. [High]

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Division 3, Communicable Diseases

§748.1581. What health precautions must I take if

someone in my operation has a communicable disease?
Subchapter J, Child Care
Division 3, Communicable Diseases
January 2017

(a) You must notify the Department of State Health Services (DSHS) after you become
aware that a person in your care, a person who resides at your operation, an
employee, a contract service provider, or a volunteer has contracted a communicable
disease that the law requires you to report to the DSHS as specified in 25 TAC 97,
Subchapter A (relating to Control of Communicable Diseases). [Medium-High]
(b) If a person in your care or a person who resides at your operation has symptoms of a
communicable disease that is reportable to the Department of State Health Services,
you must:
(1) Consult a health-care professional about the person’s treatment [Medium-
High];
(2) Follow the treating physician’s orders, which may include separating the person
from others [Medium-High];
(3) Notify the person’s parent, if applicable [Medium]; and
(4) Sanitize all items used by the sick person before another person uses one of
them. [Medium-High]

(c) If a health-care professional diagnoses a person in your care or a person who resides
at your operation with a communicable disease that is reportable to DSHS, a health-
care professional must authorize the person’s participation in any routine activities at
your operation. The authorization must [Medium-High]:

(1) Be in the person’s record, if the person is in care at your operation [Medium-
Low];

(2) Include a written statement that the person will not pose a serious threat to
the health of the others [Medium]; and

(3) Include any specific instructions and precautions to be taken for the protection
of others, if necessary. [Medium]

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 (d) If an employee, contract service provider, or volunteer has a communicable disease
that is reportable to DSHS, you must obtain written authorization from a health-care
professional for the person to be present at the operation. The written authorization
must include a statement that the person will not pose a serious threat to the health
of the others. [Medium]
(e) You must follow any written instructions and precautions specified by a health-care
professional. [Medium-High]

Technical Assistance
Communicable diseases that exclude a child from routine activity are defined by the
Department of State Health Services (DSHS) in 25 TAC §97.7 (relating to Diseases Requiring
Exclusion from Child-Care Facilities and Schools). You can obtain this information from the
Department of State Health Services.

§748.1583. Who must have a tuberculosis (TB)

examination?
Subchapter J, Child Care
Division 3, Communicable Diseases
September 2010

(a) All persons over the age of one year old must have a documented tuberculosis
screening that was conducted as recommended by the Center for Disease Control,
within 30 days before or after beginning to live, work, or volunteer at your
operation unless the person [Medium]:
(1) Has lived, worked, or volunteered at a regulated residential child-care
operation within the previous 12 months. For example, an employee
beginning employment in a regulated residential child-care operation for the
first time would need a baseline tuberculosis screening. Employment in a
different residential child-care operation would not require a new screening,
as long as documentation in paragraph (2) of this subsection is also
provided. If the employee left employment in regulated residential child-
care for more than 12 months and then returned, a new screening would be
required; and
(2) Provides documentation of a tuberculosis screening.

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 (b) Documentation must consist of a copy of the results of the baseline tuberculosis
screening or chest radiograph, which must be in the person’s record at your
operation within 40 days of the person beginning to live, work, or volunteer at
your operation. Documentation of a copy of the results of treatment (if treatment
is required) must also be maintained in the person’s record. For a child in DFPS
conservatorship, documentation in the child’s health passport is sufficient.
[Medium-Low]
(c) Except on the advice of a physician, no additional screening is required for a
person who continues to live, work, and/or volunteer in a regulated residential
child-care setting.
Technical Assistance

Current CDC recommendations are as follows:

● Conduct a baseline tuberculosis screening. This screening includes a two-step

tuberculosis skin test or a single blood assay for mycobacterium tuberculosis to test for
infection with mycobacterium tuberculosis.
● After the initial baseline screening is conducted and shows negative for tuberculosis, no
other testing is required as long as the person continues to live, work, or volunteer in a
regulated residential child-care operation.
● In any of the following circumstances, use a chest radiograph to exclude TB disease:
o The person’s baseline screening shows positive,
o The result shows a mycobacterium tuberculosis infection, or
o There is documentation of treatment for latent tuberculosis infection or
tuberculosis disease.
Obtain the chest radiograph within a six-month period from the initial baseline screening.
Repeat radiographs are not needed unless symptoms or signs of TB disease develop, unless
recommended by a physician, or unless the person ceases to live, work, or volunteer in a
regulated residential child-care operation for more than 12 months.

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Division 4, Protective Devices

§748.1611. What is a protective device?

Subchapter J, Child Care
Division 4, Protective Devices
September 2010
(a) A protective device:
(1) Protects a person from involuntary self-injurious behavior or permits wounds
to heal; and
(2) Does not prohibit a person’s mobility.
(b) Examples of a protective device are helmets, elbow guards, mittens, and wheelchair
seat belts.
(c) If used appropriately, devices intended to encourage mobility or minimally restrain a
young child for safety purposes, such as wheelchairs, car seats, high chairs, strollers,
bed rails, and child leashes manufactured and sold specifically to harness a young
child for safety purposes, are not protective devices.

§748.1613. What does “involuntary self-injurious

behavior” mean when used in this division?
Subchapter J, Child Care
Division 4, Protective Devices
January 2007

Involuntary self-injurious behavior means a person’s physical movements that are automatic
and not subject to control of the person’s will that may inflict injury to the person.

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§748.1615. May I use protective devices?
Subchapter J, Child Care
Division 4, Protective Devices
January 2007

(a) You may use protective devices if a licensed physician orders their use for a specific
child. The orders must indicate the circumstances under which the protective device
is permitted. [Medium-High]
(b) You may not use protective devices as:
(1) Punishment [Medium-High];
(2) Retribution or retaliation [Medium-High];
(3) A means to get a child to comply [Medium-High];
(4) A convenience for caregivers or other persons [Medium-High]; or
(5) A substitute for effective treatment or habilitation. [Medium-High]

(c) You must document the use of protective devices in the child’s record, service plan,
and service plan reviews. The service planning team must discuss and document in
the child’s service plan reviews [Medium]:

(1) Clinical justification for continued use of protective devices [Medium]; and

(2) Ways to reduce the need for protective devices. [Medium]

§748.1617. Who may use PRN orders with respect to

protective devices?
Subchapter J, Child Care
Division 4, Protective Devices
January 2007

A licensed physician ordering protective devices may use PRN orders. The physician must review
PRN orders for protective devices at least every 90 days. [Medium-High]

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Division 5, Supportive Devices

§748.1631. What is a supportive device?

Subchapter J, Child Care
Division 5, Supportive Devices
January 2007

(a) A supportive device is used:

(1) To support a person’s posture;
(2) To assist a person who cannot obtain and/or maintain normal physical
functioning to improve his mobility and independent functioning; or
(3) As an adjunct to proper care and treatment, for example physical therapy.

(b) The purpose of a supportive device is not to restrict movement.

§748.1633. May I use supportive devices?

Subchapter J, Child Care
Division 5, Supportive Devices
January 2007

(a) You may use supportive devices if a licensed physician orders their use for a
specific child. The orders must indicate the circumstances under which the
supportive device is permitted. [Medium-High]
(b) You may not use a supportive device as a substitute for appropriate nursing
care. [Medium-High]
(c) You may not use supportive devices that include tying or depriving or limiting
the use of a child’s hands or feet. [Medium-High]
(d) You may not use supportive devices as:
(1) Punishment [Medium-High];
(2) Retribution or retaliation [Medium-High];
(3) Means to get a child to comply [Medium-High];
(4) A convenience for caregivers or other persons [Medium-High]; or
(5) A substitute for effective treatment or habilitation. [Medium-High]

(e) If a device is not specifically for assisting with sleep or safety during sleep, you
must remove the device during rest periods. [Medium-High]

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 (f) You must document the use of supportive devices in the child’s record, service
plan, and service plan reviews. The service planning team must discuss and
document in the child’s service plan review [Medium]:

(1) Clinical justification for continued use of supportive devices [Medium];

and
(2) Ways to reduce the need for supportive devices. [Medium]

§748.1635. Who may use PRN orders with respect to

supportive devices?
Subchapter J, Child Care
Division 5, Supportive Devices
January 2007

A licensed physician ordering supportive devices may use PRN orders. The physician must review
PRN orders for supportive devices at least every 90 days. [Medium-High]

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Division 6, Tobacco and E-Cigarette Use

§748.1661. What policies must I enforce regarding tobacco

products and e- cigarettes?
Subchapter J, Child Care
Division 6, Tobacco and E-Cigarette Use
January 2017
(a) A child may not use or possess tobacco products, e-cigarettes, or any type of vaporizers.
[High]
(b) An adult may not smoke tobacco products, e-cigarettes, or vaporizers in the children’s
living quarters or inside any building on your premises where children are present.
[Medium-High]
(c) An adult may only smoke tobacco products, e-cigarettes, or vaporizers on your premises
at a safe distance from the children’s living quarters. [Medium-High]
(d) No one may smoke tobacco products, e-cigarettes, or vaporizers in motor vehicles when
transporting children in care. [Medium-High]

Division 7, Nutrition and Hydration

§748.1691. How often must I feed children in care?

Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007

(a) You must feed an infant whenever the infant is hungry. [Medium-High]
(b) For a toddler or school-age child:

(1) You must provide the child with three meals and at least one snack a day [Medium-
High]; and
(2) No more than 14 hours may pass between the last meal or snack of the day and
the serving of the first meal of the following day. [Medium-High]

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 Technical Assistance

Best practice suggests that toddlers and pre-school children should not go more than three
hours without a meal or snack being offered, unless the child is sleeping or unless otherwise
justified in writing by the child’s health-care professional. Likewise, school-age children
should not go more than six hours without a meal or snack being offered, unless the child is
sleeping or unless otherwise justified in writing by the child’s health-care professional.

§748.1693. What type of food and water must I provide

children?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007
(a) You must provide a child with food that is:
(1) Of adequate variety, quality, and in sufficient quantity to supply the
nutrients needed for proper growth and development according to the United
States Department of Agriculture guidelines [High]; and
(2) Appropriate for the child’s age and activity level. [High]
(b) You must not serve a child nutrient concentrates and supplements, such as protein
powders, liquid protein, vitamins, minerals, and other nonfood substances, in lieu
of food to meet the child’s daily nutritional needs, except with written instructions
from a licensed health-care professional. [Medium-High]
(c) You must ensure drinking water is always available to each child and is served in a
safe and sanitary manner. Children must be well hydrated and must be encouraged
to drink water during physical activity and in warm weather. [Medium-High]

Technical Assistance
Children’s Nutrition
Research suggests the following:

● Milk and milk products served to children 12 months old or older should be Grade A
pasteurized or from sources approved by the Department of State Health Services.
The following milks do not contain the right amounts of all the nutrients infants need and can
harm an infant’s health. Iron-fortified infant formula is the best substitute for breast milk.

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Technical Assistance
Infants should not be given the following unless recommended by the infant’s health-care
professional:

● Cow’s milk;
● Evaporated cow’s milk or home-prepared evaporated cow’s milk formula;
● Sweetened condensed milk;
● Goat’s milk;
● Soy milk; or
● Imitation milks, including those made from rice or nuts (such as almonds) or nondairy
creamer.

([Link]

Feeding Infants: A Guide for Use in the Child Nutrition Programs p.24)

● Milk should be fluid milk.

● Breads and grains should be made from whole-grain or enriched meal or flour.
● Cereal should be whole grain or enriched or fortified.
● Vegetable or fruit juices should be 100% vegetable or fruit juice when used to meet a
serving from the vegetable or fruit group.
● Children under one year old should not be offered unpasteurized or raw honey because
it may contain spores that pose a health risk.
Food Allergies
A food allergy is caused by the body’s immune system reacting inappropriately to a food or
food additive. Symptoms may include wheezing, difficulty breathing, diarrhea, rashes,
itching, hives, and headaches. Food allergies are most common in infants, due to their
immature digestive systems. Food allergies are usually outgrown during the preschool years.
Although any food may cause an allergic reaction, six foods are responsible for most of these
reactions in children. These foods are:

● Peanuts;
● Eggs;
● Milk;
● Tree nuts;

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Technical Assistance
● Soy; and
● Wheat.
A child who is pregnant or breastfeeding should avoid consuming peanuts and peanut
products due to its association with the development of peanut allergies in infants. It is best
not to offer children under two to three years old peanuts or peanut products, such as peanut
butter and foods containing or cooked in peanut oil, because of the potential of developing
this life-threatening and often life-long allergy. Foods that cause allergic reactions should be
eliminated from the diet. However, it is important that the diet still contain a variety of foods
for healthy growth and development. A child should receive a medical evaluation if food
allergies are suspected. If the child’s licensed physician determines that the child has a food
allergy, a determination should be made of whether the child’s allergic condition meets
USDA’s definition of disability.
Food Intolerance
A food intolerance is an adverse food-induced reaction that does not involve the body’s
immune system. Lactose intolerance is one example of food intolerance. A person with
lactose intolerance lacks an enzyme needed to digest milk sugar. When that person eats milk
products, gas, bloating, and abdominal pain may occur. It is best to provide food
substitutions for children with food intolerances who cannot consume the regular meal.
([Link] - pg. 18) Choking
Research has shown that 90% of fatal choking occurs in children younger than four years old.
Examples of foods that present a risk of choking include hot dogs sliced into rounds, whole
grapes, hard candy, nuts, seeds, raw peas, dried fruit, pretzels, chips, peanuts, popcorn,
marshmallows, spoonsful of peanut butter, and chunks of meat larger than can be swallowed
whole.

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§748.1695. What are the specific requirements for feeding
an infant?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2017

(a) You must feed the infant:

(1) On demand following the infant’s lead on when to feed, how long to feed, and how
much to feed [Medium-High]; and
(2) Based on the recommendation of the infant’s health-care professional, who must
approve you giving the infant any milk other than fortified formula. [Medium-High]
(b) You must hold the infant while feeding an infant that is:
(1) Birth through six months old [Medium-High]; or
(2) Unable to sit unassisted in a high chair or other seating equipment during feeding.
[Medium-High]
(c) You must never prop a bottle by supporting it with something other than the infant’s or
adult’s hand. [Medium-High]
(d) If you care for more than one infant, you must:
(1) Label each bottle and training cup with the child’s first name and initial of last name
[Medium-High];
(2) Not permit the infant to share bottles or training cups [Medium-High]; and
(3) Sanitize high chair trays before each use. [Medium-High]

Technical Assistance
Best practice suggests:

● Feeding infants while infants are awake;

● Providing regular snack and meal times for infants who eat table food; and
● Ensuring children no longer being held for feeding are fed in a safe manner.

Suggested meals:

Infant’s age Breakfast Lunch and Supper Snack

Birth through 4 to 6 oz. of iron 4 to 6 oz. of iron 4 to 6 oz. of iron
three months: fortified infant fortified infant formula fortified infant
Serve liquids only formula formula

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 Infant’s age Breakfast Lunch and Supper Snack
Four months • 4 to 8 oz. of • 4 to 8 oz. of iron 4 to 6 oz. of iron
through seven iron fortified fortified infant fortified infant
months: infant formula formula
Add semisolid formula • 0 to 3 tablespoons
foods • 0 to 3 of iron fortified
tablespoons infant cereal
of iron • 0 to 3
fortified tablespoons of
infant strained fruit
cereal and/or strained
vegetables
* May be started later
in the age range
Eight months • 6 to 8 oz. of • 6 to 8 oz. of iron • 2 to 4 oz. of
through eleven iron fortified fortified infant iron fortified
months: infant formula infant formula
Add modified formula • 2 to 4 tablespoons or 100% fruit
table foods • 2 to 4 of iron fortified juice
tablespoons infant cereal, • 0 to 1/2 slice of
of iron and/or soft bread, or
fortified • 1 to 4 tablespoons 0 to 2 crackers
infant strained meat, fish,
cereal or poultry, mashed
• 1 to 4 egg yolk, or
tablespoons mashed cooked dry
of strained beans or peas, or
fruit and/or • 1/2 to 2 oz. of
strained Cottage cheese,
vegetables yogurt, or cheese,
or
• 1 to 4 tablespoons
mashed or diced
soft fruit or mashed
or soft cooked
vegetables

([Link] - pg. 24)

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 Technical Assistance (continued)
An infant who is hungry may wake and toss, suck on his or her fist, cry or fuss, or look like
he or she is going to cry. It is best to respond to early signs of hunger rather than waiting
until the infant is upset and crying hard from hunger. (Feeding Infants: A Guide for Use in the
Child Nutrition Programs p.33)
Signs of fullness include the infant sealing his or her lips together, decreased sucking, spitting
out the nipple, turning away from the bottle, or pushing the bottle away.

§748.1697. What are the specific requirements for feeding

toddlers and older children?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2017

(a) A toddler or older child must eat meals in the dining areas unless the service
planning team’s recommendations are to the contrary. [Medium]
(b) Food service practices for children receiving treatment services for primary medical
needs or an intellectual disability, including non-mobile children, must encourage
self- help and development. [Medium]

Technical Assistance
The daily food needs for children 12 months through 23 months are included in the following
chart:

Food Groups Number of Servings Number of Serving Size

to Meet 1/3 of Servings to
Daily Needs Meet Daily
Needs
Milk, 1 and 1/3 4 • 4 oz. Milk or
Yogurt, • 1/2 oz.
and Cheese or
Cheese • 4 oz. Yogurt

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 Food Groups Number of Servings Number of Serving Size
to Meet 1/3 of Servings to
Daily Needs Meet Daily
Needs
Meat, 1 3 • 1/2 to 1 oz.
Poultry, Cooked meat or
Fish, Dry • 1/2 to 1 Egg or
Beans, • 1/2 c.
Eggs, and Cooked
Nuts beans

Vegetables 1 and 1/3 + 5 • 2 to 3 Tb.

and Fruit Another Cooked
vegetable should vegetables
be offered to a of
child when dried • 2 to 3 Tb.
peas or beans Canned fruit
are counted as a or
meat alternative. • 1/4 to 1/2
Small fresh
fruit or
• 1/4 to 1/2 c.
Juice
Bread, 1 and 1/3 + 5 • 1/2 Slice
Cereal, Rice, Bread or
and Pasta • 1/4 to 1/2 c.
Cooked Cereal
or
• 4 oz. To 1/3
c. Pasta or
Rice or
• 1 or 2 Crackers

Technical Assistance (continued)

The daily food needs for children two years through five years old are included in the
following chart:

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 Food Groups Number of Number of Serving Size
Servings to Servings to
Meet 1/3 of Meet Daily
Daily Needs Needs
Milk, Yogurt, 2/3 of 2 • 1 c. Milk or
and Cheese one • 2 oz. Cheese or
serving • 1 c. Yogurt

Meat, Poultry, 2/3 of 2 • 2 & 1/2 oz. Cooked meat

Fish, Dry one or
Beans, Eggs, serving • 1 Egg or
and Nuts • 1/2 c. Cooked beans

Vegetable 1 3 • 1/2 c. Raw or

Another cooked vegetables
vegetable of
should be • 1 c. Raw leafy vegetable.
offered to a
child when
dried peas or
beans are
counted as a
meat
alternative.
Fruit 2/3 of 2 • 1/2 c. Canned or
one chopped fruit or
serving • 1 Piece fruit or
melon wedge or
• 1/4 c. Dried fruit or
• 3/4 c. Juice

Bread, 2 6 • 1 Slice Bread or

Cereal, Rice, • 1/2 c. Cooked Cereal or
and Pasta • 1 oz. Ready to eat cereal
or
• 1/2 c. Cooked pasta
or Rice or
• 3 to 5 Crackers

Technical Assistance (continued)

The daily food needs for children six years old and older are included in the following chart:

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 Food Groups Number of Number of Serving Size
Servings to Servings to
Meet 1/3 of Meet Daily
Daily Needs Needs

Milk, Yogurt, 2/3 to 1 2 to 3 • 1 c. Milk, or

and Cheese A child who is • 1 c. Yogurt, or
pregnant or • 1 & 1/2 oz. Natural
breast feeding cheese, or
should have at • 2 oz. Processed cheese
least 3 servings
of milk or dairy
products.
* Teenagers
and young
adults should
have at least 3
servings of milk
or dairy
products.
Meat, Poultry, 2/3 to 1 2 • 3 oz. Cooked meat,
Fish, Dry poultry, or fish, or
Beans, Eggs, • 1 egg or
and Nuts • 1/2 c. Cooked dry beans,
or
• 1/2 c. Tofu, or
• 2 Tb. Peanut butter
Vegetable 1 to 1 and 2/3 4 • 1/2 c. Raw or
Another cooked vegetables,
vegetable of
should be • 1 c. Raw leafy
offered to a vegetable, or
child when • 3/4 c. vegetable juice
dried peas or
beans are
counted as a
meat
alternative.

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 Food Groups Number of Number of Serving Size
Servings to Servings to
Meet 1/3 of Meet Daily
Daily Needs Needs

Fruit 2/3 to 1 and 2 to 4 • 1 medium piece of fruit,

1/3 or
• 1/2 c. Canned,
chopped, or cooked
fruit, or
• 1/4 c. Dried fruit or
• 3/4 c. Fruit juice

Bread, 2 to 3 and 2/3 6 to 11 • 1 slice bread, or

Cereal, Rice, • 1 oz. Ready-to-eat
and Pasta cereal or
• 1/2 c. Cooked Cereal or
• 1/2 c. Cooked pasta
or Rice or
• 4 to 6 Crackers

Technical Assistance (continued)

Most teenage boys will need to eat the higher number of servings from each food group, and
teenage girls who participate in vigorous sports may need to eat a higher number of
servings. It is best to serve enough food to allow these children second servings from the
vegetable, fruit, grain, and milk groups and have snacks available if the child becomes
hungry.
Best practice suggests that snacks be nutritious and include at least one of the following,
which can be included in the child’s daily food needs:

● One serving from the fruit or vegetable group;

● One serving from the milk group;
● One serving from the grain group; or
● One serving from the meat or meat alternative group.

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§748.1699. What must I do if a child refuses to or cannot
eat a meal or snack that I offer?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007

(a) You must offer a child a meal or snack according to this division, but you may not
force the child to eat. You are not required to offer other food to a child who
[Medium-High]:
(1) Refuses a meal or snack; or
(2) Chooses not to be present when a meal or snack is scheduled.
(b) You must discuss recurring eating problems with the child’s parent. [Medium-Low]
(c) If a meal or snack is not appropriate to meet a child’s individual needs, for example
food allergies or religious reasons, then you must offer the child an appropriate
nutritional substitute. [Medium]

§748.1701. What must I do if a child requires a therapeutic

or special diet?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007

(a) To serve a therapeutic or special diet to a child, you must have written approval in
the child’s record from a licensed physician or a registered or licensed dietitian.
[Medium-High]
(b) If a child requires a therapeutic or special diet, you must give the following people
information regarding the diet:
(1) All employees who prepare and serve food [Medium]; and
(2) The child’s caregivers. [Medium]
(c) You must make dietary alternatives available to a child who has special health needs.
[Medium]

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§748.1703. What are the requirements for daily menus?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
September 2010

(a) You must maintain daily menus showing all meals and snacks that you prepare and serve.
[Low]
(b) You must document food substitutions on the menu. Food substitutions must be of
comparable food value. [Low]
(c) You must date menus and keep copies for 90 days. [Low]
(d) This rule does not apply to meals prepared and served in cottage homes.

§748.1705. What are the nutrition requirements for a child

with primary medical needs?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
September 2008

(a) You must feed a child with primary medical needs according to his medical and
developmental needs. [Medium-High]
(b) A licensed physician must prescribe tube feeding. A dietitian or physician must plan the
diet that the physician prescribes. [Medium-High]
(c) Children must eat in an upright position unless the service planning team
recommendations are to the contrary. [Medium-High]

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§748.1707. What are the requirements for tube-feeding
formula?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007

(a) A registered or licensed dietitian, physician, or a registered nurse must ensure the
caregiver that prepares the formula is adequately trained and has demonstrated
competency in preparing the formula. [Medium-High]
(b) Tube feeding formulas must supply the recommended dietary allowance for each child.
[Medium-High]
(c) You must prepare and store the formula [Medium-High]:
(1) According to directions; or
(2) As prescribed by a health-care professional.

§748.1709. What are the requirements for using a

nasogastric tube to feed a child?
Subchapter J, Child Care
Division 7, Nutrition and Hydration
January 2007

(a) Only the following may insert a nasogastric tube [High]:

(1) A physician; or
(2) A registered nurse according to a physician’s written orders.

(b) You must document each insertion in the child’s record. The documentation for each
insertion must include the [Medium]:
(1) Signature of the nurse who inserted the tube [Medium]; and
(2) Date of the insertion. [Medium]

(c) You must follow the physician’s written orders concerning the tube. [High]

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Division 8, Additional Requirements for Infant Care

§748.1741. What do certain words mean in this division?

Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

These terms have the following meaning in this division:

(1) Baby doorway jumper – A bucket seat that is suspended from a doorway by an
elastic bungee cord that allows an infant to bounce while sitting in the seat.
(2) Baby walker – A baby walker allows an infant to sit inside the walker equipped with
rollers or wheels and move across the floor.
(3) Bouncer seat – A stationary seat designed to provide gentle rocking or bouncing
motion by an infant’s movement, or by battery-operated movement. This type of
equipment is designed for an infant’s use from birth until the child can sit up
unassisted.
(4) Restrictive device – Equipment that places the body of an infant in a position that
may restrict airflow or cause strangulation; usually, the infant is placed in a semi-
seated position. Examples of restrictive devices are car seats, swings, bouncy
seats, and high chairs.

§748.1743. What are the basic care requirements for an

infant?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

(a) Each infant must receive individual attention, including playing, talking, cuddling, and
holding. [Medium-High]
(b) When an infant is upset, a caregiver must hold and comfort the infant. [Medium-High]
(c) A caregiver must provide prompt attention to an infant’s physical needs, such as feeding
and diapering. [Medium-High]
(d) An infant’s caregiver must ensure that the environment is safe. For example, the
caregiver must free the area of objects that may choke or harm the infant, take measures
to prevent electric shock, free the area of furniture that is in disrepair or unstable, and
allow no unsupervised access to water to prevent the risk of drowning. [Medium-High]

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 (e) Items necessary for diaper changing must be kept out of the reach of children, but do not
need to be in locked storage. [Medium]
(f) An infant’s caregiver must never leave the infant unsupervised. A sleeping infant is
considered supervised if the caregiver is within eyesight or hearing range of the infant and
can intervene as needed, or if the caregiver uses a video camera or audio monitoring
device to monitor the infant and is close enough to the infant to intervene as needed.
[Medium-High]

§748.1745. What steps must a caregiver follow when

changing a child’s diaper?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2007

A caregiver must:
(1) Promptly change soiled or wet diapers or clothing [Medium];

(2) Thoroughly cleanse children with individual cloths or disposable towels [Medium];
(3) Use a clean, individual cloth or disposable towel to dry the child [Medium];
(4) Ensure that the child is dry before placing a new diaper on the child [Medium]; and

(5) Keep all diaper-changing supplies out of children’s reach. [Medium]

§748.1747. What must I do to prevent the spread of germs

when diapering children?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2007

To prevent the spread of germs when diapering a child, you must:

(1) Wash your hands with soap and running water before and after diapering a child
[Medium];
(2) Cover a container used for soiled diapers or keep it in a sanitary manner, such as placing
soiled diapers in individual sealed bags [Medium];
(3) Discard a disposable towel after use [Medium]; and
(4) Launder any cloth before reusing it. [Medium]

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§748.1749. What furnishings and equipment must I have in
my infant care area?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2007

Your infant care area must at a minimum include the following furnishings and equipment:

(1) An individual crib for each infant [Medium]; and

(2) A sufficient number of toys to keep each child engaged in activities. [Medium-Low]

§748.1751. What specific safety requirements must my

cribs meet?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

(a) All cribs must have:

(1) A firm, flat mattress that snugly fits the sides of the crib. The mattress must not be
supplemented with additional foam material or pads [Medium-High];
(2) Sheets that fit snugly and do not present an entanglement hazard [Medium-High];
(3) A mattress that is waterproof or washable [Medium-High];
(4) Secure mattress support hangers, and no loose hardware or improperly installed or
damaged parts [Medium-High];
(5) A maximum of 2 3/8 inches between crib slats or poles [Medium-High];
(6) No corner posts over 1/16 inch above the end panels [Medium-High];
(7) No cutout areas in the headboard or footboard that would entrap an child’s head or
body [Medium-High];
(8) Drop gates, if present, which fasten securely and cannot be opened by a child
[Medium-High]; and
(9) Documentation that each crib meets the applicable federal rules at Title 16, Code of
Federal Regulations, Parts 1219 or 1220, concerning “Safety Standards for Full-Size
Baby Cribs” and “Safety Standards for Non-Full-Size Baby Cribs,” respectively, or
documentation that each crib is a medical device listed and registered with the U.S.
Food and Drug Administration. [High]

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(b) You must sanitize each crib when soiled and before reassigning the crib to a
different child. [Medium-High]

(c) You must never leave a child in the crib with the drop gate down. [High]

(d) You may not have stackable cribs. [Medium-High]

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Technical Assistance
● Research shows more babies die in incidents involving cribs than with any other piece of
nursery equipment.
● Non-full-size cribs may be either smaller or larger than a full size crib, or shaped
differently than the usual rectangular crib. The category of non-full-size cribs includes
oversized, specialty, undersized, and portable cribs, but does not include any product
with mesh/net/screen siding, non-rigidly constructed cribs, cradles, car beds, baby
baskets, or bassinets. For requirements for play yards, which are mesh or fabric sided
products, see §748.1753 of this title (relating to Are play yards allowed?).
● Regarding paragraph (1), a mattress is too loose if there are more than two finger
widths between the edge of the mattress and the crib side.
● Regarding paragraph (5), if a soda can fits easily between the slats on a crib, the slats
are too wide.
Regarding paragraph (9):
● Cribs manufactured before 06/28/2011 may not meet the safety standards established
by the Consumer Product Safety Commission (CPSC).
● Documentation that you may use to verify your crib is in compliance with CPSC
regulations includes the certificate of compliance, registration card, or tracking label.
You may request this documentation from the manufacturer or retailer.
o The certificate of compliance is a document that describes the crib and
whether the crib complies with 16 CFR 1219 or 16 CFR 1220. The certificate
includes the contact information for the importer or domestic manufacturer
and the testing lab. It also lists the date and location of manufacture and
testing.
o The registration card is a postage-paid form provided by the crib
manufacturer. The card includes the manufacturer’s name and contact
information, model name, model number, and the date of manufacture.
o The tracking label is attached to the crib and contains basic information such
as the date of manufacture and the source of the crib.
o You may find additional guidance on obtaining supporting documentation for
your cribs on the CPSC website at [Link]
● In order to maintain the required documentation for each crib consider developing a
system to easily tie the required documentation to the appropriate crib. Examples may
include photographs of each crib attached to the documentation or a tracking sheet that
includes information such as the date of purchase, manufacturer and model number,
date of manufacture, and what documentation is on file (certificate of compliance,
tracking label, or registration card).
● A crib that meets the definition of “device” in the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. § 201(h)) is subject to regulation by the Food and Drug Administration
(FDA), not CPSC. A crib that is not a “device” is subject to CPSC’s crib standards. If
your crib is a medical device, the manufacturer must be registered with the FDA. For
additional information, visit the FDA website at
[Link]
vice/RegistrationandListing/[Link]

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§748.1753. Are play yards allowed?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

(a) Play yards, which are mesh or fabric sided cribs, are allowed if they meet the
following safety requirements:
(1) The play yards must be used according to the manufacturer’s instructions,
including the cleaning of the cribs [Medium-High];
(2) Play yards must have:
(A) A firm, flat mattress that snugly fits the sides of the crib and that
is designed for the crib. The mattress must not be supplemented
with additional foam material or pads [Medium-High];
(B) Sheets that fit snugly and do not present an entanglement hazard
[Medium-High];
(C) A mattress that is waterproof or washable [Medium-High];
(D) Secure mattress support hangers, and no loose hardware or
improperly installed or damaged parts [Medium-High];
(E) A minimum height of 22 inches from the top of the railing to the
mattress support at its lowest level [Medium-High];
(F) Folded sides that securely latch in place when raised [Medium-
High];
(G) For mesh cribs, mesh openings that are 1/4 inch or less [Medium-
High]; and
(H) Mesh or fabric that is securely attached to the top rail, side rail,
and floor plate [Medium-High]; and
(3) You must never leave an infant in a play yard with a side folded down.
[High]

(b) If you become aware of a recall for a non-full-size crib or a mesh crib that you are
using, you must discontinue its use immediately. [High]

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§748.1755. What equipment must have safety straps
before I can use it with an infant?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2007

If you use a high chair, swing, stroller, infant carrier, rocker, bouncer seat, or a similar type of
equipment for an infant:
(1) It must be equipped with safety straps [High]; and
(2) The safety straps must be fastened whenever the infant is using the equipment. [High]

§748.1757. What types of equipment are not allowed for

use with infants?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

(a) You may not use any of the following types of equipment with infants:
(1) Baby walkers [Medium-High];
(2) Baby doorway jumpers [Medium-High];
(3) Accordion safety gates [Medium-High];
(4) Toys that are not large enough to prevent swallowing or choking [High]; and
(5) Bean bags, waterbeds, and foam pads for use as sleeping equipment. [High]
(b) Except for a tight fitting sheet and as provided in subsection (c), the crib must be bare for
an infant younger than twelve months of age. [High]
(c) A crib mattress cover may be used to protect against wetness, but the cover must:
(1) Be designed specifically for the size and type of crib and crib mattress that it is
being used with [Medium-High];
(2) Be tight fitting and thin [Medium-High]; and
(3) Not be designed to make the sleep surface softer. [Medium-High]
(d) An infant receiving treatment services for primary medical needs may have special items
that assist with safe sleep at the written recommendation of a health-care professional.
You must keep the recommendation in the child’s record. [Medium-High]

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Technical Assistance
The prohibited equipment is not safe or beneficial to an infant’s development and is not
recommended by either the American Academy of Pediatrics or the Consumer Product Safety
Commission.
● Regarding paragraph (1), baby walkers present a hazard due to risk of falling down
stairs or steps and tipping over thresholds or carpet edges. They provide infants
accessibility to potentially hot surfaces, containers of hot liquids such as coffee,
dangling appliance cords, poisonous plants or hazardous substances and buckets, toilets
or other containers of water.
● Regarding paragraph (2), baby doorway jumpers present a hazard due to increased risk
of injury to the child as a result of spinning, swinging, or bumping into walls while
placed in the jumper.
● Regarding paragraph (3) accordion gates with large V-shaped openings along the top
edge and diamond shaped openings between the slats present entrapment and
entanglement hazards resulting in strangulation, choking or pinching to children who try
to crawl through or over the gate.
● Regarding paragraph (4), examples of items that present a choking hazard for infants
and toddlers include coins, balloons, safety pins, marbles, Styrofoam ©
and similar
products, and anything that can fit into the inside tube of a toilet-paper roll.
● Regarding paragraph (6), studies on SIDS support eliminating soft bedding materials,
sleep positioning devices, and stuffed toys used for infants under twelve months.
Examples of items that can be used as alternatives to blankets and sheets are a one-
piece footed sleeper, a body shirt or undershirt underneath a sleeper, sleep sack or
wearable blanket that zips up the front and can be worn over a sleeper. Wearable
blankets are sleeveless, so a baby can still move his arms around while the rest of his
body stays covered.

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§748.1759. What activities must I provide for infants?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

You must provide the following activities for an infant:

(1) Multiple opportunities each day to explore in a safe and clean area that is outside
of the crib or restrictive device [Medium-High];
(2) Opportunities for visual, auditory, and sensory stimulation [Medium-High];

(3) Opportunities for small- and large-muscle development [Medium-High]; and

(4) A supervised nap period that allows the infant to maintain the child’s own pattern
of sleeping and waking. [Medium-High]

§748.1761. How long may an infant remain in a crib after

awakening?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

An infant may remain in the crib for up to 30 minutes after awakening, as long as the infant is
content and responsive. [Medium-High]

§748.1763. What are the specific sleeping requirements for

infants?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

(a) You must place an infant not yet able to turn over on his own in a face-up sleeping
position unless a health-care professional orders otherwise. You must keep any
orders from a health-care professional in the child’s record. [High]
(b) An infant’s head, face, or crib must not be covered at any time by an item such as a
blanket, linen, or clothing. [High]
(c) An infant may not sleep in a prone position with a sleeping adult at any time,
including in the adult’s bed, on a couch, etc. [High]

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§748.1765. May I allow infants to sleep in a restrictive
device?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
January 2017

No. You may not allow an infant to sleep in a restrictive device. If an infant falls asleep in a
restrictive device, the infant must be removed from the device and placed in a crib as soon as
possible. [High]

Technical Assistance
● Infants sleeping in restrictive devices are at risk for strangulation, injury, and positional
asphyxiation.
● You must not place a car seat in a crib with a sleeping infant.

§748.1767. May I swaddle an infant to help the infant

sleep?
Subchapter J, Child Care
Division 8, Additional Requirements for Infant Care
April 2021

You may not lay a swaddled infant down to sleep or to rest on any surface at any time, unless
you have an order signed by a health-care professional. You must keep the order in the child’s
record. [High]

Technical Assistance
There is evidence that swaddling can increase the risk of serious health outcomes, including
SIDS and hip disease, and research does not provide definitive data to support the use of
swaddling. Even with newborns, research does not provide conclusive data about whether
swaddling should be used. Swaddling blankets that become loose during sleep pose an
additional risk for infants. For concerns with maintaining an infant’s temperature, appropriate
clothing and/or a sleeveless infant sleep sack that does not restrict the infant’s movement
can be utilized. For more information on safe sleep, see the American Academy of Pediatrics
Health Initiatives for Safe Sleep and the National Institutes of Health Safe to Sleep
Campaign.

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Division 9, Additional Requirements for Toddler Care

§748.1791. What are the basic care requirements for a

toddler?
Subchapter J, Child Care
Division 9, Additional Requirements for Toddler Care
January 2017

(a) Each toddler must receive individual attention, including playing, talking, and cuddling.
[Medium-High]
(b) A toddler’s caregiver must ensure that the environment is safe. For example, the
caregiver must free the area of objects that may choke or harm the toddler, take
measures to prevent electric shock, free the area of furniture that is in disrepair or
unstable, and allow no unsupervised access to water to prevent the risk of drowning.
[High]
(c) A toddler’s caregiver must never leave the toddler unsupervised. A sleeping toddler is
considered supervised if the caregiver is within eyesight or hearing range of the toddler
and can intervene as needed, or if the caregiver uses a video camera or audio monitoring
device to monitor the toddler and is close enough to the toddler to intervene as needed.
[High]

§748.1793. What furnishings and equipment must I

provide for toddlers?
Subchapter J, Child Care
Division 9, Additional Requirements for Toddler Care
January 2017

Furnishings and equipment for toddlers must at a minimum include the following:

(1) Age-appropriate seating, tables, and nap and sleep equipment. Toddlers may use
cribs or beds, as appropriate [Medium];

(2) Enough popular items available, so a toddler is not forced to compete for them
[Medium]; and

(3) Containers or low shelving that are accessible to toddlers, so toddlers can safely
obtain the items without adult intervention. [Medium]

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§748.1795. What activities must I provide for toddlers?
Subchapter J, Child Care
Division 9, Additional Requirements for Toddler Care
January 2007
You must provide the following activities for a toddler:
(1) Daily opportunities for outdoor play, when weather permits; [Medium]
(2) Opportunities for thinking skills and sensory development; [Medium]
(3) Opportunities for small and large-muscle development; [Medium]
(4) Opportunities for language development [Medium];
(5) Opportunities for social/emotional development [Medium];
(6) Opportunities to develop self-help skills such as toileting, hand washing, and feeding
[Medium]; and
(7) Supervised naptimes. You must provide a supervised sleep or rest period after the noon
meal for all toddlers. [Medium]

Technical Assistance
Best practices for nap or rest time include the following:

● Schedule a supervised sleep or rest period after the noon meal for children 12 months
of age or older or according to the child’s individual physical needs;
● Lighting should allow for visual supervision of the children;
● Limit the sleep or rest period to no more than three hours;
● Do not force children to sleep and do not put anything in or on a child’s head or body to
force the child to rest or sleep;
● Allow each child who is awake after resting or sleeping for one hour to participate in an
alternative, quiet activity until the nap/rest time is over for other children who may be
resting; and
● Take a toddler who sleeps or rests in a crib out of the crib for other activities when the
child awakens.

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Division 10, Additional Requirements for Pregnant and
Parenting Children
Technical Assistance
If you have a pregnant child in care in the final trimester of pregnancy, it is best to have a
complete and sterile emergency obstetrical kit available in a designated location at your
operation and when transporting the child.
A sterile emergency obstetrical kit should contain the following supplies:
● Pair of sterile exam gloves such as latex gloves;
● One disposable plastic apron;
● One plastic lined underpad;
● Three disposable towels;
● Two O.B. towelettes to wipe and clean the birth opening prior to delivery;
● Four sterile gauze sponges;
● Two sterile umbilical cord clamps to clamp the umbilical cord before cutting;
● One sterile disposable pair of scissors to cut the umbilical cord;
● One disposable bulb syringe for fluid removal from the infant’s mouth and throat;
● Receiving blanket;
● One plastic bag to hold the placenta for the hospital placenta examination;
● Two twist ties for use with the plastic bag; and
● One sterile O.B. pad for post delivery.
It is also advisable for your operation to have the following items easily accessible:
● An instruction manual for caregivers on emergency childbirth delivery;
● A clean sheet and/or blanket for the mother who is about to give birth to prevent
hypothermia; and
● A clean knit infant cap to prevent hypothermia in a newborn infant.

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§748.1821. What information must I provide a pregnant
child regarding her pregnancy?
Subchapter J, Child Care
Division 10, Additional Requirements for Pregnant and Parenting Children
September 2010

You must:

(1) Ensure information, training, and counseling is available regarding health aspects
of pregnancy, preparation for child birth, and recovery from child birth [Medium];
(2) Ensure the pregnant child receives nutritional counseling and guidance that meets
generally accepted standards, including nutrition during pregnancy, lactation, and
foods to avoid [Medium]; and
(3) Inform the child, within seven days of admission or upon learning of the
pregnancy, of her right to be free from pressure to get an abortion, relinquish her
child for adoption, or to parent her child. [Medium]

§748.1823. Is the use of emergency behavior intervention

of a pregnant child permitted in my operation?
Subchapter J, Child Care
Division 10, Additional Requirements for Pregnant and Parenting Children
January 2007

If your policies allow for the use of personal restraints on a pregnant child:
(1) The health-care professional attending to the child’s pregnancy must document
whether any type of emergency behavior intervention that your policies allow is
inadvisable [Medium-High]; and
(2) You may not use any emergency behavior intervention that the child’s health-
care professional attending to her pregnancy finds inadvisable. [High]

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§748.1825. If my policies permit the admission of
adolescent parents with their child(ren), who is responsible
for the care of the adolescent’s child(ren)?
Subchapter J, Child Care
Division 10, Additional Requirements for Pregnant and Parenting Children
January 2007

If your policies permit the admission of adolescent parents with their child(ren):
(1) An adolescent parent must provide most of the care for her child [Medium];

(2) Caregivers must be available to the adolescent parent as a resource and support
[Medium-High]; and
(3) When you care for an adolescent’s child in the adolescent parent’s absence, you are
responsible for that child as if the child is in your care. [Medium-High]

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Subchapter K, Operations That Provide Care for Children
and Adults

Division 1, Scope

§748.1901. What operations do the rules in this subchapter

apply to?
Subchapter K, Operations That Provide Care for Children and Adults
Division 1, Scope
January 2007

The rules in this subchapter apply to operations that provide care for both children and adults.

Division 2, General Requirements

§748.1931. After a child in my care turns 18 years old, may

the person remain in my care?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
September 2010

(a) A young adult may remain in your care until his 23rd birthday in order to [Low]:
(1) Transition to independence, including attending college or vocational or technical
training;
(2) Attend high school, a program leading to a high school diploma, or GED classes;
(3) Complete your program; or

(4) Stay with a minor sibling.

(b) A young adult who turns 18 in your care may remain in your care indefinitely if
the person [Low]:

(1) Continues to need the same level of care; and

(2) Is unlikely to physically and/or intellectually progress over time.

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§748.1933. May I admit a young adult into care?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
September 2010

(a) You may admit a young adult into your transitional living program.
(b) For other programs or services, the young adult must [Low]:
(1) Come immediately from another residential child-care operation if the reason for
admittance is consistent with a condition listed in §748.1931 of this title (relating to
After a child in my care turns 18 years old, may the person remain in my care?); or
(2) Be in the care of the Texas Department of Family and Protective Services.
(c) A young adult may remain in your care until his 23rd birthday. [Low]

§748.1935. How does the child/caregiver ratio apply if I

provide care to both children and adults?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
January 2007

(a) If you provide care to both children and adults, you may maintain the required
child/caregiver ratio by [Medium-High]:

(1) Counting all residents in your care as children and maintaining the appropriate
ratio; or

(2) Assigning caregivers to work exclusively with the children in care.

(b) The child/caregiver ratio for minor and adult residents applies to operation-sponsored
activities or appointments, regardless of where they occur. [Medium-High]

(c) You may not count adult residents as caregivers in the child/caregiver ratio. [Medium-
High]

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§748.1937. May an adult in care share a bedroom with a
child in care?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
April 2022

(a) An adult in care may share a bedroom with a child in care if [Medium-Low]:
(1) The adult and child are siblings;

(2) The adult is the child’s parent;

(3) Both of them are non-ambulatory and receive treatment services for primary medical
needs; or
(4) The child is at least 16 years old, the age difference between them does not exceed 24
months, and the adult meets the requirements of:
(A) §748.1931 of this division (relating to After a child in my care turns 18 years old,
may the person remain in my care?); or
(B) §748.1933 of this division (relating to May I admit a young adult into care?).
(b)The following must occur before you may allow an adult in care and a child in care to share a
bedroom, unless the adult is the child’s parent:

(1) The service planning team must determine that there is no known risk of harm to the
child after assessing [Medium]:
(A) Their behaviors [Medium];

(B) Their compatibility with each other [Medium];

(C)Their respective relationships [Medium];
(D)Any history of possible sexual trauma or sexually inappropriate behavior [Medium];
and
(E) Any other identifiable factor that may affect the appropriateness of the adult and
the child sharing a bedroom [Medium]; and

(2) The service planning team must date and document the assessment and approval in the
child’s service plan. [Medium-Low]

(c) The adult and the child must not sleep in the same bed unless the adult is the child’s parent,
and the child is between the ages of one year and 10 years old. [High]

(d) Subsections (a) and (b) of this section do not apply to travel and camping situations. [No
Weight]

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§748.1939. How much general living space and floor space
in a bedroom must I provide for children and young adults
who are in my care?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
January 2007

For adult residents, you must meet the space requirements listed in §748.3351 of this title
(relating to What are the requirements for general living space?) and §748.3357 of this title
(relating to What are the requirements for floor space in a bedroom used by a child?). [Medium-
Low]

§748.1941. What must I do if an adult resident is

responsible for his own medication?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
January 2007

If an adult resident is responsible for his own medication, you must:

(1) Establish written safeguards to prevent children in care from having access to
the medications [Medium]; and
(2) Implement the safeguards. [Medium]

§748.1943. Must adult residents have a tuberculosis (TB)

examination?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
January 2007

Yes. You must meet applicable requirements listed in §748.1583 of this title (relating to Who
must have a tuberculosis (TB) examination?). [Medium]

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§748.1945. What must I do if an adult resident has a
positive tuberculosis test result?
Subchapter K, Operations That Provide Care for Children and Adults
Division 2, General Requirements
January 2007

You must meet applicable requirements listed in §748.1581 of this title (relating to What health
precautions must I take if someone in my operation has a communicable disease?). [Medium]

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Subchapter L, Medication

Division 1, Administration of Medication

§748.2001. What consent must I obtain to administer

medications?
Subchapter L, Medication
Division 1, Administration of Medication
January 2007

(a) You must obtain a general written consent to administer routine, preventive,
and emergency medications. [High]
(b) You must obtain a written, signed, and dated consent, specific to the
psychotropic medication to be administered, from the person legally
authorized to give medical consent before administering a new psychotropic
medication to a child, per §748.2253 of this title (relating to If my operation
employs or contracts with a health-care professional who prescribes
psychotropic medications to a child in care, what information must I provide
the person legally authorized to give consent before requesting his consent for
the child to be placed on psychotropic medication?) or §748.2255 of this title
(relating to If my operation does not employ or contract with a health-care
professional who prescribes psychotropic medications to a child in care, what
information must I provide the person legally authorized to give medical
consent prior to the health-care professional prescribing psychotropic
medications to a child in care?). [High]

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 Technical Assistance
The following are recommended before a health-care professional prescribes a psychotropic
medication for a child in care:

● Develop clearly defined target symptoms and treatment goals for the child’s use of
psychotropic medications.
● Ask the health-care professional to consider potential side effects for the child and
evaluate the overall benefit-to-risk ratio of pharmacotherapy for the child.
● Consider the role of nonpharmacological interventions, except in urgent situations.
● Document appropriate monitoring of indices such as height, weight, blood pressure, or
other medical/laboratory findings.

§748.2003. What are the requirements for administering

prescription medication?
Subchapter L, Medication
Division 1, Administration of Medication
January 2017

(a) To the best of your knowledge, you must inform the person legally authorized to give
medical consent of the benefits, risks, and side effects of all prescription medication
and treatment procedures used and the medical consequences of refusing them,
and/or provide the name and telephone number of the prescribing health-care
professional for more information. [High]
(b) For prescription medications, you must:
(1) Be informed about possible side effects of medications administered to the
child [Medium-High];
(2) Store all medication in the original container unless you have an additional
container with the same label and instructions [Medium-High];
(3) Administer all medications according to the instructions on the label or
according to a prescribing health-care professional’s subsequent signed orders
(See §748.2005 of this title (relating to May I accept verbal orders on the
administration of medication?)) [Medium-High];
(4) Administer each child’s medication within one hour of preparation [Medium];
(5) Ensure the child has taken the medication as prescribed [Medium-High];

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 (6) Ensure a person trained in and authorized to administer medication
administers the medication to a child in care unless the child is on a self-
medication program [Medium-High];
(7) Maintain any documentation provided by the health-care professional on the
administration of current medication [Medium];
(8) Not physically force a child to take medication except as allowed by
§748.2455(a)(2)(B) of this title (relating to What actions must a caregiver
take before using a permitted type of emergency behavior intervention?)
[Medium-High];
(9) Ensure that your employees do not provide any medication or treatment to a
child except on written orders of a health-care professional [High];
(10) Not borrow or administer medication to a child that is prescribed to another
person [Medium-High]; and
(11) Not administer medication to more than one child from the same container.
Only the child for whom the medication was prescribed may use the
medication. [Medium-High]

§748.2005. May I accept verbal orders on the

administration of medication?
Subchapter L, Medication
Division 1, Administration of Medication
January 2007

(a) Assuming you have obtained written consent according to §748.2001 of this title
(relating to What consent must I obtain to administer medications?), a licensed
health-care professional may provide verbal orders. However, the health-care
professional must write and sign orders within 72 hours of the verbal order.
[Medium-High]
(b) The verbal order must be documented in the child’s record, including the health
care professional’s name and the date and time of the call. [Medium-High]

§748.2009. What are the requirements for administering

non-prescription medication and supplements?
Subchapter L, Medication
Division 1, Administration of Medication
April 2022

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 (a) For non-prescription medications and supplements, you must:
(1) Follow the label instructions for dosage [High]; and
(2) Ensure that the non-prescription medication or supplement is not contraindicated
with any medication prescribed for the child or medical condition that the child has.
[Medium-High]
(b) You may give nonprescription medication or supplements to more than one child from one
container.

Technical Assistance
Regarding subsection (a), the consultations regarding routine over-the-counter medications
may occur at times when medications are being prescribed.

Division 2, Self-Administration of Medication

§748.2051. What are the requirements for a self-

medication program?
Subchapter L, Medication
Division 2, Self-Administration of Medication
September 2010

For a child to be on a self-medication program:

(1) The child’s parent must give written authorization for the child to be on the program
[Medium];

(2) The child’s service plan must include the self-medication program and any requirements
for caregiver supervision [Medium]; and

(3) The health-care professional who prescribed the medication must be consulted, and any
concerns of the health-care professional documented in the child’s record. [Medium-High]

§748.2053. Who must record the medication dosage if a

child is on a self-medication program?
Subchapter L, Medication
Division 2, Self-Administration of Medication
January 2017

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When a child who is on a self-medication program takes a dosage of the medication, you must
ensure there is a system for reviewing the child’s medication each day and that the child either
[Medium]:
(1) Records the daily dosage; or
(2) Reports the medication to an appropriate employee or service provider, who must then do
the actual daily recording.

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Division 3, Medication Storage and Destruction

§748.2101. What medication storage requirements must

my operation meet?
Subchapter L, Medication
Division 3, Medication Storage and Destruction
January 2017

You must:

(1) Store medication in a locked container [High];

(2) Keep medication inaccessible other than to employees responsible for stored medication
[High];

(3) Store medication covered by Schedule II of the Texas Controlled Substances Act under
double lock in a separate container. For example, a double lock can include a lock on the
cabinet or filing cabinet and the door to the closet where medications are stored [Medium-
High];

(4) Make provisions for storing medication that requires refrigeration [Medium-High];

(5) Keep medication storage area(s) clean and orderly [Medium-High];

(6) Remove discontinued medication immediately and destroy it in a way that ensures that
children do not have access to it [Medium-High];

(7) Remove medication on or before the expiration date and destroy it in a way that ensures
that children do not have access to it [Medium-High];

(8) Remove medication of a discharged or deceased child immediately and destroy it in a way
that ensures that children do not have access to it [Medium]; and

(9) Provide prescription medication to the person to whom a child is discharged or transferred
if the child is taking the medication at that time. [Medium-High]

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§748.2103. What are the requirements for discontinued or
expired medication?
Subchapter L, Medication
Division 3, Medication Storage and Destruction
January 2007

(a) Discontinued medication, expired medication, and medication left at your

operation must be inventoried and stored separately from current medications as
directed by the administrator. [Medium-High]

(b) When you have an accumulation of this medication, you must destroy the
medication in accordance with state and federal law and in a way that ensures
children do not have access to it. The medication must be destroyed by
[Medium]:

(1) A health-care professional or pharmacist; or

(2) The licensed child-care administrator and another adult who is not a
resident.

Technical Assistance
When medication is destroyed, it is a good idea to have the person(s) involved in the
medication destruction sign a record that lists the following information:

● Name of the child to whom the medication was prescribed;

● Another form of identification for the child, such as a child’s file number;
● The prescription number and the name of the pharmacy;
● The name of the medication, strength, and quantity destroyed; and
● The date of destruction.
It is best to retain the record of destroyed medication at least one year from the date of
destruction.

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Division 4, Medication Records

§748.2151. What records must you maintain for each child

receiving medication?
Subchapter L, Medication
Division 4, Medication Records
January 2017

(a) You must maintain a cumulative medication record of all [Medium-High]:

(1) Prescription medication dispensed to each child; and
(2) Nonprescription medications and supplements that are dispensed to a child under
five years old.
(b) The cumulative medication record must be updated:
(1) Within 2 hours of administering medication, unless you operate a cottage home
model [Medium-High]; or
(2) Within 24 hours of administering medication if you operate a cottage home model.
[Medium-High]
(c) You must maintain the medication record, which must include:

(1) Child’s full name [Medium-High];

(2) Prescribing health-care professional’s name, if applicable; [Medium]
(3) Reason medication was prescribed, for prescription medication [Medium];
(4) Medication name, strength, and dosage [Medium-High];
(5) Date (day, month, and year) and time the medication was administered [Medium-
High];
(6) Name and signature of the person who administered the medication [Medium];
(7) Child’s refusal to accept medication, if applicable [Medium]; and
(8) Reasons for administering the medication, including the specific symptoms,
condition, and/or injuries of the child that you are treating, only for [Medium-High]:
(A) PRN psychotropic medications; and
(B) Nonprescription medications and supplements for children under five years
old.
(d) Unless you operate on a cottage home model, you must count each medication
prescribed to a child at least daily and document the count. The medication
count must match the medication documentation. [Medium-High]

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 (e) You must document in the medication record any non-prescription medication or
supplement that is given to the child and how often the child receives the
medication or supplement. [Medium]
(f) You must document any prohibited prescription medications (for example,
medication allergies or contraindications) or prohibited nonprescription
medications and supplements in the medication record. [High]
(g) You must incorporate the medication record into the child’s record. [Medium-
Low]

Technical Assistance
Documenting the time a medication is given:

For medications with regularly scheduled doses, you may use the regularly scheduled time to
document giving the medication as long as it is given within thirty minutes of the scheduled
time. Otherwise, you must document the actual time the medication is given.

Example: For a regularly scheduled 9:00 a.m. medication given at 9:20, you may document
9:00 a.m.; if the medication is given at 9:45, then you must document 9:45 a.m.

If you document the time by initialing the regularly scheduled time (pre-printed on the form),
there must be space on the form to document the time given when it is outside the 30-
minute window.

For medications that are PRN or one-time only, you must document the exact time the
medication is given.

Documenting the name and signature of the person who administered a medication:

The purpose of the signature is to be able to identify the person who administered a specific
medication to a child, if a concern arises later about that medication. Licensing requires one
full signature for each person who administers medication, but there is no need for the
person to record a full signature for each dose of medication that he/she administers. Most
medication records provide space for a signature and matching initials (usually at the bottom
of the page or on the back), then only require a person to use his/her initials to record each
time he/she actually gives a dose of medication. Using this system, the initials can be
matched to the signature as needed. This complies with minimum standards.

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Division 5, Medication and Label Errors

§748.2201. What is a medication error?

Subchapter L, Medication
Division 5, Medication and Label Errors
January 2007

A medication error includes, but is not limited to, the following:

(1) A child receives the wrong medication;

(2) A child receives medication prescribed for someone else;
(3) A child receives the wrong dosage of medication;

(4) A child receives medication at the wrong time;

(5) A medication dose is skipped or missed;
(6) A child receives expired medication;

(7) Not following the medication administration instructions, such as giving a child medication
on an empty stomach when the medication should be given with food; and
(8) A child receives medication that was not stored as required to maintain the effectiveness
of the medication, such as refrigerating or not refrigerating the medication or exposing the
medication to heat or sunlight.

§748.2203. What must I do if I find a medication error?

Subchapter L, Medication
Division 5, Medication and Label Errors
January 2007

(a) If you find a medication error regarding a prescribed medication, you must contact a
health-care professional immediately, unless the error is the type described in
paragraph (4) or (5) of §748.2201 of this title (relating to What is a medication
error?), and follow the health-care professional’s recommendations. [Medium-High]
(b) If you find a medication error regarding an nonprescription medication, you must take
the appropriate and necessary actions as required by the circumstances. [Medium-
High]

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 (c) For all medication errors, you must document the following within 24 hours [Medium-
High]:
(1) The time and date of the error [Medium-High];
(2) The medication error [Medium-High];
(3) The time and date of the call(s) to the licensed health-care professional, if
applicable [Medium-High];
(4) The name and title of the health-care professional contacted, if applicable
[Medium-High]; and
(5) The health-care professional’s medical recommendations for ensuring the child’s
safety, if applicable. [Medium-High]

§748.2205. What must I do if I find a medication label

error?
Subchapter L, Medication
Division 5, Medication and Label Errors
January 2007

If you find a medication label error, you must:

(1) Report the error to the pharmacist [Medium]; and

(2) Have the label on the medication container corrected as soon as possible, but no
later than the next business day. [Medium]

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Division 6, Side Effects and Adverse Reactions to Medication

§748.2231. What must I do if a child has an adverse

reaction to a medication?
Subchapter L, Medication
Division 6, Side Effects and Adverse Reactions to Medication
January 2017

If a child has an adverse reaction (unexpected or dangerous reaction) to a medication, you

must:
(1) Immediately report the reaction to a health-care professional and the child’s parent
[High];
(2) Follow the health-care professional’s recommendations [High];
(3) Seek further medical care for the child if the child’s condition appears to worsen [High];
and
(4) Document in the child’s medical record the:
(A) Adverse reactions that the child had to the medication; [Medium-High]
(B) Time and date of call(s) to the health-care professional; [Medium-High]
(C)Name and title of the health-care professional contacted [Medium-High]; and
(D) Health-care professional’s medical recommendations for ensuring the child’s
safety. [Medium-High]

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§748.2233. What must I do if a child experiences side
effects from any medications?
Subchapter L, Medication
Division 6, Side Effects and Adverse Reactions to Medication
January 2017

(a) A side effect from any medication is an effect of medication in addition to the
medication’s intended effect, often an undesirable effect.
(b) If a child experiences side effects from any medication, you must:
(1) Document the observed and reported side effects [Medium-High];
(2) Immediately report any serious side effects to the child’s prescribing health-
care professional and the child’s parent [Medium-High]; and
(3) Report any other side effect to the prescribing health-care professional
within 72 hours. [Medium-High]

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Division 7, Use of Psychotropic Medication

§748.2253. If my operation employs or contracts with a

health-care professional who prescribes psychotropic
medications to a child in care, what information must I
provide the person legally authorized to give consent
before requesting his consent for the child to be placed on
psychotropic medication?
Subchapter L, Medication
Division 7, Use of Psychotropic Medication
January 2007

(a) Before requesting the person’s written consent to give the child psychotropic
medication, the prescribing health-care professional must give the following in writing
or document a discussion with the person or a combination of both [Medium-High]:
(1) The child’s diagnosis [Medium-High];
(2) The nature of the child’s mental illness or condition [Medium-High];
(3) An explanation of the purpose of the medication [Medium-High];
(4) A description of the benefits expected Medium;
(5) A description of any accompanying discomforts and risks, including those which
could result from long-term use of the medication, and possible side effects,
including side effects that are known to frequently occur in persons, side
effects to which the child may be predisposed, and the nature and possible
occurrence of irreversible symptoms [Medium-High];
(6) A statement of whether the medication is habituating in nature [Medium-High];
(7) Alternative interventions to the use of psychotropic medication that have been
attempted and that have been unsuccessful [Medium-High];
(8) Other alternative treatments or procedures to the use of the psychotropic
medication [Medium-High];
(9) Risks and benefits of the alternative treatments or procedures [Medium-High];
(10) Risks and benefits of not receiving or undergoing a treatment or procedure
[Medium-High];

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 (11) An explanation that the person legally authorized to give medical consent
may ask questions about the child’s response to the medication, and may
review your daily records on request [Medium-High]; and
(12) An explanation that the person legally authorized to give medical consent
may withdraw consent and request the medication be discontinued at any
time. [Medium-High]
(b) The health-care professional must offer to answer any questions the person legally
authorized to give consent has about the medication. [Medium-High]
(c) The person must sign a consent form that acknowledges that you have provided all of
the information set forth in subsection (a) of this section. A copy of this signed
consent form must be filed in the child’s record. [Medium-High]

§748.2255. If my operation does not employ or contract

with a health-care professional who prescribes
psychotropic medications to a child in care, what
information must I provide the person legally authorized to
give medical consent prior to the health-care professional
prescribing psychotropic medications to a child in care?
Subchapter L, Medication
Division 7, Use of Psychotropic Medication
January 2007

If you are requesting consent and the person legally authorized to give consent is not privy to
this information, you must:
(1) Before requesting the person’s written consent to give the child psychotropic medication,
provide information in writing or document a discussion with the person regarding
[Medium-High]:

(A) The nature of the child’s mental illness or condition [Medium-High];

(B) A general explanation of the purpose of the medication [Medium-High];

(C)A general description of the benefits expected Medium;

(D) An explanation that the person may ask questions about the child’s response to
the medication [Medium-High]; and
(E) An explanation that the person may withdraw medical consent and request the
medication be discontinued at any time. [Medium-High]

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 (2) Offer to answer any questions the person legally authorized to give medical
consent has about the medication and/or provide the name and telephone number
of the prescribing health-care professional for further information. [Medium-High]
(3) Obtain a signed consent form from the person legally authorized to give medical
consent that acknowledges that you have provided all of the information set forth
in paragraph (1) of this section. A copy of this signed consent form must be filed
in the child’s record. [Medium-High]

§748.2257. What are the requirements if a physician orders

administration of a psychotropic medication to a child in an
emergency?
Subchapter L, Medication
Division 7, Use of Psychotropic Medication
January 2007

(a) If a physician has made a determination that there is an emergency according to

§266.009 of the Family Code and the emergency requires the administration of a
psychotropic medication, then you must follow the physician’s orders and do not have to
obtain consent prior to the administration of the medication. [Medium-High]

(b) Within 72 hours after you have administered the medication, you must notify the parent
and the person legally authorized to give medical consent. [Medium-High]
(c) The physician’s statement regarding the emergency and the prescription must be

documented in the child’s record. [Medium]

§748.2259. What information must I document about a

child’s use of psychotropic medication?
Subchapter L, Medication
Division 7, Use of Psychotropic Medication
January 2007

(a) You must maintain a daily record of the child’s use of such medication according to
the requirements in §748.2151 of this title (relating to What records must I maintain
for each child receiving medication?). [Medium-High]
(b) You must document in the child’s record a description of any noticeable change in
the child’s behavior in response to the medication. [Medium]

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 (c) You must provide the information in subsection (b) of this section to the prescribing
health-care professional or the child’s current health-care professional to use in
evaluating the appropriateness of continuing the medication. You must document the
health-care professional’s evaluation and review in the child’s record. [Medium]

§748.2261. If my operation employs or contracts with a

health-care professional who prescribes psychotropic
medications to a child in care, what are the requirements
for evaluating whether a child should continue taking a
psychotropic medication?
Subchapter L, Medication
Division 7, Use of Psychotropic Medication
January 2007

(a) If a child takes psychotropic medications, the prescribing health-care professional

must evaluate and document in the child’s medication record a description of the
child’s response to the medication and an assessment of its effectiveness and the
appropriateness of continuing the medication at least quarterly. The written
evaluation must include any reasons for discontinuing the medication. [Medium-
High]
(b) If the health-care professional decides that he can evaluate the appropriateness of
continuing the medication without seeing the child, you do not have to schedule an
appointment for the evaluation.
(c) The health-care professional must consider the target symptoms and treatment
goals in evaluating the child’s use of psychotropic medications. [Medium]
(d) The health-care professional must document whether the child needs to continue
taking the medication. You must document the health-care professional’s decision in
the child’s record. [Medium-High]
(e) If the health-care professional does not substantiate the effectiveness of a specific
psychotropic medication within 90 days, the health-care professional must provide a
written rationale for continuing the medication for an additional period. The
continuation of the medication may not exceed an additional 90 days (for a total of
180 days) if effectiveness is not substantiated by the health-care professional. A
copy of the written rationale must be documented in the child’s record. [Medium-
High]

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Division 8, Unassigned Epinephrine Auto-Injectors

§748.2271. What are the requirements if my operation

chooses to maintain and administer unassigned
epinephrine auto-injectors?
Subchapter L, Medication
Division 8, Unassigned Epinephrine Auto-Injectors
October 2021

If your operation maintains and administers unassigned epinephrine auto-injectors to use when
a child in care has an emergency anaphylaxis reaction, you must:

(1) Adopt and implement a written policy that complies with the unassigned epinephrine auto-
injector requirements set by the Texas Department of State Health Services, as specified
in 25 TAC Chapter 40, Subchapter C (relating to Epinephrine Auto-Injector Policies in
Youth Facilities) and Texas Health and Safety Code §773.0145 [High];

(2) Notify the child’s parent, immediately after ensuring the safety of the child, if the child has
had an emergency anaphylaxis reaction that required administration of an unassigned
epinephrine auto-injector [High]; and

(3) Maintain and make available for review, upon our request, proof that you have notified
the child’s parent of an incident where the child in care had an emergency anaphylaxis
reaction that required administration of an unassigned epinephrine auto-injector.
[Medium]
Technical Assistance
DSHS requirements for the maintenance and administration of unassigned epinephrine auto-
injectors include requirements for:
• Training;
• Storage;
• Administration;
• Disposal;
• Reporting; and
• Parental notification of policies.
You can find more information about these requirements, as well as definitions pertaining to
anaphylaxis, at Allergies and Anaphylaxis, Epinephrine Auto-Injector Policies in Youth
Facilities, and in the CCR TA Library.

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Subchapter M, Discipline and Punishment

§748.2301. What are the requirements for disciplinary

measures?
Subchapter M, Discipline and Punishment
January 2007

(a) Only a caregiver known to and knowledgeable of a child may discipline the child.
[Medium]
(b) Each disciplinary measure must:
(1) Be consistent with your policies and procedures [Medium];
(2) Not be physically or emotionally damaging to the child [High];
(3) Be individualized to meet each child’s needs [Medium];
(4) Be appropriate to the child’s level of understanding, age, and developmental level
[Medium]; and
(5) Be appropriate to the incident and severity of the behavior demonstrated. [Medium]
(c) The goal of each disciplinary measure must be to teach the child acceptable behavior
and self-control. The caregiver must explain the reason for the disciplinary measure
when the caregiver imposes the measure. [Medium]

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 Technical Assistance
It is a good idea for disciplinary measures to be consistent among caregivers. Using positive
methods of discipline and guidance encourage self-esteem, self-control, and self-direction.
Positive methods of discipline include the following:

● Using praise, positive reinforcement, and encouragement of good behavior instead of

focusing only on unacceptable behavior;
● Reminding a child of behavior expectations daily by using clear, positive statements;
● Talking with the child about the situation;
● Focusing on the rule to learn and the reason for the rule;
● Focusing on solutions that are respectful, reasonable, and related to the problem
behavior, rather than blaming or focusing on consequences;
● Redirecting the child’s attention or behavior using positive statements;
● Providing prior notice of possible consequences for inappropriate behaviors;
● Giving the child acceptable choices or alternatives;
● Using brief supervised separation or time away from the group or situation, when
appropriate for the child’s understanding, age, and development. Best practice suggests
that quiet time or time out from the group be limited to no more than one minute per
year of the child’s chronological or developmental age. However, this time frame may
need to be adjusted for some children, such as a child who has attention-deficit
disorder. Time out is not appropriate for infants and is not recommended for toddlers,
since they are too young to understand this intervention;
● Arranging the environment to allow safe testing of limits;
● Using kind but firm action;
● Giving logical consequences that are appropriate to the situation and severity of the
behavior; and
● Withholding privileges.

§748.2303. May I use corporal punishment for children in

care?
Subchapter M, Discipline and Punishment
January 2007

(a) You may not use or threaten to use corporal punishment with any child in care. [High]
(b) Corporal punishment is the infliction of physical pain on any part of a child’s body as a
means of controlling or managing the child’s behavior. It includes:
(1) Hitting or spanking a child with a hand or instrument; or
(2) Forcing or requiring the child to do any of the following as a method of managing or
controlling behavior:
(A) Perform any form of physical exercise, such as running laps or doing sit
ups or push ups;
(B) Hold a physical position, such as kneeling or squatting; or

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 (C) Do any form of “unproductive work.”

§748.2305. What is “unproductive work”?

Subchapter M, Discipline and Punishment
January 2007

(a) “Unproductive work” is work that serves no purpose except to demean the child. Examples
include moving rocks or logs from one pile to another or digging a hole and then filling it
in. Unproductive work is never an appropriate behavior management tool.
(b) “Unproductive work” does not include work that corrects damage that the child’s behavior
caused. For example, you may require a child who defaces a fence or wall to repaint it.
This example includes a logical consequence and is an acceptable behavior management
tool.

§748.2307. What other methods of punishment are

prohibited?
Subchapter M, Discipline and Punishment
April 2022

In addition to corporal punishment, prohibited discipline techniques include:

(1) Any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline or

punishment [High];
(2) Denial of mail or visits with their families as discipline or punishment [Medium];
(3) Threatening with the loss of placement as discipline or punishment [Medium-Low];
(4) Using sarcastic or cruel humor [Medium-High];
(5) Maintaining an uncomfortable physical position, such as kneeling, or holding his arms out
[Medium-High];
(6) Pinching, pulling hair, biting, or shaking a child [High];
(7) Putting anything in or on a child’s mouth [High];

(8) Humiliating, shaming, ridiculing, rejecting, or yelling at a child [Medium-High];

(9) Subjecting a child to abusive or profane language [Medium-High];

(10) Placing a child in a dark room, bathroom, or closet [High];

(11) Requiring a child to remain silent or inactive for inappropriately long periods of time for
the child’s age [Medium-High];

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 (12) Confining a child to a highchair, box, or other similar furniture or equipment as discipline
or punishment [Medium-High];

(13) Denying basic child rights as discipline or punishment [High];

(14) Withholding food that meets the child’s nutritional requirements [High]; and

(15) Using or threatening to use emergency behavior intervention as discipline or punishment

[High].

Technical Assistance

Regarding subsection (7), examples include, but are not limited to, soap, tape, hot peppers,
and hot sauce.

§748.2309. To what extent may I restrict a child’s activities

as a behavior management tool?
Subchapter M, Discipline and Punishment
January 2017

(a) Within limits, a caregiver may restrict a child’s activities as a behavior management tool.
(b) Restrictions of activities that will be imposed on a child for more than fourteen days, must
have prior approval by the treatment director, service planning team, or professional level
service provider. [Medium-Low]
(c) Restrictions to a particular room or building that will be imposed on a child for more than
24 hours must have prior approval by the treatment director, service planning team, or
professional level service provider. [Medium-Low]
(d) You must inform the child and parent about any restrictions that you place on the child.
[Low]
(e) Documentation of all approvals, justification for the restriction, and informing the child
and parents must be in the child’s record. [Low]

§748.2311. May a child or adult in care discipline or punish

another person in care?
Subchapter M, Discipline and Punishment
January 2007

No. A person in care must not discipline or punish another person in care. [Medium-High]

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Subchapter N, Emergency Behavior Intervention

Division 1, Definitions

§748.2401. What do certain words mean in this

subchapter?
Subchapter N, Emergency Behavior Intervention
Division 1, Definitions
January 2017

These terms have the following meaning in this subchapter:

(1) Transitional hold – The use of a temporary restraint technique that lasts no longer than
one minute as part of the continuation of a longer personal or mechanical restraint.

(2) Triggered review – A review of a specific child’s placement, treatment plan, and orders or
recommendations for intervention, because a certain number of interventions have been
made within a specified period of time (e.g. three seclusions within a seven-day period).

Division 2, Types of Emergency Behavior Intervention That

May Be Administered

§748.2451. What types of emergency behavior intervention

may I administer?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
February 2017

(a) If permitted in your policies and you meet the requirements of this subchapter, you
may administer the following types of emergency behavior intervention to a child in
your care:
(1) Short personal restraint [Medium-High];
(2) Personal restraint [Medium-High];
(3) Emergency medication [Medium-High];
(4) Seclusion:

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 (A) Only for a child with an emotional disorder or an Autism Spectrum
Disorder; and only if you provide treatment services to 25 or more
children with emotional disorders or Autism Spectrum Disorder, or if
more than 30% of the children in your care receive treatment services
for emotional disorders or Autism Spectrum Disorder. Seclusion is not
permitted for children receiving therapeutic camp services [Medium-
High]; or
(B) Only if you provide emergency care services to the child and only
while waiting for the arrival of law enforcement or emergency medical
services [Medium-High]; and
(5) Mechanical restraint, only if you are a Residential Treatment Center. [Medium-
High]

(b) You may never administer chemical restraints. [High]

(c) Protective and supportive devices, used appropriately, are not considered emergency
behavior interventions. For information on protective and supportive devices, see
Divisions 4 and 5 of Subchapter J of this chapter (relating to Child Care).

§748.2453. Who may administer emergency behavior

intervention?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
January 2007

Only a caregiver qualified in emergency behavior intervention may administer any form of
emergency behavior intervention, except for the short personal restraint of a child. [High]

§748.2455. What actions must a caregiver take before

using a permitted type of emergency behavior
intervention?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
September 2010

(a) Before using a permitted type of emergency behavior intervention, the caregiver must:

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 (1) Attempt less restrictive behavior interventions that prove to be ineffective at
defusing the situation [Medium-High]; and
(2) Determine that the basis for the emergency behavior intervention is [Medium-
High]:
(A) An emergency situation; or
(B) A need for a personal restraint to administer intra-muscular medication or
other medical treatments prescribed by a licensed physician, such as
administering insulin to a child with diabetes.

(b) A child’s active attempt to run away may be considered an emergency situation
when the following is a factor:
(1) The child is developmentally or chronologically under six years old;
(2) The child is suicidal;
(3) The operation is located near a high traffic area;
(4) Adverse weather conditions pose a clear safety risk to the child; or
(5) Other clear safety risks are present.

§748.2459. What is the appropriate use for a short

personal restraint?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
September 2010

Generally, a short personal restraint is used in urgent situations, such as:

(1) To protect the child from external danger that causes imminent significant risk to the
child, such as preventing the child from running into the street or coming into contact with
a hot stove. The restraint must end immediately after the danger is averted;

(2) To intervene when a child under five years old (chronological or developmental age)
demonstrates disruptive behavior, if other efforts to de-escalate the child’s behavior have
failed;

(3) When a child over five years old demonstrates behavior disruptive to the environment or
milieu, such as disrobing in public, provoking others that creates a safety risk, or to
intervene to prevent a child from physically fighting; or
(4) When a child is significantly damaging property, such as breaking car windows or putting
holes into walls.

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§748.2461. What precautions must a caregiver take when
implementing a short personal restraint?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
January 2007

(a) When a caregiver implements a short personal restraint, the caregiver must:
(1) Minimize the risk of physical discomfort, harm, or pain to the child [High]; and
(2) Use the minimal amount of reasonable and necessary physical force. [High]
(b) A caregiver may not use any of the following techniques as a short personal restraint:
(1) A prone or supine restraint [High];
(2) Restraints that impair the child’s breathing by putting pressure on the child’s torso,
including leaning a child forward during a seated restraint [High];
(3) Restraints that obstruct the airways of the child or impair the breathing of the child,
including procedures that place anything in, on, or over the child’s mouth, nose, or
neck, or impede the child’s lungs from expanding [High];
(4) Restraints that obstruct the caregiver’s view of the child’s face [High];
(5) Restraints that interfere with the child’s ability to communicate or vocalize distress
[High]; or
(6) Restraints that twist or place the child’s limb(s) behind the child’s back. [High]

§748.2463. Are there any purposes for which emergency

behavior intervention cannot be used?
Subchapter N, Emergency Behavior Intervention
Division 2, Types of Emergency Behavior Intervention That May Be Administered
January 2007

Emergency behavior intervention may never be used as:

(1) Punishment [Medium-High];

(2) Retribution or retaliation [Medium-High];
(3) A means to get a child to comply [Medium-High];

(4) A convenience for caregivers or other persons [Medium-High]; or

(5) A substitute for effective treatment or habilitation. [Medium-High]

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Division 3, Orders

§748.2501. Are written orders required to administer

emergency behavior intervention, and if so, who can write
them?
Subchapter N, Emergency Behavior Intervention
Division 3, Orders
January 2007

According to the following chart, written orders by certain professionals are required to
administer certain emergency behavior intervention:

Weight Type of (A) Are written orders (B) Who can

Emergency required to administer the write orders
Behavior intervention for a specific for the use of
Intervention child? the
intervention
for a specific
child?
No Weight (1) Short (A) NO. (B) Not
personal applicable.
restraint
No Weight (2) Personal (A) NO. However, successive (B) Not
restraint restraints, a restraint Applicable.
simultaneous with emergency
medication, and/or a restraint that
exceeds the maximum time limit
all require orders as specified in
this subchapter. PRN orders are
also permitted under §748.2507
of this title (relating to Under
what conditions are PRN orders
permitted for a specific child?).
(A) High (3) Emergency (A) YES. (B) A
(B) High medication licensed
physician.
(A) Medium- (4) Seclusion (A) YES, except written orders (B) A
High are not required when you licensed
(B) Medium- provide emergency care services psychiatrist,
High to the child placed in seclusion. psychologist,
or physician.

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 Weight Type of (A) Are written orders (B) Who can
Emergency required to administer the write orders
Behavior intervention for a specific for the use of
Intervention child? the
intervention
for a specific
child?
(A) High (5) Mechanical (A) YES. (B) A
(B) High restraint licensed
psychiatrist.

§748.2503. Must the written order be in a child’s record

before a caregiver can use an emergency behavior
intervention on a child?
Subchapter N, Emergency Behavior Intervention
Division 3, Orders
January 2007

Yes, any type of written order that is required, must be in the child’s record before a caregiver
can use emergency behavior intervention on that child, except for seclusion when it is necessary
to prevent the child from endangering himself or others. In this seclusion situation, a licensed
psychiatrist, psychologist, or physician must provide a verbal order within one hour after a
caregiver initiates the seclusion. The caregiver must document this order, and the professional
who provides the verbal order must provide a written version of the order within 72 hours after
issuing the order. The written copy must include the time, date, and the professional’s signature.
[Medium-High]

§748.2505. What information must a written order include?

Subchapter N, Emergency Behavior Intervention
Division 3, Orders
January 2007

(a) All written orders must include the following:

(1) A statement that the particular type of emergency behavior intervention may only
be used in an emergency situation [Medium-High];
(2) Designation of the specific intervention and procedure or technique that is
authorized [Medium-High];

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 (3) Any specific measures for ensuring the child’s health, safety, and well being, and
the privacy of the setting that safeguards the child’s personal dignity [Medium-
High];
(4) A complete description of the behaviors and circumstances under which the
intervention may be used [Medium-High];
(5) Instructions for observation or heightened observation of the child during the
intervention [Medium-High];
(6) The behaviors that indicate the child is ready to be released from the intervention
[Medium-High];
(7) The maximum length of time the child may be restrained or secluded regardless of
behaviors exhibited [Medium-High];
(8) The prescribing professional’s consideration of any potential medical and/or
psychiatric contraindications for the specific child, such as a history of physical or
sexual abuse or victimization involving the type of intervention [Medium-High]; and
(9) Clinical justification for the intervention. [Medium-High]
(b) For emergency medication, the written order must also include instructions on how to
administer the medication. [Medium-High]
(c) For mechanical restraint, the written order must also include the specific device or devices
authorized. [Medium-High]

§748.2507. Under what conditions are PRN orders

permitted for a specific child?
Subchapter N, Emergency Behavior Intervention
Division 3, Orders
April 2022

(a) PRN orders for certain emergency behavior interventions are permitted under the following
conditions:

Type of Conditions:
Emergency
Behavior
Intervention
(1) Short personal Not applicable, because short personal restraints do not require orders.
restraint.

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 Type of Conditions:
Emergency
Behavior
Intervention
(2) Personal Note: Continuation orders are required for extending the maximum
restraint. amount of time for a personal restraint; and an order or
recommendation from the service planning team is needed to forestall
some triggered reviews.
(A) Orders must originate from a licensed psychiatrist or psychologist
and include the number of times a child may be restrained in a
seven-day period. [Medium-High]
(B) If the orders allow more than three restraints within a seven-
day period, the order must include a plan for reducing the
need for emergency behavior intervention. [Medium-High]
(C)The licensed psychiatrist or psychologist must review PRN orders
for personal restraint at least every 30 days. The review must
include written clinical justification for the continuation of PRN
orders and be documented in the child’s record. [Medium-High]
(D) PRN orders may not be used to restrain a child beyond the
maximum length of time for personal restraint. See §748.2801 of
this chapter (relating to What is the maximum length of time that
an emergency behavior intervention can be administered to a
child?). [Medium-High]
(3) Emergency The licensed physician must review PRN orders for emergency
medication. medication at least every 30 days. The review must include written
clinical justification for the continuation of PRN orders and be
documented in the child’s record. [Medium-High]
(4) Seclusion. (A) A licensed psychiatrist ordering seclusion is permitted to use
PRN orders; however, a licensed psychologist is not. [Medium-
High]
(B) PRN orders may not be used to seclude a child beyond the
maximum length of time for seclusion. See §748.2801 of this
chapter. [Medium-High]
(C)The psychiatrist must review PRN orders for seclusion at least
every 30 days. The review must include written clinical justification
for the continuation of PRN orders and be documented in the child’s
record. [Medium-High]
(5) Mechanical PRN orders are not permitted. [High]
restraint.

(b) If you obtain a PRN order, you must provide the parent with a copy of the PRN order within
72 hours. [Medium]

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Division 4, Responsibilities During Administration of Any
Type of Emergency Behavior Intervention

§748.2551. What responsibilities does a caregiver have

when implementing a type of emergency behavior
intervention?
Subchapter N, Emergency Behavior Intervention
Division 4, Responsibilities During Administration of Any Type of Emergency Behavior
Intervention
February 2017

(a) The use of emergency behavior intervention must be an appropriate response to

the behavior demonstrated, and de-escalation must have failed. [Medium-High]
(b) The caregiver must act to protect the child’s safety and consider [High]:
(1) The characteristics of the immediate physical environment [High];
(2) The permitted types of emergency behavior intervention [Medium-High];
and
(3) The potential risk of harm in using emergency behavior intervention versus
the risk of not using emergency behavior intervention. [High]
(c) The caregiver must:
(1) Initiate an emergency behavior intervention in a way that minimizes the
risk of physical discomfort, harm, or pain to the child [High]; and
(2) Use the minimal amount of reasonable and necessary physical force to
implement the intervention. [High]

(d) The caregiver must make every effort to protect the child’s:
(1) Privacy, including shielding the child from onlookers [Medium]; and
(2) Personal dignity and well-being, including ensuring that the child’s body is
appropriately covered. [Medium]
(e) As soon as possible after starting any type of emergency behavior intervention, the
caregiver must:
(1) Explain to the child the behaviors the child must exhibit to be released or have the
intervention reduced, if applicable [Medium-High]; and

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 (2) Permit the child to suggest actions the caregivers can take to help the child de-
escalate. [Medium-High]
(f) If the child does not appear to understand what the child must do to be released from the
emergency behavior intervention, the caregiver must attempt to re-explain it every 15
minutes until the child understands or is released from the intervention. [Medium-High]

§748.2553. When must a caregiver release a child from an

emergency behavior intervention?
Subchapter N, Emergency Behavior Intervention
Division 4, Responsibilities During Administration of Any Type of Emergency Behavior
Intervention
April 2022

A child must be released as follows:

Type of The caregiver must release the child if any of the following apply:
Emergency
Behavior
Intervention
(1) Short (A) Immediately when an emergency health situation occurs during the
personal restraint and the caregiver must obtain treatment immediately [High];
restraint. or

(B) Within one minute, or sooner if the danger is over or the emergency
situation no longer exists. [Medium-High]

(2) Personal (A) Immediately when an emergency health situation occurs during the
restraint. restraint and the caregiver must obtain treatment immediately [High];
(B) Within one minute of the implementation of a prone or supine
transitional hold [High];

(C)As soon as the child’s behavior is no longer a danger to himself or

others [Medium-High];
(D) As soon as the medication is administered [Medium-High]; or
(E) When the maximum time allowed for personal restraint is reached.
[Medium-High]

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 Type of The caregiver must release the child if any of the following apply:
Emergency
Behavior
Intervention
(3) Emergency Not applicable.
medication.

(4) Seclusion. (A) Immediately when an emergency health situation occurs during
the seclusion and the caregiver must obtain treatment
immediately [High];
(B) As soon as the child’s behavior is no longer a danger to himself or
others [Medium-High];
(C)No later than five minutes after the child begins exhibiting the required
behaviors [Medium-High];
(D) When the maximum time allowed for seclusion is reached [Medium-
High];

(E) If the child falls asleep in seclusion, the caregiver must:

(i) Unlock the door [Medium];
(ii) Continuously observe the child until he awakens [Medium]; and
(iii)Evaluate his overall well-being [Medium-High]; or
(F) If the child is receiving emergency care services:

(i) As soon as the child is no longer a danger to himself or others

[Medium-High];

(ii) Upon the arrival of a medical professional [Medium-High]; or

(iii)Upon assistance from law enforcement or the fire department.
[Medium-High]

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 Type of The caregiver must release the child if any of the following apply:
Emergency
Behavior
Intervention
(5) Mechanical (A) Immediately when an emergency health situation occurs during the
restraint. restraint and the caregiver must obtain treatment immediately [High];
(B) As soon as the child’s behavior is no longer a danger to himself or
others [Medium-High];

(C)No later than five minutes after the child begins exhibiting the required
behaviors [Medium-High];

(D) When the maximum time allowed for mechanical restraint is reached
[Medium-High]; or
(E) If the child falls asleep in the mechanical restraint. In this situation, the
caregiver must release the child from the restraint and continuously
observe the child until he awakens and evaluate him. [Medium-High]

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Division 5, Additional Responsibilities During
Administration of a Personal Restraint

§748.2601. Who must monitor a personal restraint?

Subchapter N, Emergency Behavior Intervention
Division 5, Additional Responsibilities During Administration of a Personal Restraint
February 2017
(a) During any personal restraint, a caregiver qualified in emergency behavior
intervention must:
(1) Monitor the:
(A) Personal restraint to make sure it is being performed appropriately [High]; and
(B) Child’s breathing and other signs of physical distress [High]; and
(2) Take appropriate action to ensure adequate respiration, circulation, and
overall well-being. [High]
(b) If available, a caregiver who is not restraining the child should monitor the child.
However, general residential operations with a capacity of more than 16 children
must monitor prone and supine restraints as required in §748.2605(b) of this title
(relating to What personal restraint techniques are prohibited?).

§748.2603. What is the appropriate action for a caregiver

to take to ensure the child’s adequate respiration,
circulation, and overall well-being?
Subchapter N, Emergency Behavior Intervention
Division 5, Additional Responsibilities During Administration of a Personal Restraint
February 2017

Appropriate action includes responding prudently to a potentially life-threatening situation, for

example, releasing a child when a child is unresponsive or indicates the child cannot breathe and
immediately seeking medical assistance from a health-care professional.

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 Technical Assistance
Signs of distress:

● Circulation – Are the child’s extremities cold to the touch? Are the child’s extremities
turning blue or is the child turning blue around the mouth?
● Respiration – Is the child’s breathing rapid and shallow? Is there an absence of
breathing? Is the child saying he or she cannot breath?
● Neurological – Is the child disoriented? Is he or she having a seizure?
● Gastrointestinal – Is the child vomiting or losing control of his or her bowels?
● Muscular-Skeletal – Is there apparent bruising, swelling, and/or complaints of pain?

§748.2605. What personal restraint techniques are

prohibited?
Subchapter N, Emergency Behavior Intervention
Division 5, Additional Responsibilities During Administration of a Personal Restraint
September 2010

(a) The following personal restraint techniques are prohibited:

(1) Restraints that impair the child’s breathing by putting pressure on the child’s
torso, including restraints that obstruct the child’s lungs from expanding such
as leaning a child forward during a seated restraint [High];

(2) Restraints that obstruct the child’s airway, including procedures that place
anything in, on, or over the child’s mouth, nose, or neck [High];

(3) Restraints that obstruct a caregiver’s ability to view the child’s face [High];

(4) Restraints that interfere with the child’s ability to communicate or vocalize
distress [High]; or

(5) Restraints that twist or place the child’s limb(s) behind the child’s back. [High]

(b) Prone and supine restraints are prohibited except:

(1) As a transitional hold that lasts no longer than one minute [High];

(2) As a last resort when other less restrictive interventions have proven to be
ineffective [High]; and
(3) When an observer meeting the following qualifications ensures the child’s breathing
is not impaired [High]:

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 (A)Trained to identify risks associated with positional, compression, or
restraint asphyxia [High];

(B)Trained to identify risks associated with prone and supine holds [High]; and

(C)Not involved in the restraint. General residential operations and residential

treatment centers with a capacity of 16 or fewer children are exempt from
meeting this requirement. [High]

Division 6, Additional Responsibilities During

Administration of Seclusion

§748.2651. What are the additional responsibilities for

implementing seclusion?
Subchapter N, Emergency Behavior Intervention
Division 6, Additional Responsibilities During Administration of Seclusion
April 2022

(a) Caregivers must continuously observe the child placed in seclusion. This
observation can take place through a window or a one-way mirror. The use of a
video camera in lieu of direct observation to continuously observe a child in
seclusion is not permitted. [Medium-High]
(b) There must be a protected, private, and observable environment or room that
safeguards the child’s personal dignity and well-being that must [Medium]:
(1) Have 40 square-feet of floor space and a ceiling height of at least eight feet
[Medium];
(2) Be free of safety hazards [Medium-High];
(3) Be adequately ventilated during warm weather and adequately heated
during cold weather [Medium-High];
(4) Be appropriately lighted [Medium-High]; and
(5) Have a mat and bedding, unless the prescribing professional writes orders to
the contrary. [Medium]

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§748.2653. What must occur for a caregiver to remove the
mat or bedding without a written order?
Subchapter N, Emergency Behavior Intervention
Division 6, Additional Responsibilities During Administration of Seclusion
January 2007

(a) If a caregiver cannot obtain a written order to remove the mat or bedding, the
caregiver must obtain and document a licensed psychiatrist’s, psychologist’s, or
physician’s verbal order with the rationale for the removal no later than one hour
following the intervention. [Medium-Low]
(b) The verbal order must include an evaluation by the psychiatrist, psychologist, or
physician assessing whether seclusion is the most appropriate intervention for the
child given the situation. [Medium]
(c) The professional who provides the verbal order must provide a written version of the
order within 72 hours of issuing the order. The written copy must include the time,
date, and the professional’s signature. [Medium-Low]

Division 7, Additional Responsibilities During

Administration of a Mechanical Restraint

§748.2701. What are the additional responsibilities for

implementing a mechanical restraint?
Subchapter N, Emergency Behavior Intervention
Division 7, Additional Responsibilities During Administration of a Mechanical Restraint
February 2017

(a) Only commercially available devices specifically designed for the safe and
comfortable restraint of humans may be used as mechanical restraints. [High]
(b) Mechanical restraint devices must be inspected after each use to ensure that they
are in good repair and are free from tears or protrusions that may cause injury.
Damaged devices may not be used to restrain a child. [Medium-High]
(c) There must be a protected, private, and observable environment or room that
safeguards the child’s personal dignity and well-being. [Medium]

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 (d) Caregivers must continuously observe the child placed in mechanical restraint
ensuring the child has adequate respiration, circulation, and overall well-being. This
observation can take place through a window or a one-way mirror. The use of a
video camera to continuously observe a child in mechanical restraint is not
permitted. In addition to continual observation, a caregiver must check for
circulation, skin color, and respiration at least every 15 minutes. [High]
(e) You must notify a child’s parent that mechanical restraint was used on the child
within 72 hours after the restraint is concluded. [Medium]

§748.2703. May my residential treatment center use

altered mechanical restraint devices when restraining a
child?
Subchapter N, Emergency Behavior Intervention
Division 7, Additional Responsibilities During Administration of a Mechanical Restraint
January 2007

Yes; however, any alteration of commercially available mechanical restraint devices must be
reviewed and approved by a licensed psychiatrist who must [Medium-High]:

(1) Base his approval on the individual child’s special physical needs [Medium-High]; and
(2) Take into consideration any potential medical contraindications, including psychiatric
contraindications, such as the child’s history of sexual abuse or previous use of
mechanical restraints. [Medium-High]

§748.2705. What mechanical and other restraint devices

are prohibited?
Subchapter N, Emergency Behavior Intervention
Division 7, Additional Responsibilities During Administration of a Mechanical Restraint
September 2010

The following must not be used as restraint devices:

(1) Devices with metal wrist or ankle cuffs, such as handcuffs or shackles [Medium-High];

(2) Devices with rubber bands, rope, or cord [Medium-High];

(3) Devices with padlocks, key locks, or fastening devices [Medium-High];

(4) Long ties, such as leashes [Medium-High];

(5) Bed sheets or blankets [Medium-High]; and

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(6) Veil beds. [Medium-High]

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Division 8, Successive Use and Combinations of Emergency
Behavior Intervention

§748.2751. May a caregiver successively use emergency

behavior interventions on a child?
Subchapter N, Emergency Behavior Intervention
Division 8, Successive Use and Combinations of Emergency Behavior Intervention
February 2017

(a) A caregiver may successively use emergency behavior interventions on a child only if:
(1) Allowed by your policies [Medium-High];
(2) Permitted by rules of this subchapter for both types of emergency behavior
intervention [Medium-High]; and
(3) The following written orders are met:
(A)If the successive intervention is seclusion immediately following a personal
restraint or mechanical restraint: the written order for the seclusion meets
the requirements in Division 3 of this subchapter (relating to Orders) and
provides clinical justification for the use of the seclusion successive to a
personal restraint or a mechanical restraint [Medium-High];
(B)If the successive intervention is a mechanical restraint immediately
following a personal restraint or seclusion: the written order for the
mechanical restraint meets the requirements in Division 3 of this subchapter
and permits and provides clinical justification for the use of the mechanical
restraint successive to a personal restraint or a seclusion [Medium]; and
(C)If the successive intervention is a personal restraint immediately following a
seclusion or a mechanical restraint: The professional ordering the seclusion
or mechanical restraint must approve of and provide clinical justification for
the successive use of the personal restraint in a written order. [Medium]

(b) If the successive intervention is personal restraint immediately following another

personal restraint, the time spent in the personal restraints is cumulative and may not
exceed the maximum length of time permitted. [Medium-High]

(c) A caregiver must allow the child:

(1) Bathroom privileges as needed and at least once every two hours [Medium-
High];

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 (2) An opportunity to drink water at least once every two hours [High];

(3) Regularly prescribed medications unless otherwise ordered by the licensed

physician [Medium-High];

(4) Regularly scheduled meals and snacks served in a safe and appropriate manner
[Medium-High]; and

(5) An environment that is adequately ventilated during warm weather, adequately

heated during cold weather, appropriately lighted, and free of safety hazards.
[Medium-High]

§748.2753. May a caregiver simultaneously use emergency

medication in combination with another emergency
behavior intervention?
Subchapter N, Emergency Behavior Intervention
Division 8, Successive Use and Combinations of Emergency Behavior Intervention
January 2007

(a) A caregiver may simultaneously use emergency medication in combination with

personal restraint or seclusion only if:
(1) Allowed by your policies [Medium-High];
(2) Permitted by the rules of this subchapter for both types of emergency behavior
intervention [Medium-High]; and
(3) Written orders specifically allow the combination. [Medium-High]

(b) The written orders must include clinical justification for the combination of emergency
medication with personal restraint or seclusion that goes beyond the justification for
the use of a single emergency behavior intervention. Clinical justification for the
combination must be provided by [Medium-High]:

(1) The licensed physician ordering the emergency medication for the combination
of emergency medication and seclusion; or

(2) Both the licensed physician ordering the emergency medication and the
professional ordering the personal restraint, if they are different people.

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§748.2755. May a caregiver simultaneously implement
mechanical restraint in combination with emergency
medication?
Subchapter N, Emergency Behavior Intervention
Division 8, Successive Use and Combinations of Emergency Behavior Intervention
September 2010

(a) A caregiver may simultaneously implement mechanical restraint in combination with

emergency medication only if:
(1) Allowed by your policies [Medium-High];
(2) Permitted by the rules of this subchapter for both types of emergency behavior
intervention [Medium-High]; and
(3) Written orders specifically allow the combination. [Medium-High]

(b) The written orders must include clinical justification for the combination of mechanical
restraint with emergency medication that goes beyond the justification for the use of a
single emergency behavior intervention. Clinical justification for the combination of
mechanical restraint and emergency medication must be coordinated and provided by
the licensed psychiatrist ordering the mechanical restraint and the licensed physician
ordering the emergency medication, if they are different people. [Medium-High]

§748.2757. May a caregiver simultaneously implement

mechanical restraint in combination with seclusion?
Subchapter N, Emergency Behavior Intervention
Division 8, Successive Use and Combinations of Emergency Behavior Intervention
January 2007

No, mechanical restraint and seclusion may not be simultaneously implemented. [Medium-High]

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Division 9, Time Restrictions for Emergency Behavior
Intervention

§748.2801. What is the maximum length of time that an

emergency behavior intervention can be administered to a
child?
Subchapter N, Emergency Behavior Intervention
Division 9, Time Restrictions for Emergency Behavior Intervention
April 2022

The maximum length of time that certain emergency behavior interventions can be administered
to a child is as follows:

Types of The maximum length of time is:

Emergency
Behavior
Intervention
(1) Short personal One minute. [Medium-High]
restraint.

(2) Personal restraint. (A) For a child of any age, 30 minutes. [High]

(B) A prone or supine personal restraint transitional hold may

not exceed one minute. [High]

(3) Emergency medication. Not applicable.

(4) Seclusion. (A) For a child under nine years old, one hour. [Medium-High]
(B) For a child nine years old or older, two hours. [Medium-
High]

(5) Mechanical restraint. (A) For a child under nine years old, 30 minutes. [High]
(B) For a child nine years old or older, one hour. [High]

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§748.2803. How long may a caregiver seclude or
mechanically restrain a child who has been released within
the same 12-hour time period?
Subchapter N, Emergency Behavior Intervention
Division 9, Time Restrictions for Emergency Behavior Intervention
January 2007

If a child is released from seclusion or a mechanical restraint and then secluded or mechanically
restrained again within the same 12-hour period, the time spent in seclusion or mechanical
restraint is cumulative and may not exceed the maximum length of time permitted. [High]

§748.2805. Can a caregiver exceed the maximum length of

time that an emergency behavior intervention can be
administered to a child?
Subchapter N, Emergency Behavior Intervention
Division 9, Time Restrictions for Emergency Behavior Intervention
February 2017

A caregiver may exceed the maximum length of time for certain emergency behavior
interventions as follows:

Types of The maximum length of time is:

Emergency
Behavior
Intervention
(1)Short personal May not be exceeded. [Medium-High]
restraint

(2)Personal May be not be exceeded. [Medium-High]

restraint

(3)Emergency Not applicable.

medication

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 Types of The maximum length of time is:
Emergency
Behavior
Intervention
(4)Seclusion May be exceeded if the caregiver obtains a written continuation
order before the end of the time period from the licensed
psychiatrist, psychologist, or physician with written clinical
justification [Medium]:
(A) Indicating that the emergency situation continues to exist
[Medium]; and

(B) For the length of time the psychiatrist, psychologist, or physician

permits the child to be secluded, which must not exceed four hours.
[Medium]

(5)Mechanical May be exceeded if the caregiver obtains a written continuation

restraint order before the end of the time period from the licensed
psychiatrist with written clinical justification [Medium-High]:
(A) Indicating that the emergency situation continues to exist
[Medium-High]; and
(B) For the length of time the psychiatrist permits the child to be
restrained, which must not exceed four hours. [Medium-High]

§748.2807. May continuation orders be obtained verbally to

exceed the maximum length of time that seclusion or
mechanical restraint can be administered to a child?
Subchapter N, Emergency Behavior Intervention
Division 9, Time Restrictions for Emergency Behavior Intervention
February 2017

(a) Yes, if:

(1) The caregiver does a face-to-face evaluation of the child [Medium-High];
(2) Verbal authorization is obtained before the end of the maximum length of time
[Medium-High];
(3) The caregiver documents the verbal continuation orders [Medium]; and

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 (4) The professional who provides the verbal order provides a written version of the
order within 72 hours of issuing the order. The written copy must include the time,
date, and the professional’s signature. [Medium]
(b) If the seclusion and mechanical restraint continues beyond the maximum length of
time, then the caregiver must allow the child:
(1) Bathroom privileges as needed and at least once every two hours [Medium];
(2) An opportunity to drink water at least once every two hours [Medium-High];
(3) Regularly prescribed medications, unless otherwise ordered by the licensed
physician [Medium-High];
(4) Regularly scheduled meals and snacks served in a safe and appropriate
manner [Medium-High]; and
(5) An environment that is adequately ventilated during warm weather,
adequately heated during cold weather, appropriately lighted, and free of
safety hazards. [Medium-High]
(c) If the mechanical restraint continues beyond the maximum length of time, then the
caregiver must also allow the child an opportunity for range-of-motion exercises for
at least five minutes of each hour a child is in restraint. [Medium-High]
(d) In no event may the order permit the seclusion or mechanical restraint to exceed
four hours. [Medium-High]

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Division 10, General Caregiver Responsibilities, Including
Documentation, After the Administration of Emergency
Behavior Intervention

§748.2851. What follow-up actions must caregivers take

after the child’s behavior no longer constitutes an
emergency situation?
Subchapter N, Emergency Behavior Intervention
Division 10, General Caregiver Responsibilities, Including Documentation, After the
Administration of Emergency Behavior Intervention
January 2007

(a) The caregivers must take appropriate actions to help the child return to routine activities.
[Medium] The follow-up actions of the caregivers must include:
(1) Providing the child with an appropriate transition and offering the child an
opportunity to return to regular activities [Medium];
(2) Observing the child for at least 15 minutes [Medium-High]; and
(3) Providing the child with an opportunity to discuss the situation that led to the need
for emergency behavior intervention and the caregiver’s reaction to that situation.
The discussion must be held in private as soon as possible and no later than 48
hours after the child’s use of an emergency medication or release from any
emergency behavior intervention. [Medium]
(b) Caregivers involved in the emergency behavior intervention must conduct a post-
emergency behavior intervention discussion with the child. The goal of the discussion is to
allow the child and caregiver to discuss [Medium]:
(1) The child’s behavior and the circumstances that constituted the need for an
emergency behavior intervention [Medium];
(2) The strategies attempted before the use of the emergency behavior intervention
and the child’s reaction to those strategies [Medium];
(3) The emergency behavior intervention itself and the child’s reaction to the
emergency behavior intervention [Medium];
(4) How caregivers can assist the child in regaining self-control in the future to avoid
the administration of an emergency behavior intervention [Medium]; and

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 (5) What the child can do to regain self-control in the future to avoid the administration
of an emergency behavior intervention. [Medium]
(c) Caregivers involved in the emergency behavior intervention must:
(1) Debrief with each other concerning the incident as soon as possible after the
situation has stabilized [Medium]; and
(2) Make reasonable efforts to debrief with children in care who witness the incident.
[Medium-Low]
(d) The supervisor(s) of the caregivers involved in the emergency behavior intervention must
review the use of the emergency behavior intervention within 72 hours of the
intervention. [Medium-High]
(e) The caregivers do not have to return the child to previous activities or place the child in
current activities that the group is participating in if the caregivers deem the child’s
participation is not in the best interests of the child or the other children in the group.
However, caregivers must engage the child in an alternative routine activity.
(f) This rule does not apply to the following types of emergency behavior intervention:
(1) Short personal restraint; and
(2) Seclusion, if the child is receiving emergency care services.

§748.2853. What must the caregiver document after

discussing with the child the use of the emergency
behavior intervention?
Subchapter N, Emergency Behavior Intervention
Division 10, General Caregiver Responsibilities, Including Documentation, After the
Administration of Emergency Behavior Intervention
September 2010

The caregiver must document the following after discussing with the child the use of the
emergency behavior intervention:

(1) The date and time the caregiver offered the discussion [Medium-Low];
(2) The child’s reaction to the opportunity for discussion [Medium-Low];

(3) The date and time the discussion took place, if applicable [Medium-Low]; and
(4) The content of the discussion, if applicable. [Medium-Low]

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§748.2855. When must a caregiver document the use of an
emergency behavior intervention, and what must the
documentation include?
Subchapter N, Emergency Behavior Intervention
Division 10, General Caregiver Responsibilities, Including Documentation, After the
Administration of Emergency Behavior Intervention
February 2017

(a) As soon as possible, but no later than 24 hours after the initiation of the emergency
behavior intervention, the caregiver involved in the intervention must document in
the child’s record the following information [Medium]:

(1) The child’s name [Medium];

(2) A description and assessment of the circumstances and specific behaviors that
caused the basis for the emergency behavior intervention [Medium];

(3) The de-escalation attempted before and during the use of the emergency
behavior intervention and the child’s reaction to those strategies [Medium];

(4) The specific emergency behavior intervention administered [Medium];

(5) The date and time the intervention was administered [Medium];

(6) The length of time the child was restrained or secluded [Medium];

(7) The name of the caregiver(s) that participated in the incident that led to the
intervention, and who administered the intervention [Medium];

(8) The name of the person(s) who observed the child [Medium];

(9) The names of any witnesses to the emergency behavior intervention, including
any child who witnessed the intervention [Medium];

(10) All attempts to explain to the child what behaviors were necessary for
release from the intervention [Medium];

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 (11) The child’s condition following the use of the medication or release from the
intervention, including any injury the child sustained as a result of the
intervention or any adverse effects caused by the use of the intervention. If
the child received medical assistance or treatment, the caregiver must
document the name of the person(s) who provided the medical assistance or
treatment [Medium]; and

(12) The actions the caregiver(s) took to facilitate the child’s return to normal
activities following the end of the intervention. [Medium]

(b) Supervisors of caregivers involved in emergency behavior intervention of a child

must document their review of the use of the intervention within 72 hours of the
incident. [Medium-High]
(c) If personal restraint is used, documentation must also include the specific restraint
techniques used, including a prone or supine restraint used as a transitional hold.
[Medium]

(d) If emergency medication is used, documentation must also include the specific
medication used and the dosage administered to the child. [Medium]
(e) If mechanical restraint is used, documentation must also include:
(1) The specific restraint device used [Medium]; and
(2) Continuous observation and regular respiration and circulation checks and
times the checks were conducted. [Medium]

(f) This rule does not apply to short personal restraints.

§748.2857. What notice must I provide to the parent when

I use an emergency behavior intervention with a child in
care?
Subchapter N, Emergency Behavior Intervention
Division 10, General Caregiver Responsibilities, Including Documentation, After the
Administration of Emergency Behavior Intervention
April 2022

(a) As soon as possible, but no later than 72 hours after the initiation of the
intervention, you must provide written notice to the parent that includes [Medium]:

(1) The child’s name [Medium];

(2) The specific emergency behavior intervention administered [Medium];

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 (3) The length of time the child was restrained [Medium];

(4) The child’s condition following the use of the medication or release from the
intervention, including:

(A)Any injury the child sustained as a result of the intervention or any

adverse effects caused by the use of the intervention [Medium]; and

(B)If the child received medical assistance or treatment, the name of

each person who provided the medical assistance or treatment
[Medium];

(5) If a personal restraint was used, the specific restraint technique used,
including a prone or supine restraint used as a transitional hold [Medium]; and

(6) If emergency medication was used, the specific medication used and the
dosage administered to the child. [Medium]

(b) A copy of the documentation provided to the parent must be maintained in the
child’s record. [Medium-Low]

(c) This rule does not apply to short personal restraints. [No Weight]

Technical Assistance

Regarding subsection (a), if the incident report has the information required by this subsection
and constitutes what was provided to the parents, a copy of the incident report in the child’s
record will suffice.

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Division 11, Triggered Reviews

§748.2901. What circumstances trigger a review of the use

of emergency behavior intervention for a specific child?
Subchapter N, Emergency Behavior Intervention
Division 11, Triggered Reviews
February 2017

(a) The following circumstances trigger a review for certain emergency behavior
interventions:

Types of Circumstances that trigger a review:

Emergency
Behavior
Intervention
(1) Short Not applicable, because short personal restraints are not monitored.
personal
restraint

(2) Personal Except as provided by subsection (b) of this section:

restraint (A) The same child is personally restrained:
(i) four times within a seven-day period. [Medium-High]

(ii) more than 12 times in a single 30-day period [Medium-High];

or
(B) The same child is personally restrained more often than the written
order or service planning team recommendation allows. [Medium-
High]

(3) Emergency Emergency medication is used on the same child three times in a 30-day
medication period. [Medium-High]

(4) Seclusion (A) The seclusion of the same child continues for more than 12 hours
[Medium-High]; or
(B) The same child is secluded three times in a seven-day period. [Medium-
High]

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 Types of Circumstances that trigger a review:
Emergency
Behavior
Intervention
(5) Mechanical (A) The mechanical restraint of the same child continues for more than
restraint three hours [Medium-High]; or

(B) The same child is mechanically restrained three times in a seven-day

period. [Medium-High]

(b) You may exceed the number of restraints otherwise allowed in (2) Personal restraint
of Figure: 40 TAC §748.2901(a) for a child if a licensed psychiatrist or psychologist
issues a written order or if a service planning team makes a recommendation
allowing you to do so and you ensure the following:

(1) If applicable, the recommendation from the service planning team includes
the same written information as an order, as specified in §748.2505 of this
title (relating to What information must a written order include?); and

(2) At least one triggered review is conducted in accordance with §748.2907 of

this title (relating to What must the triggered review include and what must
be documented in the child’s record?) every 30 days that personal restraints
in excess of the threshold are authorized.

§748.2903. When must a triggered review occur?

Subchapter N, Emergency Behavior Intervention
Division 11, Triggered Reviews
January 2007

(a) A triggered review must occur as soon as possible, but no later than 30 days
after the review is triggered. [Medium-High]
(b) The regularly scheduled review of the child’s service plan can serve as the
triggered review if it meets the requirements in §748.2907 of this title (relating
to What must the triggered review include and what must be documented in the
child’s record?) and takes place no later than 30 days after the review is
triggered. [Medium-High]

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§748.2905. Who must participate in the triggered review?
Subchapter N, Emergency Behavior Intervention
Division 11, Triggered Reviews
February 2017

(a) A full service planning team must participate in the triggered review. You must invite the
child, as appropriate, and the parents to the review, so they may have the opportunity to
participate and provide input into the content of the review. However, you are not
required to delay the review because a parent or child is unable to participate in the
review at its scheduled time [Medium-High].

(b) Even if the child is not receiving treatment services, the two additional professions
required in §748.1339(b) of this title (relating to Who must be involved in developing an
initial service plan?) must be involved in the triggered review. [Medium-High]

§748.2907. What must the triggered review include and

what must be documented in the child’s record?
Subchapter N, Emergency Behavior Intervention
Division 11, Triggered Reviews
February 2017

(a) Except in cases in which the regularly scheduled review of the child's service
plan also addresses the requirements of a triggered review in accordance with
§748.2903(b) of this title (relating to When must a triggered review occur?), a
triggered review is not a full review of the child's service plan and is focused on
the requirements identified in subsection (c) of this section.

(b) Other than the requirements in this section and in §748.2905 of this title
(relating to Who must participate in the triggered review?), the notification,
participation, implementation, and documentation requirements in Division 4 of
Subchapter I (relating to Admission, Service Planning, And Discharge) do not
otherwise apply to a triggered review.

(c) The following must be included in a triggered review and documented in the
child’s record:

(1) A review of the records and orders of the emergency behavior interventions
[Medium-High];

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 (2) A review and documentation of any potential medical or psychiatric reason for not
using emergency behavior interventions on the child, including the prescribing
professional’s consideration of any potential medical and/or psychiatric
contraindications for the specific child, such as a history of physical or sexual abuse
or victimization involving the type of intervention [Medium-High];

(3) An examination of identified behaviors and patterns, any significant events leading
up to the use of emergency behavior intervention, and all attempted de-escalation
methods, whether successful or unsuccessful [Medium-High];

(4) Identification of alternatives to manage the child’s behavior and more effectively
prevent the use of emergency behavior intervention in the future [Medium-High];
and

(5) A written plan for reducing the need for emergency behavior intervention.
[Medium-High]

§748.2909. What if there are four triggered reviews within

a 90-day period?
Subchapter N, Emergency Behavior Intervention
Division 11, Triggered Reviews
January 2007

If there are four triggered reviews within a 90-day period:

(1) A licensed psychiatrist, psychologist, clinical social worker, professional counselor, or
marriage and family therapist must examine the child [Medium-High]; and
(2) The licensed professional must make service plan recommendations regarding the use of
emergency behavior interventions. You must document these recommendations in the
child’s record. [Medium-High]

Division 12, Overall Operation Evaluation

§748.2951. What is an overall operation evaluation?

Subchapter N, Emergency Behavior Intervention
Division 12, Overall Operation Evaluation
January 2007

(a) The overall operation evaluation is an annual review regarding:

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 (1) The use and effectiveness of emergency behavior interventions at your
operation [Medium]; and
(2) Your emergency behavior intervention policies and procedures, including
the training policy and curriculum. [Medium]

(b) The objectives of the evaluation are to:

(1) Develop and maintain an environment or milieu that supports positive and
constructive behaviors of children in care [Medium];
(2) Use any type of emergency behavior intervention safely, appropriately, and
effectively [Medium]; and
(3) Eliminate or reduce physical injuries and any other negative side effects on the
child’s behavior or emotional development resulting from the emergency behavior
interventions. [Medium]
(c) One focus of the evaluation must be on:
(1) The frequency, patterns, and effectiveness of the types of emergency behavior
intervention techniques that are used for all children in your operation [Medium];
(2) Strategies to reduce the need for emergency behavior interventions for all children
in your operation [Medium]; and
(3) Specific strategies to reduce the need for use of specific types of emergency
behavior intervention techniques for all children in your operation. [Medium]
(d) The results of each overall operation evaluation must be made available to us for review.
[Medium]

§748.2953. What data must be collected?

Subchapter N, Emergency Behavior Intervention
Division 12, Overall Operation Evaluation
April 2022
(a) Quarterly, you must collect, document, and review aggregate numbers of
emergency behavior interventions by type of intervention, with the exception of
short personal restraints. [Medium]
(b) This information must be reported to us no later than 15 days after the end of
each quarter. [Medium]
(c) You must maintain the data for five years. [Medium]

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Technical Assistance

You must use the provider login section of the DFPS Child Care Licensing web site to report
quarterly emergency behavior intervention statistics to Licensing. Please note that you are
expected to submit a report even if no emergency behavior interventions were used within
your operation during the quarter.
The quarterly data on emergency behavior interventions is due to Licensing at the end of each
quarter. Since the current minimum standards went into effect on January 2007, this is when
the data collection was expected to begin. The quarterly reports are based on this start date.
Therefore, quarterly reports should represent the following time frames each calendar year:
Quarter 1 – January through March

Quarter 2 – April through June

Quarter 3 – July through September

Quarter 4 – October through December

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Subchapter O, Safety and Emergency Practices

Division 1, Sanitation and Health Practices

§748.3001. When must I have an annual sanitation

inspection?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
June 2014

(a) A local sanitation official must conduct a sanitation inspection of your operation [Medium-
High]:
(1) Before we issue you an initial permit [Medium-High]; and
(2) At least once every 12 months from the date of the last sanitation inspection.
[Medium-High]

(b) Each inspection must meet regulations set by the local health department
ordinances. [Medium]

(c) If an inspection is not available from a local sanitation official, you must [Medium]:

(1) Obtain documentation from a state or local sanitation official or a county

judge stating that an inspection is not available; and

(2) Maintain this documentation at the operation and make it available to us

upon request.

§748.3003. How must I document that a sanitation

inspection has been completed?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2007

You must keep the most recent sanitation inspection report, letter, or checklist at your operation
to verify the inspection date and findings. The report must include the name and telephone
number of the inspector. [Medium-Low]

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§748.3005. Must I make all corrections specified in the
sanitation inspection report?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2007

You must correct deficiencies and comply with corrections, restrictions, or conditions that the
inspector specifies in the sanitation report, letter, or checklist. [Medium-High]

§748.3007. What must I sanitize?

Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2007

You must sanitize any item or surface that comes into contact with bodily fluids and has the
possibility for cross contamination. [Medium-High]

§748.3009. How should items be sanitized?

Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
September 2010

Items may be sanitized by [Medium-High]:

(1) Completing the four-step process outlined in the definition in §748.43(41) of this title
(relating to What do certain words and terms mean in this chapter?);
(2) Washing the items for five or more minutes in a dishwasher or washing machine that uses
hot water of a temperature of at least 160 degrees Fahrenheit;
(3) Washing in a three-compartment sink or three containers. The sinks and/or containers
must be large enough to completely immerse the items for soaking, rinsing, and
disinfecting; or

(4) Following the requirements of any alternative methods that have been approved by the
Department of State Health Services for your operation.

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§748.3013. What are the parameters for sinks used for
food service or food preparation?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2007

All sinks that you use for food service or food preparation must be supplied with hot and cold
running water under pressure. [Medium]

§748.3015. How must caregivers handle bodily fluids that

require universal precautions?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2017

Caregivers must follow universal precautions outlined by the Centers for Disease Control (CDC)
when handling blood, vomit, or other bodily fluids that may contain blood, including.
(1) Using disposable, nonporous gloves [Medium-High];
(2) Placing gloves contaminated with blood in a tied, sealed, or otherwise closed plastic bag
and discarding them immediately [Medium-High];
(3) Discarding all other gloves in a sanitary manner immediately after one use [Medium-
High];
(4) Washing hands with soap and running water after using and disposing of the gloves
[Medium-High];
(5) Disposing the bodily fluids in accordance with local regulations. Where local disposal
regulations do not exist, the Department of State Health Services must be consulted
regarding the appropriate disposal procedures and their recommendations must be
followed [Medium-High]; and
(6) Disposing disposable syringes, needles, and other sharp items used by persons for
injections or for medical or other procedures in a hard plastic, leak and puncture-resistant
container immediately after use, and keep them inaccessible to children. [Medium-High]

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§748.3017. Are animals allowed at my operation?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2017

(a) Yes; if:

(1) You have documentation at your operation showing dogs and cats have been
vaccinated for rabies as required by Texas Health and Safety Code, Chapter 826
[Medium]; and
(2) All animals on the premises, including pets and livestock, are treated according to a
licensed veterinarian’s recommendations to protect the health and safety of
children. If you choose to have animals on the premises, you must ensure that the
animals do not create health problems or a health risk for children. [Medium]
(b) For therapeutic camp services, you must house horses and other animals that you
maintain at a camp at a reasonable distance from any sleeping, living, eating, or food
preparation area. [Medium]

Technical Assistance
If a child is pregnant, the following health precautions are recommended:

● Keep litter boxes out of the child’s bedroom or bathroom, kitchen, or dining area;
● Clean litter boxes daily; and
● Do not allow the pregnant child to clean litter boxes.

§748.3019. Must I use a licensed exterminator to treat my

operation for insects, rodents, and other pests?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
March 2008

(a) You may treat your operation for pests only if the Structural Pest Control Board
or Department of Agriculture has certified you as a noncommercial applicator.
[Medium]
(b) Otherwise, you must use a pest control operator licensed by the Texas
Structural Pest Control Board or Department of Agriculture to prevent, control,
or eliminate pest infestations at your operation. [Medium]

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 (c) For therapeutic camp services, you must maintain a vector control program to
ensure effective control of all insects and rodents in the buildings and on the
premises of your permanent camp. If chemical control is needed, then you must
comply with subsections (a) and (b) of this section. [Medium]

§748.3021. How must I protect children from dangerous

tools and equipment?
Subchapter O, Safety and Emergency Practices
Division 1, Sanitation and Health Practices
January 2007

Dangerous tools and equipment, such as hatchets, saws, and axes must be stored, so they are
inaccessible to children. Children may use these tools and equipment with caregiver supervision,
as appropriate based on the child’s age, maturity, and treatment issues. [Medium-High]

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Division 2, Natural Gas and Liquefied Petroleum

§748.3061. When must my operation be inspected for gas

leaks?
Subchapter O, Safety and Emergency Practices
Division 2, Natural Gas and Liquefied Petroleum
January 2007

Your operation must be inspected for gas leaks:

(1) Before we issue your initial permit [Medium-High]; and

(2) At least once every 24 months from the date of the last inspection for gas leaks. [Medium-
High]

§748.3063. Who must conduct a gas leak inspection at my

operation?
Subchapter O, Safety and Emergency Practices
Division 2, Natural Gas and Liquefied Petroleum
January 2007

(a) If your operation uses natural gas, a licensed plumber or a gas company official
must conduct the gas leak inspection. [Medium]

(b) If your operation uses liquefied propane (LP) gas, you must have your LP-gas
system inspected for proper installation and leaks by:

(1) A licensed LP-gas servicing company [Medium]; or

(2) A licensed plumber who is also licensed with the LP-gas section of the
Texas Railroad Commission. [Medium]

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§748.3065. What documentation must I maintain regarding
gas leak inspections?
Subchapter O, Safety and Emergency Practices
Division 2, Natural Gas and Liquefied Petroleum
January 2007

(a) A written gas inspection report must show your gas system is free of leaks and
must indicate the date of the inspection, as well as the name and telephone
number of the inspector. [Medium-Low]

(b) You must keep the most recent inspection report at your operation to verify the
inspection date and findings. [Medium-Low]

(c) You must comply with all corrections, conditions, or restrictions specified in the
gas inspection report within the timeframes specified by the inspector. [Medium-
High]

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Division 3, Fire Safety Practices

§748.3101. When must I have a fire inspection?

Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

You must have a fire inspection:

(1) Before we issue your initial permit [Medium-High]; and

(2) At least once every 12 months from the date of the last fire inspection. [Medium-High]

§748.3103. Who must conduct a fire inspection?

Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) A state or local fire inspector must conduct the inspection. [Medium]
(b) If an inspector cannot conduct an inspection, you must provide documentation of this
from a state or local fire inspector or county judge. [Medium]

§748.3105. What documentation must I maintain regarding

a fire inspection?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) You must keep the most recent fire inspection report, letter, or checklist at the
operation to verify the inspection date and findings. The report must include the
inspector’s name and telephone number. [Medium-Low]
(b) You must comply with the local code and all corrections, restrictions, or conditions
specified by the inspector in the fire inspection report, letter, or checklist. [Medium-
High]

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§748.3107. What type of smoke-detection system must I
have?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) Your operation must have an operable smoke-detection system that is audible
throughout the building. This may be [Medium-High]:
(1) An electronic fire alarm and smoke-detection system; or
(2) Individual electric or battery-operated smoke detectors located according to the
state or local fire inspector’s recommendations. If no fire inspector is available
or able to give recommendations, smoke detectors must be located in the
following areas [Medium-High]:
(A)In hallways or open areas outside sleeping rooms [Medium-High]; and
(B)On each level of a building with multiple levels. [Medium-High]
(b) Depending on the size and layout of the operation, additional smoke detectors
may be required based on manufacturer’s or fire inspector’s instructions.
[Medium-High]
(c) New operations granted a permit by us on or after January 2007, must have
smoke detectors that get their power from building wiring from a commercial
source. Wiring must be permanent. Smoke detectors must [Medium-High]:
(1) Be equipped with a battery back-up [Medium-High]; and
(2) Emit a signal when the batteries are low. [Medium-High]

§748.3109. How must smoke detectors be installed at my

operation?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) Smoke detectors must be installed and maintained according to the

manufacturer’s instructions or in compliance with the state or local fire
inspector’s instructions. [Medium-High]
(b) Batteries must be changed annually or sooner, as required to maintain
operable smoke detector units. [Medium-High]

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§748.3111. How often must the smoke detectors at my
operation be tested?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) The administrator or designee must test all battery-operated smoke detectors
monthly by pressing the test button or switch on the unit. The date of the test
and the name of the employee who does the testing must be documented and
kept at the operation for review. [Medium]
(b) A company licensed by the State Fire Marshal, or the state or local fire inspector,
must test an electronic smoke alarm system at least annually. You must keep
documentation of the inspection at the operation for review. The documentation
must indicate the date of the inspection and the inspector’s name and telephone
number. [Medium]

§748.3113. Must my operation have a fire-extinguishing

system?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) Your operation must have a fire-extinguishing system, which may be a sprinkler
system and/or fire extinguishers. [Medium-High]
(b) The state or local fire inspector must approve the sprinkler system and/or fire
extinguishers in your operation. If an inspector cannot conduct an inspection,
you must have at least one fire extinguisher in the operation rated not less than
3A:40BC. [Medium-High]
(c) Any fire extinguisher that has been used or has lost operating pressure must be
serviced or replaced immediately with an equivalent unit. [Medium-High]

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§748.3115. How often must I inspect and service the fire
extinguisher(s)?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

You must inspect the fire extinguisher(s) monthly and ensure [Medium]:
(1) There will be no interference with access to the extinguisher in an emergency, for
example, there are no objects blocking access [Medium];

(2) Fire extinguishers are accessible for immediate use by employees, caregivers, and
volunteers [Medium]; and
(3) Fire extinguishers are serviced as required by manufacturer’s instructions, or as required
by the state or local fire inspector. [Medium-High]

Technical Assistance
It is a good idea to mount fire extinguishers on the wall by a hanger or bracket, with the top
of the extinguisher no higher than five feet above the floor and the bottom at least four
inches above the floor or any other surface. If a state or local fire inspector has different
mounting instructions, follow those instructions.

When inspecting a fire extinguisher, best practice suggests ensuring that:

● The fire extinguisher pressure is at the recommended level. On extinguishers with a

gauge, the needle must be in the green zone;
● The pin and tamper seal are intact, if applicable;
● There are no leaks, dents, rust, chemical deposits or other signs of abuse or wear; and
● The date of the inspection and the name of the employee is recorded and maintained at
the operation for one year.

§748.3117. How often must the state or local fire inspector

inspect fire extinguisher(s)?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
September 2010

(a) A company licensed by the State Fire Marshal must inspect each fire extinguisher at
least annually and conduct any required service or testing. Newly purchased fire
extinguishers do not require inspection during the first 12 months of service unless
indicated by the monthly inspection. [Medium]

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 (b) You must keep documentation of the inspection and/or the purchase of new fire
extinguishers at the operation for review. The documentation must indicate the date
of the inspection and the inspector’s name and telephone number. [Medium-Low]

§748.3119. How often must a fire sprinkler system be

inspected?
Subchapter O, Safety and Emergency Practices
Division 3, Fire Safety Practices
January 2007

(a) If your operation has a fire sprinkler system, a company licensed by the State Fire
Marshal must inspect the fire sprinkler system at least annually and conduct any
required service or testing. [Medium]
(b) You must keep the most recent inspection report at the operation for review. The
documentation must indicate the date of the inspection and the inspector’s name
and telephone number. [Medium-Low]

Division 4, Heating Devices

§748.3161. What steps must I take to ensure that heating

devices do not present hazards to children?
Subchapter O, Safety and Emergency Practices
Division 4, Heating Devices
September 2010

(a) Gas appliances must be safe and in good repair. [Medium-High]

(b) Space heaters must be enclosed and have a screen or guard. [Medium-High]
(c) You must ensure that children do not have access to floor and wall furnace grates, steam
and hot water pipes, and electric space heaters. [Medium-High]
(d) If you use a fireplace or wood-burning stove, it must be kept clean and have a screen or
guard. [Medium-High]
(e) You may not use a stove to heat any part of the operation, including portable camp
stoves. [Medium-High]
(f) You may not use open flame or liquid fuel heaters. [Medium-High]

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Division 5, Carbon Monoxide Safety Practices

§748.3191. Must I have a carbon monoxide detector-

system?
Subchapter O, Safety and Emergency Practices
Division 5, Carbon Monoxide Safety Practices
January 2007

You must have an operable carbon monoxide detector-system if your operation has gas
appliances. This may be [Medium-High]:

(1) An electronic carbon monoxide detector-system; or

(2) Individual electric or battery-operated carbon monoxide detectors.

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Technical Assistance
Some sources of carbon monoxide include: appliances fueled with natural gas, liquefied
petroleum (LP gas), oil, kerosene, coal, or wood may produce carbon monoxide, such as
unvented kerosene and gas space heaters; leaking chimneys and furnaces; back-draft from
furnaces, gas water heaters, wood stoves, and fireplaces; gas stoves; gas air conditioners
and refrigerators. Burning charcoal and automobile exhaust also produce carbon monoxide.
Avoid conditions that place people in closed spaces where exhaust can accumulate and cause
carbon monoxide poisoning.

It is best to:

● Not turn on a gasoline or kerosene-operated engine or tools, charcoal grill or a

barbecue grill inside buildings or living quarters;
● Not burn charcoal indoors;
● Not use portable fuel-burning camping equipment inside a home, building, garage,
vehicle, cabin, camper or tent;
● Open the garage door and garage windows fully for ventilation before starting a
gasoline or kerosene operated engine, such as a generator, lawn mower or vehicle.
● Drive out as soon as possible if you turn on a vehicle in a garage, or keep the door
connecting the garage to the building closed when the vehicle is running in the garage.
Carbon monoxide can easily go from the garage through the door that opens into the
building, even if your garage door is open to let in fresh air;
● Ensure appliances are installed according to manufacturer’s instructions and local
building codes;
● Buy equipment carrying the seal of a national testing agency, such as the American Gas
Association or the Underwriters’ Laboratory;
● Have the heating system (including chimneys and vents) inspected and serviced
annually. The inspector should also check chimneys and flues for blockages, corrosion,
partial and complete disconnections, and loose connections; and

Keep your vehicle windows open while driving in heavy traffic or when the vehicle is idling,
even when you run the air conditioner. Even with an air conditioner, carbon monoxide can be
pulled into your car or truck while you drive slowly in heavy traffic.

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§748.3193. How must carbon monoxide detectors be
installed?
Subchapter O, Safety and Emergency Practices
Division 5, Carbon Monoxide Safety Practices
January 2007

(a) You must install carbon monoxide detectors that meet Underwriters Laboratories Inc.
requirements (UL-Listed). [Medium-High]
(1) You must install carbon monoxide detectors according to manufacturer’s
specifications for proper location and installation [Medium-High]; and
(2) Furniture, draperies, or other items must not cover up detectors. [Medium-High]

(b) If you use an electronic carbon monoxide detection-system connected to an

alarm/smoke detection system, the system must be installed according to the
state or local fire inspector’s requirements. [Medium-High]

§748.3195. How must I maintain carbon monoxide

detectors?
Subchapter O, Safety and Emergency Practices
Division 5, Carbon Monoxide Safety Practices
January 2007

You must maintain electric or battery-operated carbon monoxide detectors in compliance with
the manufacturer’s instructions. [Medium-High]

Division 6, Emergency Evacuation and Relocation

§748.3231. What is an emergency evacuation and

relocation plan?
Subchapter O, Safety and Emergency Practices
Division 6, Emergency Evacuation and Relocation
January 2007

(a) An emergency evacuation and relocation plan is a plan designed to ensure the safety
of children during a fire, severe weather conditions, or another type of emergency
requiring evacuation or relocation of children in care.

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 (b) In an emergency, your first responsibility is to move all the children to a designated
safe area known to all employees, caregivers, and volunteers. Your plan must also
require the person in charge of your operation during the emergency to [High]:
(1) Designate an employee to call the fire department in case of fire or danger
of fire, explosion, toxic fumes, or other chemical release. If the danger
requires immediate evacuation of the operation, this person must first
evacuate the operation and then make the necessary call from another
location [Medium-High];
(2) Designate an employee responsible for securing children’s emergency
numbers, emergency medical authorizations, and medications during the
emergency [Medium];
(3) Once the person in charge is at the designated safe area, account for all
children who were in attendance at the time of the emergency [Medium-
High]; and
(4) Ensure that no one uses elevators during a fire. [Medium-High]

§748.3233. Must I have an emergency evacuation and

relocation diagram?
Subchapter O, Safety and Emergency Practices
Division 6, Emergency Evacuation and Relocation
January 2007

(a) You must have a written emergency evacuation and relocation diagram specifying
directions for egress on file at your operation. [Medium-High]
(b) The emergency evacuation and relocation diagram must show the following:
(1) A floor plan of your operation [Medium-High];
(2) The designated location outside of the operation where all caregivers and children
meet to ensure everyone has exited the operation safely [Medium-High];
(3) The designated location inside the operation where all caregivers and children
take shelter from threatening weather [Medium-High]; and
(4) At least two exit routes that [Medium-High]:
(A)Are located in distant parts of the building and lead to the outside
[Medium-High];
(B)Are not blocked in any way, including with furniture or equipment
[Medium-High];

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 (C)Are not through a kitchen or other hazardous area, unless specifically
approved in writing by the state or local fire inspector. The written approval
must be signed and dated by the state or local fire inspector and
maintained at your operation for our review [Medium-High];
(D)Are not a window, unless children and caregivers are physically able to
exit through the window to the ground outside safely and quickly [Medium-
High];
(E)Are not doors or windows that are locked and require a key to open from
the inside, unless specifically approved in writing by the state or local fire
inspector. The written approval must be signed and dated by the state or
local fire inspector and maintained at your operation for our review
[Medium-High];
(F)Do not lead into a pool area [Medium-High]; and
(G)If above the ground level, are served by standard stairs and do not
require ladders, folding stairs, or trap doors to gain access to the ground
floor. [Medium-High]

§748.3235. Where must I post the emergency evacuation

and relocation diagram?
Subchapter O, Safety and Emergency Practices
Division 6, Emergency Evacuation and Relocation
January 2007

You must post the emergency evacuation and relocation diagram in a prominent and visible
location in all buildings used by an employee, volunteer, or child. [Medium-High]

§748.3237. What other safety provisions must I make?

Subchapter O, Safety and Emergency Practices
Division 6, Emergency Evacuation and Relocation
January 2007

(a) Closet door latches must allow children to open the door from the inside of the closet.
[Medium-High]
(b) In case of electrical failure, you must have an operable source of emergency lighting that
is approved by the state or local fire inspector, or operable battery-powered lighting.
[Medium-High]

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 (c) Children must be able to open emergency exit doors easily from the inside, unless
specifically approved in writing by the state or local fire inspector. The written approval
must be signed and dated by the state or local fire inspector and maintained at your
operation for our review. [Medium-High]

§748.3239. How often must I practice my emergency

evacuation and relocation plans?
Subchapter O, Safety and Emergency Practices
Division 6, Emergency Evacuation and Relocation
January 2007

(a) You must practice an unannounced fire drill at least once every six months from
the date of the last fire drill. During each drill [Medium]:
(1) You must set off a fire alarm or smoke detector [Medium-Low];
(2) The participants must use alternate exit routes [Medium];
(3) The children must be able to safely exit the building to the designated
meeting place within three minutes [Medium]; and
(4) The participants must not use elevators. [Medium]
(b) You must practice a severe weather drill at least once every six months from the
date of the last severe weather drill. [Medium]
(c) Emergency evacuation and relocation plans must be routinely practiced at
different times during hours of operation. [Medium]
(d) You must document these drills, including the date of the drill, time of the drill,
type of drill, and length of time for the evacuation or relocation to take place.
[Medium-Low]

Division 7, First-Aid Kits

§748.3271. Must I have a first-aid kit at my operation?

Subchapter O, Safety and Emergency Practices
Division 7, First-Aid Kits
January 2007

Yes. All separate living areas and buildings must have a complete first-aid kit available. A first-
aid kit must also be available for all field trips. Each first-aid kit must be [Medium]:

(1) Clearly labeled [Medium-Low];

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 (2) Kept in a clean and sanitary condition [Medium];

(3) In good condition and not have expired medications or supplies [Medium-High];

(4) Easily accessible to all employees [Medium];

(5) Stored in a designated location known to all employees [Medium]; and

(6) Kept out of the reach of children. [Medium]

§748.3273. What must each first-aid kit contain?

Subchapter O, Safety and Emergency Practices
Division 7, First-Aid Kits
April 2022

Each first-aid kit must contain at least the following supplies:

(1) A current guide to first aid and emergency care [Medium];

(2) Adhesive tape [Medium];

(3) Antiseptic solution or wipes [Medium];

(4) Adhesive bandages [Medium];

(5) Scissors [Medium-Low];

(6) Sterile gauze pads [Medium];

(7) Thermometer [Medium-Low];

(8) Tweezers [Medium-Low]; and

(9) Waterproof, disposable gloves. [Medium-Low]

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Division 8, Product Safety

§748.3281. When is a product considered unsafe?

Subchapter P, Physical Site
Division 8, Product Safety
April 2022

A product is considered unsafe if, after it has been recalled for any reason by the United States
Consumer Product Safety Commission [No Weight]:

(1) The recall has not been rescinded; and

(2) The product has not been made safe through being remanufactured or retrofitted.

§748.3283. What are my responsibilities regarding unsafe

products at my operation?
Subchapter P, Physical Site
Division 8, Product Safety
April 2022

(a) You are responsible for reviewing the United States Consumer Product Safety Commission
(CPSC) recall list. You may view all current and past recalls through the CPSC’s Internet website
at: [Link]. You must ensure that there are no unsafe products at your operation unless
one or more of the following apply:

(1) The product is an antique or collectible and is not used by, or accessible to any child
[Medium-High]; or

(2) The unsafe product is being retrofitted to make it safe and the product is not used by, or
accessible to any child. [Medium-High]

(b) You are responsible for ensuring that no unsafe products are at the operation. You must post
a notice for parents and employees in a prominent and publicly accessible place that includes
information on how to access a listing of unsafe products through the CPSC Internet website or
through the Texas Health and Human Services Internet website. [Medium-High]

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Subchapter P, Physical Site

Division 1, Grounds and General Requirements

§748.3301. What general physical site requirements must

my operation meet?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
April 2022

(a) Buildings, including exterior and interior surfaces (such as walls, floors, and
ceilings), must:
(1) Be structurally sound and not pose a risk to the health and safety of children
[High];
(2) Be clean and in good repair [Medium]; and
(3) Comply with applicable building, plumbing, electrical, fire, and similar codes.
[High]
(b) Paints used at the operation after January 1, 2007, must be lead-free. [High]
(c) Windows and doors must be in good repair and free of broken glass or hazards.
Windows used for ventilation, including windows in doors, must be provided with
properly fitted and secure screens in good repair for protection from insects when
windows are open. [Medium-High]
(d) Walkways must be free of ice, snow, and obstruction. [Medium]
(e) Outdoor areas must be well drained. [Medium]
(f) The grounds of the operation must be well maintained and free of hazards.
[Medium-High]
(g) The grounds of the operation must be free of accumulation of garbage and debris
and maintained in a sanitary manner. All garbage must be disposed of in a sanitary
manner in accordance with the Texas Commission on Environmental Quality (see 30
TAC Chapter 330, Municipal Solid Waste). Outdoor garbage cans must have lids.
[Medium]
(h) The building must be free of rodents and insects.
(i) Equipment and furniture must be safe for children and must be kept clean and in
good repair. [Medium-High]

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 Technical Assistance

● Repair work that is scheduled or in progress may be considered as compliance with the
requirements in this rule, as long as any risk to children has been adequately
addressed.
● Related to subsection (d), this includes reasonable and timely efforts to shovel the snow
from the walkways and/or deicing the ice and/or snow.
● Related to subsection (h), this includes reasonable and timely efforts to control insects,
such as regularly scheduled exterminator visits.

§748.3303. What parts of my operation must be ventilated?

Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

Living quarters, recreation areas, dining areas, bathrooms, bedrooms, and kitchens must be
adequately ventilated by at least one operable window or mechanical ventilation system.
[Medium-High]

§748.3305. What are the requirements for handrails,

railings, and stairway and stairwell landings?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

(a) Each ramp, stairway, and steps exceeding two steps must have a well-secured handrail.
Stairs must have a minimum width of 36 inches. [Medium]
(b) Each porch or deck that has over an 18-inch drop must have a well-secured railing.
[Medium-High]
(c) If a door opens directly to a stairway, the door must be a minimum of 34 inches wide.
There must be a landing between the door and the stairs. The landing must be wide
enough to allow the door to open and a person to safely step on to the landing while
closing the door. [Medium]

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§748.3307. What are the requirements for lighting?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

(a) All living quarters must be provided with electric services. [Medium-High]
(b) The following must be lighted in order to avoid accidents:
(1) Habitable rooms [Medium-High];
(2) Common use rooms, such as dining rooms, living rooms, laundry rooms, and
gymnasiums [Medium-High];
(3) Bathrooms [Medium-High];
(4) Hallways [Medium-High];
(5) Interior stairs; [Medium-High]
(6) Outside steps and doorways [Medium];
(7) Porches [Medium];
(8) Ramps [Medium]; and
(9) Fire escapes. [Medium-High]
(c) You may not use propane, kerosene, or other flammable fuel as a light source. [High]

§748.3309. What are the requirements for a

communication system?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

Your operation must have:

(1) An operable telephone with an outside line that is accessible to employees in
emergencies. This telephone must have a listed telephone number and not be
coin-operated [Medium]; and
(2) A communication system to allow employees to contact other employees in
the operation for assistance in an emergency or as needed. [Medium]

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§748.3311. What are the requirements for using a tractor?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

You must never permit a child:

(1) Under 16 years old to operate a tractor [Medium]; or
(2) To ride as a passenger on a tractor. [Medium]

Technical Assistance
A riding lawn mower is not considered a tractor. Riding lawn mowers are used only for
mowing. A tractor is a multi-purpose vehicle used for towing or pulling something which
cannot propel itself and, often, powering it too. A riding lawn mower is lawn equipment, while
a tractor is farm equipment.

§748.3313. May I use water from a private water system?

Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

You may use water from a private water system if you maintain:
(1) The water supply in a safe and sanitary manner [Medium-High]; and
(2) Written records indicating the private water supply meets the requirements of the Texas
Commission on Environmental Quality. [Medium-Low]

§748.3315. What are the requirements for running hot

water?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

A thermostat must control the temperature of hot water accessible to children, so the water
temperature is no higher than 120 degrees Fahrenheit. [High]

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§748.3317. May I use a septic system for sewage disposal?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
January 2007

You may use a septic system for sewage disposal if the septic system [Medium-High]:
(1) Is sanitary; and
(2) Meets the standards of the Texas Commission on Environmental Quality, including any
routine inspections required by law.

§748.3319. What “No Trespassing” signs must I post if my

operation is a residential treatment center?
Subchapter P, Physical Site

Division 1, Grounds and General Requirements

December 2022

(a) If your operation is a residential treatment center, you must post the “No Trespassing”
signs required by subsections (b) and (c) of this section. [Medium]

(b) You may create your own “No Trespassing” signs or use the ones we provide you, but the
signs must:

(1) State that entry to the property is forbidden;

(2) Include a description of the provisions of §30.05, Penal Code, including the
penalties for violating §30.05, Penal Code;

(3) Include the name and address of the person under whose authority the notice is
posted, unless your operation provides trafficking victim services under Subchapter
V of this chapter (relating to Additional Requirements for Operations that Provide
Trafficking Victim Services);

(4) Be written in English and Spanish; and

(5) Be at least 8-1/2 by 11 inches in size.

(c) You must post the “No Trespassing” signs in the following places:

(1) Parallel to and along the exterior boundaries of the grounds;

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 (2) For grounds not fenced, at least every 500 feet along the exterior boundaries of the
grounds;

(3) At each roadway or other way of access to the grounds;

(4) At each entrance to the grounds; and

(5) In conspicuous places reasonably likely to be viewed by intruders.

Technical Assistance

Regarding paragraph (c)(1), at least one sign needs to be posted on each side of fenced
property.

Regarding paragraph (c)(5), conspicuous places for posting include any other location on the
grounds that an intruder may be likely to gain access to children, but does not include every
door or window at the operation. Additionally, each sign should be placed where the sign can
be easily seen and read. The signs should not be obstructed from view.

§748.3321. What additional responsibilities do I have

regarding the “No Trespassing” signs if my operation is a
residential treatment center?
Subchapter P, Physical Site
Division 1, Grounds and General Requirements
December 2022
Regarding the “No Trespassing” signs described in §748.3319 of this chapter (relating to What
“No Trespassing” signs must I post if my operation is a residential treatment center?), you:
(1) Must ensure each “No Trespassing” sign is legible and reflects under whose authority the
sign is currently posted [Medium-Low]; and

(2) May request new “No Trespassing” signs from us, as needed to ensure you are in
compliance with the rules in this chapter.

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Division 2, Interior Space

§748.3351. What are the requirements for general living

space?
Subchapter P, Physical Site
Division 2, Interior Space
January 2017

You must provide:

(1) Living space, appropriate furnishings, and bathroom facilities that are safe,
clean, and maintained in good repair [Medium-High];

(2) Provisions for personal storage space in the child’s bedroom for each child’s
clothing and belongings [Medium-Low];

(3) At least 40 square feet per child, including adult residents and children of
caregivers residing at the operation, of indoor activity space, excluding
bedrooms, halls, kitchens, bathrooms, and any other space not regularly
available to a child [Medium-Low];

(4) Each bedroom with at least one window with outside exposure as a source of
natural light, unless you were granted a permit by us prior to January 1, 2007,
and your permit is still valid [Low]; and

(5) Every bedroom window with curtains, blinds, shades, or other provisions for
rest and privacy. [Medium-Low]

§748.3353. May I use a video camera to supervise a child

in the child’s bedroom?
Subchapter P, Physical Site
Division 2, Interior Space
January 2017

(a) Video cameras may be used to supervise infants and toddlers.

(b) Video cameras may not be used to supervise children, other than infants and toddlers
unless the:

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 (1) Parent, or other person legally authorized to consent, consents to the use of the
video camera [Medium-Low]; and

(2) Child [Medium-Low]:

(A)Is younger than five years old;

(B)Has primary medical needs; or

(C)Requires heightened supervision, such as a child who sleepwalks,

experiences night terrors, engages in physically aggressive or sexual behavior
problems, or resides in a bedroom with such a child. You must document the
justification for the video camera in each child’s service plan, and each child
must have other accessible and reasonable locations where the child may
change clothing in private.

(c) Video cameras may not be used to tape the child, and images may not be accessible
except to operation employees and caregivers. [Medium-Low]

§748.3355. May I use an audio monitoring device to

supervise a child in the child’s bedroom?
Subchapter P, Physical Site
Division 2, Interior Space
January 2007

(a) Audio monitoring devices may be used to supervise infants and toddlers.
(b) Audio monitoring devices may not be used to supervise other children, except infants and
toddlers, unless the:
(1) Parent, or other person legally authorized to consent, consents to the use of the
audio monitoring device [Medium-Low]; and
(2) Child [Medium]:

(A)Is younger than five years old;

(B)Has primary medical needs; or
(C)Requires heightened supervision, such as a child who sleepwalks,
experiences night terrors, engages in physically aggressive or sexual behavior
problems, or resides in a bedroom with such a child. You must document the
justification for the audio monitoring device in each child’s service plan.

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§748.3357. What are the requirements for floor space in a
bedroom used by a child?
Subchapter P, Physical Site
Division 2, Interior Space
January 2017

(a) Floor space [Medium]:

(1) Is space that a child can use for daily activities;
(2) Does not include closets or other alcoves; and
(3) May not be averaged.

(b) You must provide comfortable sleeping arrangements that meet one of the following
[Medium-Low]:
(1) A single occupancy bedroom with at least 80 square feet of floor space [Medium];
or
(2) A bedroom with at least 60 square feet of space for each occupant and no more
than four occupants per bedroom are permitted even if the square footage of the
room would accommodate more than four occupants. The four-occupant restriction
does not apply to children receiving treatment services for primary medical needs.
[Medium]
(c) If we granted you a permit prior to January 1, 2007, then you are exempt from
the maximum bedroom occupancy requirement until:
(1) You move your operation to a new building;
(2) You structurally alter the current building by adding a new room; or
(3) Your permit is no longer valid.
(d) If we granted you a permit to provide emergency care services to a child prior to
January 1, 2007, then you are also exempt from the 60 square feet of bedroom
space for each occupant until:
(1) You move your operation to a new building;
(2) You structurally alter the current building by adding a new room; or
(3) Your permit is no longer valid.

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§748.3359. What rooms may I not use as bedrooms?
Subchapter P, Physical Site
Division 2, Interior Space
January 2007

You may not use the following as bedrooms:

(1) Rooms commonly used for other purposes, such as dining rooms, living rooms, hallways,
porches or dens, except for a child temporarily requiring close supervision or a child who
is admitted to your operation during sleeping hours (for the first night only). These
exceptions are permitted only if the child is provided with comfortable sleeping
arrangements and if supervision of the child is not compromised [Medium-Low];
(2) Rooms that are passageways to other rooms [Medium-Low]; or

(3) Basements; however, if prior to January 2007, we granted you a permit, then basements
may be used as bedrooms as long as other relevant requirements are met, and until:
(A) You move your operation to a new building [Medium-Low];
(B) You structurally alter the current building by adding a new room [Medium-Low]; or

(C)Your permit is no longer valid. [Medium-Low]

§748.3361. May a child in care share a bedroom with an

adult caregiver?
Subchapter P, Physical Site
Division 2, Interior Space
April 2022

(a) Generally, each child should have the child’s own designated bedroom or share a
bedroom with other children. [Medium-Low]
(b) A child may share a bedroom with an adult caregiver if:
(1) It is in the best interest of the child [Medium];
(2) The child is under three years old and sleeps in the bedroom of the
caregiver [Medium]; and
(3) The service planning team dates and documents the approval in the child’s
service plan. [Medium]

(c) A child must not sleep in the same bed with an adult caregiver at any time. [High]

(d) Subsections (a) and (b) of this section do not apply to travel and camping situations.

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§748.3363. May children of opposite genders share a
bedroom?
Subchapter P, Physical Site
Division 2, Interior Space
April 2022

(a) A child six years old or older must not share a bedroom with a child of the opposite gender,
unless [Medium-Low]:

(1) They are siblings;

(2) The older child is the younger child’s parent; or

(3) Both children are non-ambulatory and receive treatment services for primary medical
needs.
(b)The following must occur before you may allow children of the opposite gender to share a
bedroom, unless the older child is the younger child’s parent:
(1) The service planning team must determine that there is no known risk of harm to either of
the children after assessing [Medium]:
(A) Their behaviors [Medium];
(B) Their compatibility with each other [Medium];

(C)Their respective relationships [Medium];

(D)Any history of possible sexual trauma or sexually inappropriate behavior [Medium];
and

(E) Any other identifiable factor that may affect the appropriateness of the children
sharing a bedroom [Medium]; and

(2) The service planning team must date and document the assessment and approval in each
child’s service plan. [Medium-Low]

§748.3365. What are the requirements for beds and

bedding?
Subchapter P, Physical Site
Division 2, Interior Space
January 2017

(a) You must provide each child with an individual bed or bunk bed in the child’s bedroom
that elevates the mattress off of the floor. For infants and toddlers, a crib is allowable.

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 For crib requirements, see §748.1751 of this title (relating to What specific safety
requirements must my cribs meet?). [Medium]
(b) Each bed being used by a child must have:
(1) A clean and comfortable mattress [Medium]; and
(2) A mattress cover or protector if the child is not provided with a mattress that is
waterproof. [Medium]
(c) You must also provide the child with:
(1) A pillow and linens appropriate for the temperature, including a pillowcase, top
sheet, and fitted or bottom sheet [Medium];
(2) Extra linens as needed for the child’s warmth and comfort, such as a blanket or
bedspread [Medium]; and
(3) Clean linens that are changed or laundered if used by a different child and as
often as needed for cleanliness and sanitation, but not less than once a week.
[Medium]

(d) If laundry service is not provided, laundry facilities supplied with hot and cold water
under pressure must be provided for all children in care to use. [Medium-Low]

Technical Assistance
Mattress covers are not required to be plastic. Mattress covers are intended to provide an
additional layer of protection between the child and the mattress, which may help prevent
contamination of the mattress by a child’s bodily fluids or spread of germs from the mattress
to the child (since multiple children may use the same mattress over the course of time).

Regular washing of mattress covers may also be helpful to children who are allergic to dust
mites.

§748.3367. What types of beds are not allowed for a child?

Subchapter P, Physical Site
Division 2, Interior Space
January 2007

The following types of beds are not allowed:

(1) Triple-deck beds [Medium-High];

(2) Veil beds designed to prohibit a child from leaving the bed, not including beds that have
mosquito netting to protect the child from mosquitoes or other insects [Medium-High];
(3) Beds that have bedrails that can entrap a child [Medium-High]; or

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 (4) Any cribs, except for infants and toddlers. [Medium-High]

§748.3369. What are the requirements for bunk beds?

Subchapter P, Physical Site
Division 2, Interior Space
January 2007

(a) A bunk bed must only consist of double-deck beds. [Medium-High]

(b) A child who is under six years old, non-ambulatory, or subject to seizures or other medical
or physical problems who may require greater caregiver supervision and caregiver access
must not use a top bunk bed. [Medium-High]

(c) A bunk bed must allow enough space in between beds and the ceiling to allow a child to
sit up in bed. [Medium-High]

(d) A bunk bed must be equipped with a securely attached ladder capable of supporting the
child using the bed and an employee. [Medium-High]

(e) A bunk bed that is more than 30 inches above the floor must be equipped with securely
attached safety bedrails along the lengths of the bed on each side with a means to allow a
child to get in and out of bed. Bunk beds securely attached to a wall may use the wall as
one of the required guardrails. The top of safety guardrails must be at least five inches
above the top of the mattress. The bed rails and the mattress supports under the
mattress must not be an entrapment hazard. [High]

(f) Openings in guardrails or between ladder rungs must not have openings that can entrap a
child’s body or body part that has penetrated the opening. Openings must measure less
than 3 1/2 inches or more than nine inches to prevent a child’s body or body part from
being entrapped. [Medium-High]

(g) A bunk bed must be spaced to provide a walk space on at least one side and one end of
each bed. [Medium]

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Division 3, Toilet and Bath Facilities

§748.3391. What are the general requirements for

bathroom facilities?
Subchapter P, Physical Site
Division 3, Toilet and Bath Facilities
January 2007

(a) All bathrooms must be maintained in good repair and kept clean at all times [Medium-
High].
(b) You must provide bathrooms located on the same floor as the child’s bedroom. The child
must not have to exit the building to access the bathroom. [Medium]
(c) To provide privacy, you must ensure a child does not have to cross an activity room,
dining room, living room, or similar type room to access a bathroom from the child’s
bedroom. If prior to January 1, 2007, we granted you a permit, you are exempt from this
requirement until [Low]:
(1) You move your operation to a new location;
(2) You structurally alter the current building by adding a new room; or
(3) Your permit is no longer valid.

(d) Each bathroom or room with a lock must be able to be unlocked from the outside
during an emergency. [Medium-High]

§748.3393. What are the requirements for a toilet that a

child uses?
Subchapter P, Physical Site
Division 3, Toilet and Bath Facilities
September 2010

(a) Your operation must dispose of wastewater into a sanitary sewage system, or an
approved septic system in accordance with the Texas Commission on
Environmental Quality, and submit to any routine inspections required by law.
[Medium-High]
(b) You must provide:
(1) At least one toilet for every eight children. All toilets must provide individual
privacy, including doors to individual toilet stalls [Medium-Low]; and

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 (2) Separate toilet facilities for males and females. [Medium]

(c) When toilet facilities for each gender are located in the same building, the toilet
facilities must be:
(1) Distinctly marked for each gender [Medium-Low]; and
(2) Separated by a solid wall from floor to ceiling. [Medium-Low]

(d) Toilets must be equipped with toilet paper at all times. [Medium-Low]

(e) Toilet facilities must meet the handicap accessibility standards according to the American
with Disabilities Act, if applicable. [Medium-Low]

(f) Urinals may be substituted for the toilets for the males on a ratio of one urinal or 24
inches of trough-type urinal for one toilet, not to exceed one-third of the required toilets.
Urinals must have privacy walls on three sides that must be constructed of nonabsorbent
materials. [Low]

§748.3395. What are the requirements for hand-washing

sinks that a child uses?
Subchapter P, Physical Site
Division 3, Toilet and Bath Facilities
January 2007

(a) You must maintain all hand-washing sinks in good repair and keep them clean
at all times. [Medium]
(b) You must provide:
(1) At least one hand-washing sink for every eight children [Medium];
(2) A hand-washing sink that is adjacent to toilet facilities [Medium];
(3) Hand-washing sinks with hot and cold running water under sufficient
pressure to meet the demands of the children [Medium-Low]; and
(4) Hand-washing sinks equipped with soap and a personal towel, single-
use disposable towels, or hot air hand dryers. [Medium]

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§748.3397. What are the requirements for bathing
facilities?
Subchapter P, Physical Site
Division 3, Toilet and Bath Facilities
January 2007

(a) All bath and shower areas must provide for individual privacy. This includes
doors or nonabsorbent shower curtains to individual bathtubs and showers
stalls. [Medium]
(b) You must provide:
(1) At least one bathtub or shower for every eight females and one for
every eight males [Medium-Low]; and
(2) Separate shower and bath facilities for each gender, where
applicable. [Medium]
(c) When common-use shower facilities for each gender are located in the same
building, the facilities must be:
(1) Distinctly marked for each gender [Low]; and
(2) Separated by a solid wall from the floor to ceiling. [Low]
(d) Each shower and bathtub must be equipped with [Low]:
(1) Hot and cold running water under sufficient pressure to meet the demands of the
children [Low]; and
(2) Sufficient hot water to meet the demands of the children. [Medium-Low]

(e) If prior to January 1, 2007, we granted you a permit, then you do not have to
comply with these requirements until:
(1) You move your operation to a new location;

(2) You structurally alter the current bathroom facilities; or

(3) Your permit is no longer valid.

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§748.3399. May I use a video camera or audio monitoring
device to supervise a child while the child is in a bathroom?
Subchapter P, Physical Site
Division 3, Toilet and Bath Facilities
January 2007

No. You may not use a video camera or audio monitoring device to supervise a child while the
child is in a bathroom. [Medium-High]

Division 4, Poisons

§748.3421. What are the requirements for protecting

children from poisonous or flammable material?
Subchapter P, Physical Site
Division 4, Poisons
April 2022

You must ensure that poisonous or flammable materials are:

(1) Stored in their original, labeled containers [High];

(2) Kept separate from medication, food, food preparation surfaces, and dining surfaces
[High];
(3) Stored in an area that is inaccessible to children, unless caregivers have evaluated a child
as capable and likely to use such items responsibly [Medium-High]; and
(4) Cleaned up immediately when spilled. [High]

Division 5, Food Preparation, Storage, and Equipment

§748.3441. What general requirements apply to food

service and preparation?
Subchapter P, Physical Site
Division 5, Food Preparation, Storage, and Equipment
September 2010

(a) All food and drinks must be of safe quality and must be stored, prepared, distributed,
and served under sanitary and safe conditions. [Medium-High]

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(b) You must sanitize food service equipment, dishware, and utensils after each use. All
eating and cookware must be properly stored. [Medium]

(c) You must keep furniture, equipment, food contact surfaces, and other areas where
food is prepared, eaten, or stored clean and in good repair. [Medium-High]

(d) If your operation lacks adequate facilities for sanitizing dishes and utensils, you must
only use disposable, single-use items. [Medium]

(e) You must discard single-service napkins, bibs, dishware, containers, and utensils after
each use. [Medium]

(f) You must wash re-useable napkins and bibs after each use. [Medium]

(g) You must wash re-useable tablecloths when soiled. [Medium]

(h) Persons who handle food and/or eating utensils for the group must:

(1) Maintain personal cleanliness [Medium-High];

(2) Keep hands clean at all times [Medium-High];

(3) Wash his hands with soap and water thoroughly after each visit to the toilet
[Medium-High];

(4) Be free of infections commonly transmitted through the handling of food or

drink and free of communicable diseases [Medium-High]; and

(5) Minimize food contamination through the use of utensils. [Medium-High]

(i) Food packages must be in good condition and protect the integrity of the contents,
so food is not exposed to adulteration or potential contaminants. You must discard
cans that are leaking, bulging, or rusted. [Medium]

(j) When you serve an infant or toddler:

(1) If the child is capable of sitting up, you must serve food on plates, napkins,
or other sanitary holders, such as a high chair tray [Medium]; and

(2) You must not serve foods that present a risk of choking. [High]
(k) When you prepare a meal at the operation, the food preparation area must
be in a separate space from the eating, play, and bathroom areas. [Medium]
(l) Fruits and vegetables must be properly washed before use. [Medium-High]

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 (m) Food must be thawed in the refrigerator, in cold water in a leak-proof bag,
or in the microwave. [Medium-High]
(n) Food must be protected from contamination. [Medium-High]
(o) You must keep raw meat, poultry, fish, and their juices away from other
food. After cutting raw meat, you must wash your hands, the cutting board,
the knife, and the countertops with hot, soapy water. You must sanitize
cutting boards by using a solution of one- teaspoon chlorine bleach in one
quart of water. [Medium-High]
(p) You must maintain hot food at 140 degrees Fahrenheit or above. [Medium-
High]
(q) You must refrigerate perishable food at proper temperatures:
(1) Within one hour after use when the temperature is above 90 degrees
Fahrenheit [Medium-High]; or
(2) Otherwise, within two hours. [Medium-High]
(r) Uneaten food from a person’s plate must not be served again or used in the
preparation of other dishes. [Medium-High]
(s) You must not permit animals to be in the area of food storage, food preparation,
and dining. [Medium-High]

(t) This rule does not apply to cottage homes.

§748.3443. What are the requirements for storing food?

Subchapter P, Physical Site
Division 5, Food Preparation, Storage, and Equipment
April 2022

(a) All food items must be:

(1) Covered and stored off the floor [Medium];
(2) Stored on clean surfaces [Medium];
(3) Protected from contamination [Medium-High];
(4) Stored in a container that is protected from insects and rodents [Medium-High];
(5) Stored in the refrigerator, if the food requires refrigeration [Medium]; and
(6) Covered when stored in the refrigerator. [Medium]

(b) You must have a thermometer in refrigerators and freezers and store:
(1) Refrigerated food at 40 degrees Fahrenheit or below [Medium]; and

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 (2) Frozen food at 0 degrees Fahrenheit or below. [Medium]
(c) Subsection (b) of this section does not apply to cottage homes.

§748.3445. How must kitchen, dining areas, supplies, and

equipment be maintained in a cottage home?
Subchapter P, Physical Site
Division 5, Food Preparation, Storage, and Equipment
September 2010

(a) All food and drinks must be of safe quality and must be stored, prepared, and
served under sanitary and safe conditions. [Medium-High]

(b) You must keep furniture, equipment, food contact surfaces, and other areas where
food is prepared, eaten, or stored clean and in good repair. [Medium-High]

(c) Persons who handle food and/or eating utensils for the group must:

(1) Maintain personal cleanliness [Medium-High];

(2) Keep hands clean at all times [Medium-High];

(3) Be free of infections commonly transmitted through the handling of food or

drink and free of communicable diseases [Medium-High]; and

(4) Minimize food contamination through the use of utensils. [Medium-High]

(d) Food must be protected from contamination. [Medium-High]
(e) When you serve an infant or toddler:
(1) If the child is capable of sitting up, you must serve food on plates, napkins, or other
sanitary holders, such as a high chair tray [Medium]; and
(2) You must not serve food that presents a risk of choking. [High]
(f) Utensils and containers intended for one-time use, such as paper and plastic dishes, must
not be used more than once. [Medium]

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Division 6, Play Equipment and Safety Requirements

§748.3471. What are the minimum safety requirements for

outdoor equipment?
Subchapter P, Physical Site
Division 6, Play Equipment and Safety Requirements
September 2010

You must ensure that outdoor equipment and supplies at the operation are safe for the children
as follows [High]:

(1) The outdoor activity space must be arranged, so caregivers can adequately
supervise children at all times [High];

(2) The design, scale, and location of the equipment must be appropriate for the
body size and ability of the children using the equipment [Medium-High];

(3) Equipment must not have openings that can entrap a child’s body or body part
that has penetrated the opening [High];

(4) Equipment must not have protrusions or openings that can entangle something
around a child’s neck or a child’s clothing [High];

(5) Equipment must be securely anchored according to manufacturer’s

specifications to prevent collapsing, tipping, sliding, moving, or overturning
[High];

(6) All anchoring devices must be placed below the level of the playing surface to
prevent tripping or injury resulting from a fall [Medium-High];

(7) Equipment must not have exposed pinch, crush, or shear points on or
underneath it [High];

(8) You must not install climbing equipment, swings, or slides over asphalt or
concrete, unless the asphalt or concrete is covered with properly installed
unitary surfacing materials as specified in this subchapter [High];

(9) Outdoor platforms more than 20 inches in height for children five years old and
younger, and more than 30 inches in height for school-age children, must be
equipped with guardrails that surround the elevated surface, except for
entrances and exits, and that prevent children from crawling over or through
the guardrail [High];

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 (10) The height of the highest play surface or platform cannot be more than eight
feet [High]; and

(11) Stairs and steps on outdoor climbing equipment, regardless of height, must
have well-secured handrails on both sides of stairs and steps that the children
can reach. Rung ladders do not require handrails. [Medium-High]

§748.3473. How high must platform guardrails be?

Subchapter P, Physical Site
Division 6, Play Equipment and Safety Requirements
January 2007

Guardrails and protective barriers must be at least:

(1) 29 inches high for pre-kindergarten or younger children [Medium-High]; and

(2) 38 inches high for school-age children. [Medium-High]

§748.3475. What special maintenance procedures must I

follow for my playground?
Subchapter P, Physical Site
Division 6, Play Equipment and Safety Requirements
September 2010

(a) Your administrator or designee must inspect the playground weekly to ensure no
hazards are present. Your administrator or designee must inspect the equipment and
surfacing material for [Medium-High]:
(1) Normal wear and tear [Medium-High];
(2) Broken or missing parts [Medium-High];
(3) Debris or foreign objects [Medium-High];

(4) Drainage problems [Medium]; or

(5) Other hazards, such as tripping hazards, like exposed concrete footings, tree
stumps, and rocks. [Medium-High]
(b) Your administrator or designee must:

(1) Ensure that hazards or defects identified during the inspection are removed or
repaired promptly [Medium-High]; and
(2) Arrange for protection of the children or prohibit use of the equipment until the
hazards or defects can be removed or repaired. [Medium-High]

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§748.3477. What are the specific safety requirements for
swings?
Subchapter P, Physical Site
Division 6, Play Equipment and Safety Requirements
January 2007

(a) All swing seats must be constructed of durable, lightweight, rubber or plastic material.
[Medium]
(b) Edges of all swing seats must be smooth or rounded and have no protrusions. [Medium-
High]
(c) Swings must not be attached to a composite play structure (a playscape or structure
containing equipment for a variety of activities). [Medium-High]
(d) Only children under four years old may use a bucket swing, and only if an adult is present
to lift and secure the child into the swing. The distance between the protective surfacing
and the bottom of a bucket swing must be at least 24 inches to minimize the likelihood of
unsupervised young children climbing into the swing. [Medium-High]
(e) Tire swings must:
(1) Not be made from heavy truck tires, or tires with exposed steel-belted radials
[Medium-High];
(2) Not be suspended from a composite play structure (a playscape or structure
containing equipment for a variety of activities) or with other swings in the same
swing bay [Medium];
(3) Have drainage holes drilled in the underside of the tire and maintained to facilitate
water drainage [Medium]; and
(4) Have a minimum clearance between the seating surface of a tire swing and the
uprights of the supporting structure of 30 inches or more when the tire is in a
position closest to the support structure. [Medium-High]

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§748.3479. May I have indoor equipment such as climbing
equipment or platforms?
Subchapter P, Physical Site
Division 6, Play Equipment and Safety Requirements
January 2007

You may have indoor climbing equipment if you comply with the following safety standards:
(1) Floor surfaces under indoor climbing equipment and platforms over 20 inches in
height must have a unitary surface that will effectively cushion the fall of a child.
The surface must be installed in the use zone and maintained according to the
manufacturer’s directions. Carpeting alone, even if it is installed over thick
padding, is not an acceptable surface under indoor climbing equipment. [Medium-
High]

(2) Stairs and steps on indoor climbing equipment, regardless of height, must have
well- secured handrails on both sides of stairs and steps that the children can
reach. Rung ladders do not require handrails. [Medium-High]
(3) Platforms, including stairs and steps, over 20 inches in height must be equipped
with protective barriers that prevent young children from crawling over or falling
through the barrier, or becoming entrapped. [Medium-High]

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Division 7, Playground Use Zones

§748.3521. What does the term “use zone” mean?

Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone is the surface area under and around a piece of playground equipment
and platforms onto which a child falling from or exiting from the equipment would
be expected to land.

(b) Other than the equipment itself, the use zone must be free of obstacles that a child
could run into or fall on top of and be injured. [Medium-High]

§748.3523. How do I measure the use zone for stationary

equipment?
Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone for stationary equipment, excluding slides, must extend a minimum
of six feet in all directions from the perimeter of the equipment. [Medium-High]
(b) Use zones for stationary equipment must not overlap the use zones of any other
equipment. [Medium-High]

§748.3525. How do I measure the use zone for slides?

Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone in front of the access and to the sides of a slide must extend a
minimum of six feet from the perimeter of the equipment. [Medium-High]
(b) The use zone in front of the exit of a slide must extend a minimum of six feet.
[Medium-High]
(c) The use zone in front of the slide exit must not overlap the use zone of any other
equipment. [Medium-High]

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§748.3527. How do I measure the use zone for to-fro
swings?
Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone to the front and back of to-fro swings (single-axis swings) must
extend twice the height of the suspending bar to the protective surfacing below.
[Medium-High]
(b) The use zone to the front and back of the to-fro swing must not overlap the use
zone of any other equipment. [Medium-High]
(c) The use zone around the sides of the to-fro swing structure (frame which supports
the swings) must be at least six feet and may overlap the use zone of an adjacent
swing structure. [Medium-High]

§748.3529. How do I measure the use zone for tire swings?

Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone for tire swings or other multi-axis swings must extend in all directions
for a distance equal to the height of the suspending bar to the top of the sitting
surface of the tire, plus six feet. [Medium-High]
(b) The use zone on the sides of the tire swing support structure must be at least six
feet and may overlap the use zone on the sides of an adjacent swing support
structure. [Medium-High]

§748.3531. How do I measure the use zone for bucket

swings?
Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone to the front and rear of the bucket swing must extend twice the height
from the swing beam to the top of the swing-sitting surface. [Medium-High]
(b) The use zone specified in subsection (a) of this section must not overlap any other
use zone. [Medium-High]

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 (c) The use zone on the sides of the bucket swing structure must be at least six feet and
may overlap the use zone on the sides of an adjacent swing support structure.
[Medium-High]

§748.3533. How do I measure the use zone for rotating or

rocking equipment or for track rides?
Subchapter P, Physical Site
Division 7, Playground Use Zones
January 2007

(a) The use zone for rotating or rocking equipment on which the child sits must be at
least six feet from the perimeter when not in use. [Medium-High]
(b) The use zone for rotating or rocking equipment or track rides on which the child
stands or rides must be at least seven feet from the perimeter of the equipment
when not in use. [Medium-High]
(c) The use zone for rocking and rotating equipment must not overlap any other use
zone. [Medium-High]

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Division 8, Protective Surfacing

§748.3561. Where must I install protective surfacing?

Subchapter P, Physical Site
Division 8, Protective Surfacing
January 2007

You must install protective surfacing in use zones identified in Division 7 of this subchapter
(relating to Playground Use Zones). [Medium-High]

§748.3563. What are the requirements of protective

surfacing for use zones?
Subchapter P, Physical Site
Division 8, Protective Surfacing
January 2007

(a) There must be loose-fill surfacing material or unitary surfacing material in the use
zones for all climbing, rocking, rotating, bouncing, or moving equipment, slides,
and swings. Loose-fill surfacing materials include loose particles such as sand,
pea gravel, shredded wood products, and shredded rubber. [Medium-High]

(b) You must not install loose-fill surfacing materials over concrete or asphalt.
[Medium-High]

(c) If you use loose-fill surfacing materials, you must install nine inches or more of
uncompressed loose-fill material in the use zones. [Medium-High]

(d) You must ensure nine inches of the loose-fill materials are maintained at all
times. [Medium-High]

(e) You must mark all equipment support posts to indicate the depth at which the
loose-fill surfacing material must be maintained. [Medium]

(f) If you use unitary materials, they must be installed and maintained according to
manufacturer’s specifications. Unitary surfacing materials are manufactured
materials including rubber tiles, mats, or poured-in-place materials cured to form
a unitary shock- absorbing surface. [Medium-High]

(g) Unitary materials may be installed over concrete or asphalt only if recommended
by the manufacturer. [Medium-High]

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§748.3565. What documentation must I keep at the
operation if I use unitary surfacing materials?
Subchapter P, Physical Site
Division 8, Protective Surfacing
January 2007

(a) If you use unitary surfacing materials, you must have test data from the
manufacturer showing [Medium-High]:
(1) The impact rating of the material (the maximum height of equipment that
may be installed over the surfacing material); and
(2) Installation and maintenance requirements.

(b) This documentation must be at the operation and available for review by Licensing
staff upon request. [Medium]

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Division 9, Swimming Pools, Wading/Splashing Pools, and
Hot Tubs

§748.3601. What are the requirements for swimming pools

that a child uses?
Subchapter P, Physical Site
Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs
April 2022

If a swimming pool with more than two feet of water is used in an activity sponsored by you,
then the swimming pool, either at or away from your operation, must meet the following
criteria:
(1) At least two life-saving devices must be available, such as a reach pole, backboard, buoy,
or a safety throw bag with a brightly colored buoyant rope or throw line [High];
(2) One additional life-saving device must be available for each 2,000 square feet of water
surface, so a pool of 2,000 square feet would require three life saving devices [High];
(3) Drain grates, vacuum outlets, and skimmer covers must be in place [High];
(4) Pool chemicals and pumps must be inaccessible to all children [High];

(5) Machinery rooms must be locked when any child is present [High];

(6) All parts of the swimming pool, including the bottom of the pool, must be clearly visible
during the use of the pool [High];
(7) Pool covers must be completely removed prior to pool use and must not present an
entrapment hazard [High]; and

(8) Swimming area rules and emergency procedures must be posted at the swimming area
and explained to the children. [High]

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§748.3603. What are the additional requirements for a
swimming pool located at my operation?
Subchapter P, Physical Site
Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs
April 2022

(a) The swimming pool must be built and maintained according to the standards of
the Department of State Health Services and any other applicable state or local
regulations. [High]
(b) An adult must be present who is able to immediately turn off the pump and
filtering system when any child is in a swimming pool. [High]
(c) If the swimming pool is aboveground, it must meet all swimming pool safety
requirements specified in this subchapter and have a barrier that prevents a
child’s unauthorized access to the swimming pool. [High]
(d) Outdoor swimming pools must be enclosed with a six-foot fence or wall that
prevents children’s access to the swimming pool. It must be constructed, so the
fence or wall does not obscure the swimming pool from view. [High]
(e) Doors, operable windows, or gates of living quarters must not be part of the
swimming pool enclosure for outdoor swimming pools. [High]
(f) Fence gates leading to the outdoor swimming pool area must have self-closing
and self-latching hardware located at least 60 inches from the ground and must
be locked when the swimming pool is not in use. An indoor swimming pool must
be secured at all times to prevent children’s access to the swimming pool when a
lifeguard is not on duty. [High]
(g) Fence gates must open outward away from the swimming pool and must not be
propped open. [High]
(h) The space between the ground and the bottom of the fence must not exceed four
inches. [High]
(i) When a fence is made of horizontal and vertical slats, the horizontal slats must be
located on the swimming pool side of the fence. [Medium-High]
(j) Doors from the operation leading to the swimming pool area must have a lock
that can only be opened by an adult [High], unless:
(1) The state or local fire authority determines that the height of the lock
violates or would violate the fire code; and
(2) You have documentation of the fire authority’s determination on file.

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 (k) The doors and fence gates leading to or through the swimming pool area must
not be designated as fire and emergency evacuation exits. [Medium-High]
(l) The drain grates, vacuum outlets, and skimmer covers that must be in place,
must also be in good repair, and not be able to be removed without using tools.
[High]
(m) All indoor/outdoor areas within 50 feet outside of the fence around the swimming
pool must be free of furniture and equipment that a child could use to gain
unauthorized access to the swimming pool. [High]

§748.3605. What are the safety requirements for

wading/splashing pools at my operation?
Subchapter P, Physical Site
Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs
January 2007

(a) Wading/splashing pools (two feet of water or less) at your operation must be:
(1) Stored out of children’s reach, when not in use [Medium-High];
(2) Drained at least daily and sanitized [Medium-High]; and
(3) Stored, so they do not hold water. [Medium-High]
(b) A portable wading pool must not be placed on concrete or asphalt. [Medium-High]

§748.3607. What are the requirements for a hot tub?

Subchapter P, Physical Site
Division 9, Swimming Pools, Wading/Splashing Pools, and Hot Tubs
September 2010

A hot tub must be:

(1) Enclosed per the requirements in §748.3603 of this title (relating to What are the
additional requirements for a swimming pool located at my operation?) [Medium-High]; or

(2) Covered with a locking cover when not in use. [Medium-High]

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Subchapter Q, Recreation Activities

Division 1, General Requirements

§748.3701. What are my responsibilities for providing

opportunities for recreational activities and physical
fitness?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2017

(a) You must provide daily indoor and outdoor recreational and other activities
appropriate to the needs, interests, and abilities of the children, so every child may
participate. [Medium-Low]
(b) You must have a written plan for ensuring that a range of indoor and outdoor
recreational and leisure opportunities are provided for children in care. [Low]
(c) Except for a child who has written medical orders to the contrary, your programs for
non- ambulatory children must include:
(1) Physical fitness development that prescribes a variety of body positions
[Medium-Low]; and
(2) Changes in environment. [Medium-Low]
(d) Each child must have individual free time as appropriate to the child’s age and
abilities. [Medium-Low]
(e) You must provide the follow types of recreational activities based on each individual
child’s needs:

Type of The caregivers must:

Service
(1) Child-care (A) Ensure that opportunities to participate in community activities, such
services
as school sports or other extracurricular school activities, religious
activities, or local social events, are available to the child [Medium-
Low]; and

(B) Organize community activities, religious activities, or local social

events that are available to the child. [Medium-Low]

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 Type of The caregivers must:
Service
(2) Treatment (A) Meet the requirements in paragraph (1)(A) of this chart [Medium-Low];
services
(B) Ensure that each child receiving treatment services has an
individualized recreation plan designed by the service planning team
or professionals who are qualified to address the child’s individual
needs, that the plan is implemented, and that the plan is revised by
the service planning team or qualified professionals, as needed
[Medium-Low]; and
(C) Ensure that medical and physical support are given if the recreational
and leisure-time activities require it for a child who is receiving
treatment services for primary medical needs, autism spectrum
disorder, or intellectual disability. [Medium-Low]

§748.3703. What are the requirements for recreational

areas and equipment?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2007

You must provide indoor and outdoor recreational areas and equipment for stimulating children
in appropriate recreational activities. The activities must be in sufficient variety and quantity, so
every child may participate and have some choice of activities. [Medium]

§748.3705. What are higher risk recreational activities?

Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2017

Higher risk recreational activities are activities that present a greater potential of injury to the
child and involve special technical skill, equipment, or safety regulations for participation,
including using all-terrain vehicles, swimming activities, watercraft activities, riding horses,
wilderness hiking and camping excursions, trampoline use, and using weapons, firearms,
explosive materials, and projectiles.

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§748.3707. Does Licensing regulate higher risk recreational
activities?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2007

Licensing only regulates activities that are sponsored or conducted by the operation, including
higher risk recreational activities.

§748.3709. What are the requirements when children

participate in a higher risk recreational activity?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2007

You must meet the following requirements when children participate in a higher risk recreational
activity:
(1) There must be a person that is responsible for and supervises the higher risk recreational
activity [Medium-High];

(2) When the person supervising the higher risk recreational activity is an employee of the
operation, the supervising employee must:

(A) Determine each participant’s experience and skill level Medium]; and
(B) Take this information into account in supervising and assigning equipment or
animals to children [Medium];
(3) Continue to meet the child/caregiver ratios and appropriately supervise the children at all
times. If the person supervising the higher risk recreational activity is not a caregiver with
the operation, then that person cannot be counted in the child/caregiver ratio. For
additional requirements for child/adult ratios for swimming activities, see Division 2 of this
subchapter (relating to Swimming Activities) [Medium-High]; and
(4) You must provide children with equipment that is appropriate to the activity, properly
sized and adjusted where applicable, and in good condition. [Medium-Low]

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 Technical Assistance
It is recommended that children wear a properly fitted helmet appropriate for the activity
when participating in the following higher risk activities: bicycling, horseback riding, outdoor
in-line skating and skateboarding, white-water kayaking, snow skiing or snow boarding,
tackle football, riding on an all-terrain vehicle, or baseball, softball, and tee-ball when
batting. In addition to wearing a helmet for in-line skating, it is suggested that children wear
wrist and elbow guards, and kneepads. In addition to wearing a helmet for horseback riding,
it is suggested that children be appropriately dressed, including shoes or boots, snug
clothing, and long pants. It is recommended that barns, stables, corrals or other structures
used to house horses or other animals be at least 100 feet away from any sleeping, eating or
food preparation area, or body of water to prevent contamination.

Chapter 768 of the Texas Health and Safety Code outlines specific requirements for children
who participate in rodeos, including wearing protective gear. Operations need to be aware of
the requirements of this law if children in their care participate in rodeos.

§748.3711. Who must supervise a higher risk recreational

activity?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2007

(a) The higher risk recreational activity must be supervised by a person:

(1) Knowledgeable about safety precautions for the type of higher risk recreational
activity being performed [Medium]; and
(2) Who has the appropriate experience, training, and/or certification in the activity.
[Medium]

(b) If the person supervising a higher risk recreational activity is an employee of the
operation, you must document these qualifications in the employee’s personnel
record. [Medium-Low]

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§748.3713. What duties are required for a person
supervising higher risk recreational activities?
Subchapter Q, Recreation Activities
Division 1, General Requirements
September 2010

A person supervising higher risk recreational activities must:

(1) Be present at the site of the activity whenever the activity is being carried out [Medium];

(2) Facilitate training or experience for other persons working in the activity to prepare them
for foreseeable risks [Medium];
(3) Assign duties to other persons working in the activity [Medium-Low];

(4) Ensure there is a person at the site of the activity that has a current first-aid and CPR
certificate when the activity is in progress [Medium-High];
(5) Ensure that all necessary equipment is complete, in good repair, and safe to use [Medium-
High];
(6) Ensure there is a first-aid kit located at the site of the activity that contains appropriate
and sufficient equipment for the type of activity and number of participants [Medium-
High];
(7) Obtain information on weather and travel conditions before a trip or activity that is
outdoors [Medium-Low];
(8) Develop a plan for action in case of emergencies relevant to the terrain and activity,
including lost participants, injuries, and illnesses and communicate the plan to other
persons working on the activity [Medium];
(9) Consider each participant’s age, physical condition, and experience, as well as the season
and weather trends [Medium];
(10) Ensure that risk factors are explained to the child prior to the activity, and that the child
has an opportunity to decline participation [Medium-Low]; and
(11) Instruct children on the safety precautions and proper use of relevant items or animals.
This must be done before access to the item or animal is allowed. [Medium]

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§748.3719. May children in care use all-terrain vehicles?
Subchapter Q, Recreation Activities
Division 1, General Requirements
January 2007

(a) A child in care may not ride on or operate a three-wheel all-terrain vehicle. [Medium]
(b) Only a child 16 years or older may ride on or operate a four-wheel all-terrain vehicle.
[Medium]

Technical Assistance
The intent of this rule is to limit children’s use of all-terrain vehicles for sport or recreation,
due to safety concerns. This rule is not intended to limit the safe and appropriate use of
utility vehicles, golf carts, riding lawn mowers, etc.

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Division 2, Swimming Activities
Technical Assistance
The rules in this Division apply to swimming activities that are sponsored by the operation,
whether the swimming activities are at the operation or away from the operation.

§748.3751. Must a certified lifeguard be on duty during a

swimming activity?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
January 2017

(a) A certified lifeguard must supervise children at all times during a swimming
activity involving a body of water two feet deep or more which occurs at your
operation. [Medium-High]
(b) At all times during a swimming activity sponsored by the operation involving
a body of water two feet deep or more which occurs away from your
operation:
(1) If there are six or fewer children participating in the swimming
activity, at least one adult counted in the swimming child/adult ratio
must be able to swim or must be trained to carry out a water rescue
[Medium-High]; and
(2) If more than six children are participating in the swimming activity, a
certified lifeguard must also be on duty. [Medium-High]
(c) A child in your care who is a certified lifeguard may act as the lifeguard if he
is:
(1) At least 16 years old [Medium-High]; and

(2) Not counted as an adult or caregiver in the required child/adult

swimming ratio. [Medium-High]

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§748.3753. Who must provide a certified lifeguard’s
training?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
January 2017

A certified lifeguard’s training must be provided through a recognized organization. [Medium]

§748.3755. Where must a certified lifeguard be positioned

when supervising children who are swimming?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
January 2007

The lifeguard must be located in a position to observe all swimmers and to respond to
emergencies. [High]

§748.3757. What are the child/adult ratios for swimming

activities?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
April 2022

(a) The maximum number of children one adult can supervise during swimming activities
is based on the age of the youngest child in the group and is specified in the following
chart [High]:

If the age of the youngest child Then the Swimming Child/Adult Ratio
is… is
0 to 23 months old 1:1
2 years old 2:1
3 years old 3:1
4 years old 4:1

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 If the age of the youngest child Then the Swimming Child/Adult Ratio
is… is
5 years old or older You must meet the applicable
child/caregiver ratios as provided in
§748.1003 of this title (relating to For
purposes of the child/caregiver ratio,
how many children can a single
caregiver care for during the children’s
waking hours?).
(b) When all of the children in the group are four years old or older, in addition to
meeting the required swimming child/adult ratio listed in subsection (a) of this
section, at least two adults must supervise four or more children who are actually in
the water. [High]
(c) When a child who is non-ambulatory or who is subject to seizures is engaged in
swimming activities, you must assign one adult to that one child. This adult must be
in addition to the lifeguard on duty in the swimming area. You do not have to meet
this requirement if a licensed physician writes orders in which the physician
determines that the child [High]:
(1) Is at low risk of seizures and that special precautions are not needed; or
(2) Only needs to wear a Coast Guard approved life jacket while swimming and
additional special precautions are not needed.

(d) A child must wear a Coast Guard approved life jacket while participating in swimming
activities in other bodies of water such as ponds, rivers, lakes, and oceans if the child
is:

(1) Under the age of 12 [High]; or

(2) Unable to swim, regardless of the child’s age. [High]

(e) So long as you comply with the child/caregiver ratios required in §748.1003 of this
title, the ratios in subsection (a) of this section [No Weight]:

(1) Do not include children over the age of 12 years old who are competent
swimmers; and

(2) Are not required when children are participating in water activities such as
sprinkler play or splash pad or wading pool, as long as the standing water is
less than two feet.

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Technical Assistance
Regarding subsection (b), if you take four 4-year-olds swimming, subsection (a)
only requires one person to supervise the four children. However, if all four 4-
year-olds are actually in the water at the same time, then subsection (b)
requires there to be at least two adults to supervise the children.

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§748.3759. May I count the certified lifeguard in the
swimming child/adult ratio?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
September 2010

A lifeguard who is supervising the area where the children are swimming may be counted in the
child/adult ratio except as specified in §748.3751(c) of this title (relating to Must a certified
lifeguard be on duty during a swimming activity?). The lifeguard must never be left alone with
any of the children unless the lifeguard is also a qualified caregiver for your operation. [Medium]

§748.3763. May I include volunteers or employees who do

not meet minimum qualifications for caregivers in the
swimming child/adult ratio?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
September 2010

To meet the swimming child/adult ratio, you may include adult volunteers and employees of the
operation who do not meet the minimum qualifications for caregivers, providing you:

(1) Maintain enough caregivers to meet the ratios required in Subchapter G of this chapter
(relating to Child/Caregiver Ratios) [High]; and
(2) Ensure compliance with all other rules of this chapter, including rules relating to
supervision and discipline. [High]

§748.3765. What are the requirements for a child’s access

to a body of water?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
January 2017

(a) Prior to any activity regarding a body of water, you must explain the dangers of
the body of water and the rules governing the activity to the children in a manner
that each child can understand. [High]
(b) If your operation sponsors a swimming activity and you allow a child to swim in a
body of water:

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 (1) The supervising adult must clearly designate the swimming areas [High];
(2) You must meet the swimming child/adult ratios [Medium-High]; and
(3) If more than six children are participating in the activity, you must have
life-saving equipment present at all times that is sufficient to reach and
rescue the child, such as a safety throw bag with a brightly colored 50-foot
buoyant rope or a rescue boat equipped with a reach pole and a buoy.
[Medium-High]

§748.3767. May I use a stock tank as a pool for a

swimming activity?
Subchapter Q, Recreation Activities
Division 2, Swimming Activities
January 2007

No. You may not use a stock tank used by livestock for a swimming activity. [High]

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Division 3, Watercraft Activities
Technical Assistance
The rules in this Division apply to watercraft activities that are sponsored by the
operation, whether the water activities are at the operation or away from the
operation.

§748.3801. What watercraft activities do the rules of this

division apply to?
Subchapter Q, Recreation Activities
Division 3, Watercraft Activities
January 2017

The rules of this division apply to activities involving bodies of water:

(1) In which more than six children participate; and
(2) That involve boats, canoes, kayaks, sailboats, rafts, jet skis, or inflatable tubes.

§748.3803. What are the requirements for watercraft

activities?
Subchapter Q, Recreation Activities
Division 3, Watercraft Activities
September 2010
(a) A non-swimmer must wear a life vest. [High]
(b) At least two adults able to swim and carry out a water rescue must be at the shoreline
and/or on the water to respond to emergencies any time children are on the water during
watercraft activities. [Medium-High]

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 Technical Assistance

The following are best practice recommendations regarding watercraft activities:

● The activity supervisor should run or scout a river prior to taking children on the water,
ensure that caregivers have experience on the class of waters to be traveled, ensure
that caregivers hold a current Standard First Aid Certificate or equivalent, and ensure
that caregivers have training in hypothermia;
● There should be a warning device that can be readily heard by persons in the boats that
must indicate the need for them to return to the shore. There should be a rescue boat
available at the river or lake where boating activities take place. This rescue boat should
be in good repair and contain a buoy or a safety throw bag with brightly colored 50-foot
buoyant rope or throw line and a reach pole. When canoeing or rafting, the rescue boat
should have an extra paddle or oar; and
● Watercraft should not enter a swimming area when swimmers are in the water or use
the swimming area as a watercraft docking area unless it is an emergency and the
watercraft is man-powered. Water skiers should not launch or stop in the swimming
area.

§748.3805. What considerations must the watercraft

activity supervisor take into account prior to the
implementation of the activity?
Subchapter Q, Recreation Activities
Division 3, Watercraft Activities
January 2007

The supervisor of the watercraft activity must:

(1) Assess the skill and swimming ability of each child prior to the activity [Medium-High];

(2) Accompany children on any trip [Medium-High];

(3) Determine if an adult must be in the boat with the child or children [Medium-High]; and

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 (4) Take into account hazards, such as the size of the body of water, the skill and swimming
ability of the children, the air temperature, the conditions of the water, and the
temperature of the water when determining:
(A) Whether to permit children to participate in a watercraft activity [Medium-High];

(B) The experience and number of adults necessary [Medium-High]; and

(C)Whether or not each child must wear a life vest. [Medium-High]

§748.3807. What are the requirements for watercraft

equipment?
Subchapter Q, Recreation Activities
Division 3, Watercraft Activities
January 2007

(a) The watercraft and all equipment must be kept in good repair at all times.
(b) You must meet the watercraft requirements of Texas Parks and Wildlife, if applicable.
[Medium-High]

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Division 4, Wilderness Hiking and Camping Excursions

§748.3841. What are the requirements for hiking or

camping excursions?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
September 2010

When you participate in a hiking or camping activity in an area unfamiliar to the participating
adults, and the hiking activity lasts more than two hours:
(1) The person qualified to supervise the hiking or camping excursion must
consider the following when selecting the area for hiking or camping:
(A) Evacuation [Medium];
(B) Communication [Medium]; and
(C)Water quality and quantity [Medium];

(2) The person qualified to supervise the hiking or camping excursion must have
experience leading a group in hiking or camping at the elevation, terrain, and
climate where the activity is to take place [Medium];
(3) Before participation, the caregivers and children must receive instruction on:
(A) The fundamental safety procedures for the area where the hiking or
camping will occur [Medium];
(B) Procedures to follow if the participant gets lost [Medium];
(C)Proper health and sanitation procedures [Medium];
(D) Potential high-risk areas where the hiking or camping will occur [Medium];
and
(E) Fire risks [Medium];

(4) The emergency medical care consent forms must be readily accessible to the
caregivers accompanying them [Medium];

(5) Caregivers participating in the hiking or camping activity must regularly monitor and
care for the health and safety of children [Medium-High]; and

(6) If the excursion will be on private land, you must have an agreement with the person
responsible for that land. [Medium-Low]

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 Technical Assistance
The following are suggestions for when a child is in or around a grassy, wooded area while
camping, hiking or participating in any other outdoor activity, especially in the months
between April and October:

● Cover arms and legs. Have the child wear a long-sleeved shirt, and tuck his pants into
his socks.
● Wear a hat to help keep ticks away from the scalp. Keep long hair pulled back.
● Wear light-colored clothing to make it easier to spot ticks.
● Wear enclosed shoes or boots. Avoid wearing sandals in an area where ticks may
live.
● Use insect repellent. Products with DEET are effective against ticks and can be used
on the skin. However, large amounts of DEET can be harmful to the child if it is
absorbed through the skin. Look for products that contain no more than 30 percent
DEET. Wash the DEET off with soap and water when your child returns indoors.
Products with permethrin can be used on clothing, but cannot be applied to the skin.
● Stay on cleared trails whenever possible. Avoid wandering from a trail or brushing
against overhanging branches or shrubs.
● After coming indoors, check for ticks. This will only take a few minutes. Ticks often
hide behind the ears or along the hairline. It may take up to 48 hours for a person to
become infected, so removing any ticks soon after they have attached themselves can
help reduce the chances of becoming infected.
Removing leaves and keeping your yard clear of brush and tall grass may reduce the number
of ticks. You may wish to talk to a licensed professional pest control expert about other steps
you can take to reduce ticks in your yard.

§748.3843. What are the requirements for monitoring

children’s safety and health during hiking or camping
excursions?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

Caregivers participating in the hiking or camping activity must ensure that:

(1) Each child participating in the hiking or camping activity has the clothing,
equipment, and provisions necessary to protect the child from the environment,
including insect repellent and sunscreen [Medium];
(2) A child does not carry a load of more than 30% of the child’s body weight [Medium];

(3) Hiking does not exceed the physical capabilities of the weakest member of the
group. If a participating child cannot or will not hike, the group must not continue
unless other provisions have been made to care for the child [Medium];

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 (4) In temperatures above 80 degrees Fahrenheit:

(A) Children are offered a minimum of three quarts of drinking water per day
[Medium-High];

(B) Electrolyte replacement is available to children at all times [Medium-High];

and

(C)Other techniques are available to cool a participant, such as water to coat a

child’s body or cold packs [Medium-High]; and

(5) Potable water is available at each campsite. Caregivers must verify water cache
location information before the group leaves camp each day, if applicable.
[Medium]

§748.3845. What type of itinerary must I have for hiking or

camping excursions?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
September 2010

(a) For hiking or camping excursions that last for over five hours, you must have an
itinerary prepared prior to departure, including the [Medium-Low]:
(1) Time of departure and anticipated time of return [Medium-Low];
(2) Destination [Medium-Low]; and
(3) Travel route. [Medium-Low]
(b) For hiking or camping excursions that last overnight, each point of the itinerary
must also identify:
(1) Sources of emergency care, such as hospitals, police, and forest service
offices [Medium-Low];
(2) Methods of communicating with sources of emergency care [Medium]; and
(3) Date and time of departure and anticipated date and time of return.
[Medium-Low]
(c) The caregivers on the excursion must:
(1) Follow the itinerary as closely as possible [Medium-Low]; and
(2) Notify the operation of any change, when possible. [Medium]

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§748.3847. Where must the itinerary be kept?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) You must keep a copy of the itinerary on file at the operation. [Medium]
(b) If the excursion is on land governed by the national or state forest service, then you must
also provide the service’s office with a copy of the itinerary. [Medium-Low]

§748.3849. What are the requirements for shelter during

an overnight excursion?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) During an overnight excursion, you must provide each child with:
(1) Adequate shelter, such as a tent, tarp, or cabin [Medium]; and
(2) Reasonable insulation from cold and dampness by such things as a rain fly, ground
cloth, and an insulated pad under bedrolls or sleeping bags. [Medium]
(b) Open air sleeping is allowable if:
(1) The weather permits [Medium-Low];
(2) The child consents [Medium-Low]; and
(3) You provide a ground cloth and an insulated pad under bedrolls or sleeping bags.
[Medium-Low]

§748.3851. What are the requirements for bed equipment

used during an overnight excursion?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

You must provide each child with:

(1) An individual bed, bedroll, or sleeping bag [Medium-Low];
(2) Extra linens as needed for the child’s warmth and comfort, such as a blanket [Medium-
Low];

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 (3) Clean bed linens that are changed as often as needed for cleanliness and sanitation, but
not less than once a week, if applicable [Low]; and
(4) Provisions for proper laundering of bedrolls and sleeping bags between trips or between
uses by different individuals. [Low]

§748.3853. What are the specific requirements for storing

food during a hiking or camping excursion?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) You may only use foods capable of being maintained in a wholesome condition
with the available equipment. [Medium-Low]
(b) You must refrigerate perishable food when possible. [Medium]
(c) If you use an ice chest to refrigerate food during the excursion, you must provide
adequate ice at all times. [Medium]
(d) You must drain ice chests to prevent accumulation of water from melted ice.
[Medium-Low]
(e) You may not store meat and other highly perishable foods for more than 24
hours. [Medium]
(f) You must discard any contaminated foods. [Medium-High]

Technical Assistance
The following are health and safety recommendations related to cooking and
food storage on hiking and camping trips.

Keeping Food Cold:

It is best to:
● Fill the cooler with cold or frozen foods.
● Pack foods in reverse order. The first foods packed should be the last foods
used, except that raw meat or poultry should be packed below ready-to-
eat foods to prevent raw meat or poultry juices from dripping on the other
foods.
● Take foods in the smallest quantity needed (e.g., a small jar of
mayonnaise).

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Technical Assistance
● In the car, put the ice chest in the air-conditioned passenger section,
rather than in the trunk.
● At the campsite, insulate the cooler with a blanket, tarp, or poncho. When
the camping trip is over, discard all perishable foods if there is no longer
ice in the cooler or if the gel- pack is no longer frozen.

If you are planning to fish, check with the fish and game agency or state health
department to see where you can fish safely, then follow these guidelines:

Finfish:

● Scale, gut, and clean fish as soon as they are caught.

● Live fish can be kept on stringers or in live wells, as long as they have
enough water and enough room to move and breathe.
● Wrap fish, both whole and cleaned, in water-tight plastic and store on ice.
● Keep 3 to 4 inches of ice on the bottom of the cooler. Alternate layers of
fish and ice.
● Store the cooler out of the sun and cover with a blanket.
● Once home, eat fresh fish within 1 to 2 days or freeze them. For top
quality, use frozen fish within 3 to 6 months.

Shellfish:

● Crabs, lobsters, and other shellfish must be kept alive until cooked.
● Store in live wells or out of water in a bushel or laundry basket under wet
burlap or seaweed.
● Crabs and lobsters are best eaten the day they are caught.
● Live oysters should be cooked within 7 to 10 days.
● Live mussels and clams should be cooked within 4 to 5 days.
● Eating raw shellfish is extremely dangerous. People with liver disorders or
weakened immune systems are especially at risk.

Using a Food Thermometer:

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 Technical Assistance
If you are cooking meat or poultry on a portable stove or over a fire, you will
need a way to determine when it is done and safe to eat. Color is not a reliable
indicator of doneness, and it can be especially tricky to tell the color of a food if
you are cooking in a wooded area in the evening.

When cooking hamburger patties on a grill or portable stove, use a digital

thermometer to measure the temperature. Digital thermometers register the
temperature in the very tip of the probe, so the safety of thin foods, such as
hamburger patties and boneless chicken breasts, can be determined. A dial
thermometer determines the temperature of a food by averaging the
temperature along the stem and, therefore, should be inserted 2 to 2 ½ inches
into food. If the food is thin, the probe must be inserted sideways into the food.
It is critical to use a food thermometer when cooking hamburgers. Ground beef
may be contaminated with E. coli O157:H7, a particularly dangerous strain of
bacteria. Illnesses have occurred even when ground beef patties were cooked
until there was no visible pink. The only way to insure that ground beef patties
are safely cooked is to use a food thermometer, and cook the patty until it
reaches 160 °F. For chicken, cook breasts or cutlets to 170 °F and legs and
thighs to 180 °F. Pork should be cooked to 160 °F. Heat hot dogs and any
leftover food to 165 °F. Be sure to clean the thermometer between uses.

§748.3855. What requirements must I meet for food

utensils and equipment when camping?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) A common use drinking cup, container, or utensil must be washed with
uncontaminated hot water and detergent before another person uses it.
[Medium-Low]
(b) You must not use a dish, container, or utensil that is chipped, cracked, broken,
damaged, or constructed so as to prevent proper cleaning and sanitizing.
[Medium-Low]

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 (c) You must discard disposable or single-use dishes, containers, or utensils used in
handling food after one use. [Medium-Low]
(d) You must store eating utensils:
(1) Separately from foods or other materials or substances [Medium-Low];
and
(2) In clean, dry containers. [Medium-Low]

Technical Assistance
The following are best practices for food utensils and equipment when camping:
● Food utensils and equipment should be rinsed in hot water and sanitized in
disinfected water. Prepare each solution daily and place it in a closed and
labeled container; or
● Where group dishwashing is practiced, all food utensils should be
immersed for at least two minutes in a lukewarm chlorine bath containing
at least 50 ppm of available chlorine. Where chlorine is used, a three-
compartment vat or three containers should be used for washing, rinsing,
and immersing.

§748.3857. What parameters must I follow for drinking

water during a hiking or camping excursion?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) Drinking water used during a hiking or camping excursion must come from
a source known to be safe or must be rendered safe. [Medium-High]
(b) An adequate supply of water, under pressure where possible, must be
provided at the cooking area for hand washing, dishwashing, food
preparation, and drinking. [Medium-Low]
Technical Assistance
It is recommended that drinking water be disinfected by one of the following methods:
● Boil water for at least 1 to15 minutes after it reaches a full boil;
● A water purifier;
● A water filter;

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Technical Assistance
● Iodine tablets or crystals – add five drops of iodine per quart of clear water or ten drops
per quart of cloudy water, thoroughly mix the solution, and wait 30 minutes before
using;
● Chlorine dioxide tablets, or halazone tablets used according to the manufacturer’s
directions; or
● Liquid iodine or household chlorine bleach – add two drops of household chlorine bleach
per quart of water. You must ensure the chlorine does not have an active ingredient
other than 4% to 6% sodium hypochlorite. Thoroughly mix the solution and wait 30
minutes before using. If the water does not have a slight chlorine odor and taste, add
two more drops of chlorine bleach and wait 15 more minutes before using.

Safe Drinking Water:

It is not a good idea to depend on fresh water from a lake or stream for drinking, no matter
how clean it appears. Some pathogens thrive in remote mountain lakes or streams and there
is no way to know what might have fallen into the water upstream. It is best to bring bottled
or tap water for drinking, starting out with a full water bottle, and replenishing your supply
from tested public systems when possible. On long trips, you should consider purifying any
water taken from the wild, no matter how clean it appears.

The surest way to make water safe is to boil it. Boiling will kill microorganisms. First, bring
water to a rolling boil, and then continue boiling for 1 minute. Before heating, muddy water
should be allowed to stand for a while to allow the silt to settle to the bottom. Dip the clear
water off the top and boil. At higher elevations, where the boiling point of water is lower, boil
for several minutes.

As an alternative to boiling water, you may also wish to use water purification tablets and
water filters. The purification tablets – which contain iodine, halazone, or chlorine – kill most
waterborne bacteria, viruses, and some (but not all) parasites. Because some parasites are
not killed by purification tablets, you should also use a water filter. These water filtering
devices should be 1 micron absolute or smaller. Over time, purification tablets lose their
potency, so it is important to keep your supply fresh. Water sanitizing tablets for washing

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 Technical Assistance
dishes can also be purchased (just do not confuse the two). Water purification tablets, filters,
and sanitizing tablets can be purchased at camping supply stores.

§748.3861. What are the requirements for toilet facilities

during overnight camping excursions?
Subchapter Q, Recreation Activities
Division 4, Wilderness Hiking and Camping Excursions
January 2007

(a) If the campsite is not provided with toilet facilities, pit privies or other portable
toilets, there must be separate designated areas for each gender for toilet use.
[Low]
(b) Toilet paper must be available at all times, as needed. [Low]
(c) Privies must be located at least:

(1) 20 feet from any stream, lake, well, spring, or other water supply
[Low]; and
(2) 75 feet from the camp, tent, sleeping, or housing arrangement.
[Medium]
(d) Soap and water for hand washing must be located within 20 feet of the toilet
areas. [Low]

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Division 5, Trampoline Use

§748.3891. May I use a trampoline?

Subchapter Q, Recreation Activities
Division 5, Trampoline Use
January 2017

(a) You may use a trampoline if:

(1) The use of the trampoline and the number of children allowed on the trampoline at
one time meets the manufacturer’s instructions [Medium-High];

(2) Shock-absorbing pads cover the springs, hooks, and frame [Medium-High];

(3) Ladders are removed from the trampoline when the trampoline is not in use
[Medium-High]; and

(4) A caregiver provides supervision as follows:

(A)For children under 12 years old, the caregiver must be immediately

present, watching the child/ren at all times, enforcing safety rules and
manufacturer’s instructions, and able to respond to an emergency [Medium-
High]; and

(B)For children 12 years old and older, the caregiver must be on the premises,
visually check on the child/ren at frequent intervals, and able to respond in
an emergency [Medium-High]

(b) You may use a trampoline as gym equipment as provided in §748.3893 of

this title (relating to What are the requirements for using a trampoline as
gym equipment?).

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§748.3893. What are the requirements for using a
trampoline as gym equipment?
Subchapter Q, Recreation Activities
Division 5, Trampoline Use
January 2007

You may use a trampoline for supervised training programs, such as gymnastics, diving, and
other competitive sports if you meet the following requirements:

(1) You must prohibit the use of the trampoline when there is no trampoline supervisor
present [High];
(2) The trampoline supervisor must have formal training and experience in the use of the
trampoline and knowledge of trampoline safety and spotting techniques [Medium-High];
(3) When the trampoline is in use, personal spotters must be present, ready to intervene, and
posted on four sides of each trampoline [Medium-High];
(4) You must prohibit any child younger than six years old from using the trampoline, even in
supervised training programs [Medium-High];
(5) A safety pad must cover all portions of the steel frame and springs [High];
(6) The surface around the trampoline must have an impact absorbing surface material
[High];
(7) Only one child at a time may use a trampoline, regardless of the size of the trampoline
[Medium-High];

(8) Children must not be allowed to jump off the trampoline. If the trampoline is above
ground, children must dismount the trampoline by sitting on the edge and sliding off
[Medium-High];
(9) The trampoline must be secured and inaccessible when not in use [Medium];

(10)The condition of the trampoline must be checked for tears, rust, and detachments at
least monthly and repaired prior to its next use [Medium]; and

(11)The child using a trampoline must be at the center of the mat and must not attempt to
do maneuvers beyond the child’s capability or training. [Medium]

Technical Assistance
Consider setting the trampoline in a pit so that the mat is at ground level. Safety harnesses
and spotting belts, when appropriately used, may offer added protection for athletes learning
or practicing more challenging skills on the trampoline.

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Division 6, Weapons, Firearms, Explosive Materials, and
Projectiles

§748.3931. Are weapons, firearms, explosive materials,

and projectiles permitted at my operation?
Subchapter Q, Recreation Activities
Division 6, Weapons, Firearms, Explosive Materials, and Projectiles
April 2022

(a) Generally, weapons, firearms, explosive materials, and projectiles (such as darts or arrows),
are permitted, however, there are some specific restrictions:
(1) A handgun is a type of firearm that is never permitted at an operation or during any type
of activity [High];

(2) A child receiving treatment services or emergency care services is not permitted to use
weapons, firearms, explosive materials, or projectiles [High];

(3) If you allow weapons, firearms, explosive materials, or projectiles, you must develop and
enforce a policy identifying specific precautions to ensure that a child does not have
unsupervised access to them, including:

(A) Weapons, firearms, the ammunition, explosive materials, and projectiles must be
kept in locked storage [High];
(B) The locked storage must be made of strong, unbreakable material, except that the
storage may have a glass or another breakable front or enclosure [High];
(C)Any gun placed in a locked storage that has a glass or another breakable front or
enclosure must be secured with a locked cable or chain placed through the trigger
guard [High]; and

(D)Weapons and ammunition must be separately stored and locked [High];

(4) You must determine it is appropriate for a child receiving only child-care services to use
the weapons, firearms, explosive materials, or projectiles [High]; and

(5) No child may use a weapon, firearm, explosive material, or projectile, unless the child is
directly supervised by an adult knowledgeable about the use of the weapon, firearm,
explosive material, or projectile that is to be used by the child. [High]

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(b) A child receiving treatment services or emergency care services is not permitted to use toys
that explode or shoot. For a specific child receiving only child-care services, you must determine
whether it is appropriate for that child to use toys that explode or shoot. The child must be
supervised when using or being around toys that explode or shoot, and the toy must be age
appropriate to the child. [Medium-High]

(c) Firearms that are inoperable and solely ornamental are exempt from the storage
requirements in this rule.

Technical Assistance
Regarding subsection (b), “toys that explode or shoot” do not pertain to Nerf guns, water
guns, or other toys that are appropriate for children and do not present a risk to safety.

§748.3933. What factors must I consider when determining

whether weapons, firearms, explosive materials, or
projectiles are stored adequately?
Subchapter Q, Recreation Activities
Division 6, Weapons, Firearms, Explosive Materials, and Projectiles
January 2007

When determining if these items are stored adequately, you must consider the age, history,
emotional maturity, and background of the children in your care. [High]

§748.3935. May a caregiver transport a child in a vehicle

where weapons, firearms, explosive materials, or
projectiles are present?
Subchapter Q, Recreation Activities
Division 6, Weapons, Firearms, Explosive Materials, and Projectiles
January 2007

A caregiver may not transport a child in a vehicle where a handgun is present. Otherwise, a
caregiver may transport a child in a vehicle where weapons, firearms, explosive materials, or
projectiles are present if:
(1) The child is only receiving child-care services [High];

(2) All firearms are not loaded [High]; and

(3) The weapons, firearms, explosive materials, or projectiles are inaccessible to the child.
[High]

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Subchapter R, Transportation

Division 1, General Requirements

§748.4001. What types of transportation does Licensing

regulate?
Subchapter R, Transportation
Division 1, General Requirements
April 2022
We regulate any transportation that you provide for trips away from and to your operation.

§748.4003. What requirements must I meet when

transporting a child away from the operation?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

Anytime you transport a child away from the operation, you must comply with each of the
following requirements:
(1) Each driver must:
(A) Be at least 21 years old. For an exception for children in care, see §748.4005 of
this title (relating to May a child in care transport other children in care?) [High];
(B) Be covered by automobile insurance [Medium-Low]; and
(C)Have a current driver’s license allowing the driver to operate the type of vehicle
that is used to transport children. [Medium-High]
(2) You must not transport more people than the capacity of the vehicle. [Medium-High]
(3) The vehicle must travel at a safe speed consistent with the speed limit, terrain, and
weather conditions. [Medium-High]
(4) For requirements regarding firearms and transportation, see §748.3935 of this title
(relating to May a caregiver transport a child in a vehicle where weapons, firearms,
explosive materials, or projectiles are present?).

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§748.4005. May a child in care transport other children in
care?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

Yes, a child in care may transport other children in care if the child:
(1) Has a valid driver’s license [Medium-High];
(2) Is covered by automobile insurance [Medium-Low]; and
(3) Is given permission by the service planning team to drive and transport other children in
care. [Medium]

§748.4007. What specific information and equipment must

be in a vehicle I use to transport children during overnight
trips away from the operation?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

The following information and items must be accessible and in each vehicle you use to transport
children during overnight trips:

(1) A list of the children being transported, which you must check in order to account
for the presence of all participating children [High];

(2) Emergency medical transport and treatment authorization forms for each child
being transported [High];

(3) A list of medications each child is currently taking, the dosage, and the frequency
[High];

(4) Your operation’s name and telephone number, and the administrator’s or permit
holder’s name [Medium-High];

(5) Parent’s names and telephone numbers and emergency telephone numbers for
each child being transported [Medium-Low];

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 (6) A fire extinguisher approved by the local or state fire marshal, secured in the
passenger compartment and accessible to the adult occupants [High];

(7) A first-aid kit [High]; and

(8) An operable flashlight. [Medium-High]

§748.4009. What plan must I have for handling

transportation emergencies?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

(a) You must ensure the driver and caregivers have clear instructions in handling
emergency breakdowns and accidents, including vehicle evacuation procedures,
supervision of the children, and contacting emergency help. [Medium-High]

(b) The administrator or designee in charge of the operation must know what action to
take in responding to a transportation emergency call. [Medium-High]

(c) Emergency transportation must be available at all times. It may be provided by

the operation or pre-arranged with community services. [Medium]

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§748.4011. What safety precautions must I take when
loading and unloading a child from the vehicle?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

You must take the following precautions when loading and unloading a child from any vehicle
used for transportation, including a bus with a gross vehicular weight rating (GVWR) of 10,000
pounds or more:

(1) You must account for all children exiting the vehicle before leaving the
vehicle unattended. [High]

(2) You must not allow a child under eight years old to cross a street to enter a
vehicle or after exiting a vehicle, unless an adult accompanies the child.
[High]

(3) You must never leave a child under eight years old unattended in a vehicle.
[High]

§748.4013. What is required when my operation takes

children on out-of-state overnight trips?
Subchapter R, Transportation
Division 1, General Requirements
January 2007

(a) If your operation takes children on out-of-state overnight trips, you must:
(1) Develop a written itinerary and safety plan for each trip [Medium];
(2) Provide necessary equipment and make provisions to meet participants’ needs on
the trip [Medium]; and
(3) Inform parents before the planned departure date, and document in the child’s
record the discussion and date when this contact occurred. [Medium-Low]

(b) You must obtain the written permission from each child’s parent for each out-of-state
trip or must obtain a general written permission from each child’s parent for any out-
of-state trip in which the child will participate. [Medium-Low]

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Division 2, Safety Restraints

§748.4041. What are the requirements for transporting

children?
Subchapter R, Transportation
Division 2, Safety Restraints
January 2017

The driver and all passengers must follow all federal, state, and local laws when driving,
including laws on the use of a child passenger safety seat system, seat belts, and liability
insurance. [High]

Technical Assistance
The Transportation Code prohibits a child under five years old to ride on a motorcycle, unless
seated in a sidecar.

Below is a chart from the web site of the Texas Department of Public Safety regarding child
passenger safety seat system:

2013 Child Passenger Safety National Best Practice Recommendations

Phase Type of Best Practice Recommendation

Restrictive
Device
Phase 1 Rear-Facing Infants: Birth – 35+ pounds, 2+ years old. Rear-facing
Seats infant or rear-facing convertible safety seat as long as
possible, up to the rear-facing height or weight limit of the
seat. Properly install according to instructions in owner’s
manual, rear-facing in the back seat.

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 Phase Type of Best Practice Recommendation
Restrictive
Device
Phase 2 Forward- When children outgrow the rear-facing safety seat (2+
facing Seats years), they should ride in a forward-facing safety seat as
long as possible, up to the upper height or weight limit (40
– 80+ pounds) of the harnesses. Usually 4+ years old.
Properly installed forward-facing in the back seat. NEVER
turn forward-facing before child meets all:
AGE/HEIGHT/WEIGHT requirements set by safety seat
manufacturer for forward-facing.

Phase 3 Booster Seats After age 4 and 40+ pounds, children can ride in a booster
seat with the adult lap and shoulder belt until the adult
safety belt will fit them properly (usually when the child is
4’9” tall, 10 – 12 years old). MUST have a lap/shoulder
belt to use a booster seat.

Phase 4 Adult Safety Once children outgrow their booster seat (usually at 4’9”,
Belt 10 – 12 years) they can use the adult lap/shoulder safety
belt if it fits them properly. Lap portion low over the
hips/tops of thighs and shoulder belt crosses the center of
the shoulder and center of the chest.

Children are better protected the longer they can stay in each phase. Keep children in each seat
up to the MAXIMUM age/weight/height limits before moving to the next phase. ALL children
younger than age 13 years should ride properly restrained in the back seat.

§748.4043. Do the seat belt requirements prohibit

transporting children in the bed of a pick-up truck?
Subchapter R, Transportation
Division 2, Safety Restraints
January 2017

(a) Children may be transported in the bed of a pick-up truck on the facility grounds if the
following conditions are met:

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 (1) If children are being transported in the bed of a pick-up truck, children must be
at least 13 years old [Medium-High];
(2) Children must be seated [Medium-High];
(3) No children may sit on the side of the vehicle, the tire wells, or on the tailgate
[Medium-High];
(4) No children may lean against the tailgate [Medium-High];
(5) The tailgate must be securely closed while the vehicle is in motion [Medium-
High];
(6) The vehicle must travel at a safe speed consistent with the terrain and weather
conditions [Medium-High];
(7) The driver of the vehicle must be knowledgeable about the dangers associated
with issues, such as but not limited to, sudden braking and travel over uneven
terrain [Medium-High]; and
(8) Open bed pick-up trucks or trailers must not be used to transport children on
public roads. [High]
(b) Subsection (a) of this section does not apply to hay-rides on trailer beds for special
occasions as long as there is adequate adult supervision to prevent children from
falling off of the trailer. [High]
(c) At all other times transportation is provided by the operation, employees, or
volunteers, each child must be in a child passenger safety seat system when the
vehicle is in motion. [High]

§748.4045. May I place more than one person in each child

passenger safety seat system or seat belt?
Subchapter R, Transportation
Division 2, Safety Restraints
January 2017

No. Only one person may use each child passenger safety seat system or seat belt. [High]

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Division 3, Vehicle and Vehicle Maintenance

§748.4081. What type of vehicle may I use to transport

children?
Subchapter R, Transportation
Division 3, Vehicle and Vehicle Maintenance
January 2007

(a) We do not regulate the type of vehicle you may use to transport children.
(b) You must make special provisions if you transport non-ambulatory children. When
necessary, this may include locks for wheel chairs and hydraulic lifts. [Medium]

§748.4083. What vehicle maintenance requirements must I

maintain for a vehicle used for transporting children?
Subchapter R, Transportation
Division 3, Vehicle and Vehicle Maintenance
January 2007

(a) You must maintain a vehicle in a safe operating condition at all times. [Medium-High]
(b) Each vehicle you use must be registered and have a current inspection sticker for the
state in which it is registered. [Medium-Low]

Division 4, Transportation Records

§748.4111. What transportation records must I maintain?

Subchapter R, Transportation
Division 4, Transportation Records
January 2007

(a) You must maintain on file at your operation the name of each driver who
transports children and a copy of a valid driver’s license for that person.
[Low]
(b) You must also maintain the following:
(1) Insurance verification in the vehicle; or

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(2) If your transportation services are provided by a private person, a firm
under contract, or by another arrangement, you must maintain on file
a copy of the person’s or firm’s insurance coverage. [Low]

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Subchapter S, Additional Requirements for Operations That
Provide Emergency Care Services

Technical Assistance
Only an emergency care services program that plans to admit a specific child population
requiring treatment services is required to meet treatment service requirements. Emergency
care service programs which do not limit their admissions with regard to treatment service
needs are not required to meet minimum standards related to treatment services.

For example, an emergency care services program specifically for children with primary
medical needs is required to meet all minimum standards related to primary medical needs.

However, an emergency care services program with a broader admissions policy, able to
admit children with a variety of needs, is not required to meet treatment services
requirements.

In the first example, the emergency care services program knows that most or all of the
children admitted will require a certain type of care. Therefore, the operation is able to plan
appropriately for the required professional staff and services needed for the care of these
children. In the second example, with a broader admissions policy, the emergency care
services program is not able to predict the needs of children being admitted. Therefore, the
operation does not have the opportunity to plan in advance to have professional staff, staff
training, or services available for the specific, specialized needs of children in care.

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Division 1, Service Management

§748.4201. What must I do when I admit a child who

cannot consent to emergency care services?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007
(a) If you admit a child for emergency care services who does not meet the
requirements to consent to emergency care services, you must try to contact the
child’s parent(s) within 24 hours, if you know their identity and how to contact them.
[Medium-Low]
(b) If you cannot contact the parent(s), you must notify the appropriate public agency
(Child Protective Services, Juvenile Probation, or police department) of the child’s
presence. [Medium-Low]
(c) Your operation must document in the child’s record efforts to contact the child’s
parent(s) and contacts with public agencies. [Low]

§748.4203. What are the additional medical requirements

when I admit a child to receive emergency care services?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007

Each child receiving emergency care services must receive a health screening or EPSDT
examination within 72 hours after admission [High]:
(1) A health-care professional must provide the screening examination. The health-care
professional does not have to be your employee. [Medium-High]
(2) With the exception of EPSDT examinations, the person who does the examination must
sign and date the results of the screening examination. You must document the results of
the examination in the child’s record. [Medium-Low]

(3) If a child has been in a residential child-care operation and has had a health screening in
the last 12 months, the child does not have to have another health screening unless there
is reason to believe the child is ill or has been abused. [High]
(4) If the child is coming from a medical setting, you may accept a statement from a licensed
health-care professional in place of the examination.

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§748.4205. What is the maximum amount of time a child
receiving emergency care services may stay in care without
a placement extension?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007

A child receiving emergency care services may stay in care without a placement extension for a
maximum of 15 days. [Low]

§748.4207. What is the maximum amount of time a child

receiving emergency care services may stay in care with a
placement extension?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007

(a) If there is an appropriate reason for continuing the care, a child:

(1) Younger than five years old may continue the placement for emergency care
services for up to a total of 30 days in care [Low]; and
(2) Five years old or older may continue the placement for emergency care services for
up to a total of 90 days in care. [Low]
(b) If a child of any age has a parent under 18 years old admitted in the operation or has a
sibling five years old or older admitted in the operation, the child may continue placement
for emergency care services for the length of time the parent or sibling is receiving
emergency care services if:
(1) Deemed in the best interests of the child by the service planning team [Low]; and
(2) Only for a maximum of 90 days. [Low]

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§748.4209. What are the documentation requirements for a
placement extension?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007

(a) The child’s service planning team must document the reason for the extension in
the child’s record. [Low]
(b) If the parent responsible for the child has begun presenting the child’s information
to different operations, agencies, or foster homes based on what the parent
believes the child’s needs are and where the child’s needs can best be met, you
must document in the child’s record the following verbal information that you
receive from the parent:
(1) The reason(s) why a placement cannot be completed timely [Low]; and
(2) The date a placement is expected to be completed. [Low]
(c) In other situations, you must document the following information for the
placement extension, as appropriate:
(1) The child has qualified for financial assistance under Chapter 31, Human
Resources Code, and is on the waiting list for housing assistance [Low]; or
(2) The child meets the requirements to consent to emergency care and
consents to the continuation of services to the child or the child’s offspring.
[Low]

(d) You must document your efforts to contact the parent and obtain the rationale for
the continuation of care, including the dates you made those efforts. [Low]

§748.4211. When must I document the appropriate reason

for continuing emergency care services?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2007

(a) You must document the reason for continuing emergency care services in the
child’s record by the 16th day that the child is in care. [Low]
(b) You must include documentation of additional continuations in the child’s record
every 30 days thereafter, if applicable. [Low]

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 (c) This documentation must be available for our review. [Low]

§748.4213. What are the requirements for a preliminary

discharge plan?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 1, Service Management
January 2017

(a) If the child receives emergency care services for more than 15 days, you must have
a written preliminary discharge plan for the child from the person responsible for the
child. [Low]
(b) You must place the preliminary discharge plan in the child’s record on or before the
child’s 16th day in care at your operation. [Low]
(c) You must obtain written documentation from the person responsible for the child
that the preliminary discharge plan is reviewed and updated at least weekly. [Low]
(d) The preliminary discharge plan and weekly reviews must be available for our review.
[Low]

Division 2, Admission Assessment

§748.4231. What information must an admission

assessment include for a child needing emergency care
services, including respite child-care services?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 2, Admission Assessment
September 2010

(a) An admission assessment must provide an initial evaluation of the appropriate

placement of the child and must include [Medium]:
(1) The child’s immediate needs [Medium];
(2) The name of the referral source [Low];
(3) The date and time of placement [Low];
(4) A description of the child’s condition as observed by the intake worker
[Medium-Low]; and
(5) Only for emergency care services:

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 (A)The reason for emergency placement [Low];
(B)The child’s understanding of the need for emergency care services
[Low]; and
(C)The child’s feelings about the crisis situation and operation care.
[Low]

(b) You must also obtain the following information as soon as possible after
admission:
(1) The child’s identity, date of birth, and as applicable any additional
information needed to determine the child’s ability to consent to
emergency care services for the child or the child’s offspring. To
consent to services, the child must be [Low]:
(A)The parent of a child;
(B)Pregnant; or
(C)16 years old or older; and
(i) Residing separate and apart from the child’s parent,
regardless of whether the parent consents to the
admission and duration; and
(ii) Managing his own financial affairs, regardless of the source
of income;
(2) Name, address, and telephone number of the child’s parents, if
available. This information is not required if the child meets the
requirements to consent to emergency care services [Low];
(3) Medications the child is taking [High];
(4) Chronic health conditions, such as asthma or diabetes [High]; and
(5) Allergies to medication or food. [High]
(c) If you cannot obtain the required information for an assessment:
(1) You must make reasonable efforts to obtain all required information.
[Medium]
(2) If attempting to get information at the time of placement would not be
in the child’s best interests, you may postpone attempting to acquire
the information.
(3) In the child’s admission assessment, you must document why a:
(A)Particular piece of information is unavailable [Low]; or

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 (B)Delay in obtaining a piece of information is necessary, including
efforts made to obtain the information. [Low]

Division 3, Respite Child-Care Services

§748.4261. May I provide respite child-care services?

Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 3, Respite Child-Care Services
January 2017

(a) Respite child-care services are not subject to regulation under this subchapter, if the:

(1) Respite child-care services are completely separate from the emergency care
services. You must provide the respite child-care services in a completely separate
physical space using different caregivers from the caregivers for the emergency
care services; and
(2) Care meets the short-term program’s criteria for exemption as specified
§745.117(2) of this title (relating to Which programs of limited duration are exempt
from Licensing regulation?).
(b) An operation that only provides emergency care services to children may provide respite
child-care services, if you:
(1) Meet all applicable requirements for all services, including children admitted only for
respite child-care. This includes compliance with capacity limits, child/caregiver
ratios, and supervision rules [Medium]; and
(2) Ensure that your respite child-care services do not present a conflict of care for any
child receiving emergency care services. [Medium]

§748.4263. Whom must I notify when I accept a child for

respite child-care?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 3, Respite Child-Care Services
January 2007

You must notify the child’s parent before accepting the child for respite child-care. [Low]

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§748.4265. What information regarding a child must I
receive prior to providing respite child-care services to that
child?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 3, Respite Child-Care Services
January 2017

To ensure continuity of care, you must obtain the following information:

(1) Specific needs of a child, including [Medium]:
(A) All psychological, psychiatric, or medical treatment currently being provided
[Medium-High] ;

(B) Medication regimen and medication instructions [Medium-High];

(C)Authorization for medical treatment [Medium-High]; and
(D)Safety plans, including any special supervision precautions [Medium-High];
(E) Sleeping information [Medium];

(F) Discipline instructions [Medium-High];

(G)Any expectations that the current caregiver may have of the operation [Medium];
and

(H) Any other needs of a child that should be addressed by the operation [Medium-
High];
(2) Non-routine events taking place in the life of the child, including any scheduled
appointments such as family and sibling visits [Medium];
(3) Emergency contact information, including the [Medium-High]:
(A) Child’s physician(s) [Medium-High];

(B) Child’s parent [Medium]; and

(C)Telephone number of the agency or operation that placed the child [Medium-Low];
and
(4) The child’s history that may affect the operation’s ability to provide care for the child,
including [Medium-High]:

(A) Background of abuse and/or neglect [Medium-High];

(B) Physical aggression or sexual behavior problems [Medium-High];
(C)Fire setting [Medium-High];
(D)Maiming or killing animals [Medium-High];

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 (E) Suicidal ideations and attempts [Medium-High] ; and

(F) Run-away behaviors. [Medium-High]

§748.4267. How long may a child be in respite child-care?

Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 3, Respite Child-Care Services
January 2007

(a) With the exception of subsection (b) of this section, a child may be in respite child-
care for 14 consecutive days or 40 days each year. [Medium-Low]
(b) A respite child-care services placement that is made because a child’s foster home
is under investigation for abuse or neglect does not count toward nor is it limited by
the time frames noted in subsection (a) of this section. However, these placements
are limited to a maximum of 60 days. [Medium-Low]
(c) If a child needs respite child-care for more than 14 consecutive days or more than
60 days for an abuse or neglect investigation, this is considered a new placement
and will not be respite child-care. [Medium-Low]
(d) When a child finishes a respite child-care placement, he may not return to respite
child- care for at least 10 days. [Medium-Low]
(e) Respite child-care must not be used if it could be detrimental to the child. [Medium-
High]

Technical Assistance
The time limit of 40 days per year of respite care for each child is intended to serve the best
interests of the child by minimizing disruptions in care. To that end, and in an effort to
comply with these minimum standard rules, you are expected to seek out information about
a child’s time spent in respite child-care at any previous placement(s) earlier in the year. You
are responsible for limiting the child’s placement(s) in respite child-care accordingly for the
remainder of the year.

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§748.4269. May I update an admission assessment when I
provide respite child-care services to a child to whom I
have already provided respite child-care?
Subchapter S, Additional Requirements for Operations That Provide Emergency Care Services
Division 3, Respite Child-Care Services
January 2007

When you admit into your respite child-care services program a child to whom you have already
provided respite child-care, you may update the existing admission assessment information
rather than completing a new assessment.

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Subchapter T, Additional Requirements for Operations That
Provide an Assessment Services Program

Division 1, Regulation

§748.4301. Does Licensing regulate all assessment

services?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 1, Regulation
January 2017

(a) No. This subchapter only regulates general residential operations that also provide
an assessment services program.
(b) Services provided by other individuals, agencies, and organizations are not subject
to regulation under this subchapter.

Division 2, Admission

§748.4331. What are the requirements for approving a

child’s admission into my assessment services program?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 2, Admission
January 2007

(a) The person responsible for the assessment services program must review and
approve in writing the determination that your program will be able to provide or
obtain all assessment services the child appears to need at intake. [Medium]
(b) The review, determination, and approval must be:

(1) In writing, signed, and dated from the person responsible for the assessment
services program [Medium]; and
(2) Completed prior to the admission of the child into your assessment services
program. [Medium]

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 (c) The determination on the appropriateness of the program to meet the child’s
assessment needs must be filed in the child’s record if the child is admitted into your
assessment services program. [Medium]
(d) You must document in the child’s record whether you are [Medium]:

(1) Only providing assessment services to the child; or

(2) Also providing other services, such as emergency care services.

(e) You must document in the child’s record the date of the child’s admission into
your assessment services program. [Medium]

Division 3, Assessment Plan

§748.4361. When must I complete the child’s individual

plan for the assessment?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 3, Assessment Plan
January 2007

(a) You must complete the child’s individual plan for the assessment within 10 days
from the date of the child’s admission into the program. [Medium]
(b) You must document the plan in the child’s record. [Medium]

§748.4363. When does admission into the assessment

services program begin?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 3, Assessment Plan
January 2007

Admission into the assessment services program begins when [Medium]:

(1) The parent makes the decision to place the child into the assessment services program;
and

(2) You decide to accept the child for these services.

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§748.4365. What must an individual plan for the
assessment include?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 3, Assessment Plan
January 2007

(a) An individual plan for the assessment must include:

(1) Time frames for providing all assessment services [Medium-Low];
(2) Recommendations for the child’s care during the assessment process [Medium];
(3) Any treatment to be provided during the assessment period [Medium-High]; and
(4) Current data from the caregiver’s evaluation of the child’s behavior and level of
functioning. [Medium]
(b) The common application is not and must not serve as the individual plan for the
assessment. [Medium]

§748.4369. How must my assessment services program

collect information from a child’s caregivers?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 3, Assessment Plan
January 2007

(a) Your assessment services program must systematically collect information from
caregivers throughout the child’s participation in the assessment services
program. This information includes the caregivers’ observations and opinions of
the child. [Medium]
(b) You must document this information in the child’s record. Your documentation
must include your consideration of the caregivers’ observations and opinions.
[Medium]

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§748.4371. When is the plan for the assessment complete?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 3, Assessment Plan
January 2007

(a) The plan for the assessment is complete when it contains the necessary information
and the signed approval of the person responsible for the assessment services
program or a designated employee who meets the qualifications of a person
responsible for the assessment program. [Medium]
(b) The parent must review and be provided a copy of the plan for the assessment.
[Medium]

Division 4, Assessment Report

§748.4391. What is an assessment report?

Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 4, Assessment Report
January 2007

(a) The assessment report that is the result of the assessment services is a narrative
report that pulls together data from:
(1) Professional evaluation reports on the child [Medium]; and
(2) The program’s assessment on how the child is managing in the program.
[Medium]
(b) The report includes:
(1) Recommendations made in other professional evaluations [Medium]; and
(2) Recommendations based on the program’s experiences with and assessment of the
child. [Medium-High]
(c) The common application is not and must not serve as the assessment report. [Medium]

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§748.4393. When must I complete the assessment report?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 4, Assessment Report
September 2010

(a) The assessment report must be completed rapidly, consistent with good practice, in
order to allow for a permanent placement as soon as possible. [Medium]
(b) You must complete the assessment report within:
(1) 30 days after you admit the child, if the child is younger than five years old
[Medium]; or
(2) 45 days after you admit the child, if the child is five years old or older.
[Medium]
(c) With the approval of the child’s parent, you may extend the time frame for completing
the report for an additional 15 days. You must document the need for the extension of
time in the child’s record. [Low]
(d) You must complete the assessment report before a planned discharge of the child
from the assessment services program. However, additional assessment services may
be conducted subsequent to placement if a quick placement is in the best interest of
the child. [Medium]
(e) You must provide a copy of the assessment report to the child’s parent as soon as the
report is complete. [Medium-Low]

§748.4395. What must be included in the written

assessment report?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 4, Assessment Report
January 2007

In addition to the requirements set forth in §748.1217 of this title (relating to What information
must an admission assessment include?), a written assessment report must include [Medium]:

(1) Copies and results of the determination of the child’s basic health and social
and developmental assessment, including [Medium]:

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 (A) The child’s basic health status, as determined under the supervision
of a licensed physician [Medium-High];

(B) The child’s basic social and developmental needs, as determined

under the supervision of the person responsible for the assessment
services program or a designated employee who meets the
qualifications for a person responsible for the assessment program
[Medium];

(C)Recommendations for any further assessment services and testing

[Medium]; and

(D) An assessment of the child’s immediate and extended family in

terms of an ongoing relationship with the child [Medium-Low];

(2) Copies and results of all evaluations and testing [Medium-High];

(3) A summary of the primary caregivers’ evaluations of the child’s behavior

and level of functioning [Medium-High];

(4) An assessment of the results and summary in terms of appropriate short-

and long-term planning for the child [Medium];

(5) Recommendations for placement [Medium-High]; and

(6) A recommended behavior management plan based on the assessment

results and the primary caregivers’ evaluations of the child’s behavior and
level of functioning. [Medium-High]

§748.4397. Who must review and approve an assessment

report?
Subchapter T, Additional Requirements for Operations That Provide an Assessment Services
Program
Division 4, Assessment Report
January 2007

(a) The following people must review the assessment report:

(1) The person responsible for the assessment program or a designated employee who
meets the qualifications of a person responsible for the assessment program
[Medium-High];
(2) The child’s primary caregiver [Medium-High]; and

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 (3) The child’s parent. [Medium]
(b) The person responsible for the assessment program, or the designated qualified
employee, must approve and sign the report. [Medium]
(c) You must file the original, approved and signed assessment report, including any
addendums to the report, in the child’s record. [Medium]

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Subchapter U, Additional Requirements for Operations That
Provide Therapeutic Camp Services

Division 1, Definitions

§748.4401. What do certain words mean in this

subchapter?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 1, Definitions
January 2007

These words have the following meanings in this subchapter:

(1) Permanent camp – The permanent structure at which the basic needs for camp operation,
such as resident housing, water supply and septic systems, and permanent toilet and/or
cooking facilities, are provided.
(2) Permanent structure – Man-made permanent or semi-permanent structures in which
groups of people live, eat, sleep, or assemble, such as dining halls, dormitories, cabins, or
other structures which are not constructed to be readily movable.
(3) Primitive camp – A portion of the permanent campsite premises or another site at which
the basic needs for camp operation, such as water supply systems, and permanent toilet
and/or cooking facilities or other permanent structures, are not provided and in which a
child stays no longer than 14 days before returning to the permanent camp.

§748.4403. What children are eligible to participate in a

therapeutic camp program?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 1, Definitions
January 2017

(a) For a child to be eligible to participate in a therapeutic camp program, the child must:
(1) Be 13 years old or older [Medium];
(2) Be in need of treatment services for an emotional disorder [Medium]; and

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 (3) Have difficulty functioning in his home, school, or community. [Medium]
(b) Individuals that are not eligible to participate in a therapeutic camp program include:
(1) An adult [Medium];
(2) A child under 13 years old [Medium];
(3) A child who receives child-care services only, including a child in a transitional living
services program [Medium];
(4) A child who is pregnant. If a child becomes pregnant while in care, you must
arrange for the child’s immediate discharge or transfer from your therapeutic camp
program [Medium];
(5) An adolescent parent with his or her child [Medium-High];
(6) A child with primary medical needs or other medical conditions that cannot be
easily provided to the child at the permanent campsite or during primitive camping
excursions [High];
(7) A child diagnosed with Autism Spectrum Disorder [Medium-High];
(8) A child diagnosed with an intellectual disability [Medium-High];
(9) A child for an emergency admission [Medium]; and
(10) A child for child day care services. [Medium-High]

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Division 2, Activities Requiring Spotting or Belaying

§748.4431. What are the requirements for an

adventure/challenge program that requires spotting or
belaying?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 2, Activities Requiring Spotting or Belaying
January 2007

You must ensure that:

(1) An employee with at least six weeks experience in supervising a similar type of activity
supervises an adventure/challenge program that requires spotting or belaying [Medium-
High];

(2) Prior to assuming duty as a spotter and belayer, a person receives instruction in the
proper procedures [High];
(3) A spotter or belayer is directly supervised until the person demonstrates competency
[High];

(4) There is a method for controlling access to the equipment and the activity area in order to
prevent unauthorized or unsupervised use by a child [High];

(5) Safety checks are performed on all equipment and ropes prior to each use [High];
(6) Each child has a safety orientation before engaging in the activity [High]; and
(7) Each child wears appropriate personal protective equipment during an activity. [High]

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Division 3, Primitive Camping Excursions

§748.4461. What is considered a primitive camping

excursion?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2007

A primitive camping excursion lasts no more than 14 days, after which children on the camping
excursion must return to the permanent camp. [Medium-Low]

§748.4463. How long must children remain at the

operation’s permanent camp between primitive camping
excursions?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2007

(a) If your therapeutic camp program only allows children to stay at the camp for less
than 90 days, then children must remain at the permanent camp at least two days
between primitive camping excursions and activities. [Medium-Low]

(b) If your therapeutic camp program allows children to stay at the camp for 90 days or
more, then children must remain at the permanent camp at least 21 days between
primitive camping excursions and activities. [Medium-Low]

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§748.4465. What child/caregiver ratios apply to a primitive
camping excursion?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2007

(a) In addition to meeting the child/caregiver ratio requirements in Subchapter G of this

chapter (relating to Child/Caregiver Ratios), you must have at least two caregivers
during any primitive camping excursion. [High]
(b) In a mixed gender group, there must be a caregiver of each gender at all times.
[Medium-High]

§748.4467. What are the requirements for toilet facilities

for a primitive camping excursion?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2007

(a) You may use pit privies and portable toilets in remote camping areas. You must ensure
that the pit privies and portable toilets are:

(1) Maintained in good repair and kept clean at all times [Medium-Low];
(2) Constructed and maintained according to manufacturer designs and standards set
forth by the Department of State Health Services, General Sanitation Division
[Medium-Low];
(3) Maintained to prevent access by flies and animals to the contents contained within,
to prevent fly breeding, and to prevent contamination of any water supply
[Medium-Low];
(4) Equipped with toilet paper at all times [Low]; and
(5) Serviced for the disposal of human excreta that meet regulations set forth by the
Texas Commission on Environmental Quality. [Medium-Low]

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 (b) If the camp site is not provided with pit privies or other portable toilets, you must:
(1) Comply with the requirements of §748.3861 of this title (relating to What are the
requirements for toilet facilities during overnight camping excursions?) [Medium-
Low]; and
(2) Have a readily available supply of clean earth backfill or other disposal methods

that meet regulations set forth by the Texas Commission on Environmental Quality
for the disposal of human excreta in these areas. [Medium-Low]

§748.4469. What are the requirements for sanitizing hands

at a primitive campsite?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2007

(a) Children and employees must sanitize their hands. [Medium]

(b) At least one of the following methods for sanitizing hands must be available at the
campsite [Medium]:
(1) Bathrooms equipped with running water must always have soap available for use
within 20 feet of the toilet areas;
(2) A hand-washing sink using a portable water supply must have a sanitary catch
system approved by your local health department and must always have
antibacterial liquid soup or an alcohol-based hand sanitizer available for use:
(A)You must follow label directions when using alcohol-based hand sanitizers;
and
(B)Children must not have access to soiled water; or
(3) Privies and portable toilet facilities not equipped with running water must always
have at least a waterless alcohol-based hand sanitizer available for use adjacent to
toilet facilities. You must follow label directions when using alcohol-based hand
sanitizers.

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§748.4471. What personal hygiene provisions must I
provide to a child who participates in a primitive camping
excursion?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2017

You must provide the following to a child who participates in a primitive camping excursion with:

(1) Personal hygiene supplies that are biodegradable [Medium];

(2) A means for a child to bathe or clean the child’s body at least twice weekly [Medium]; and
(3) Females with body or hand sanitizing wipes or similar products for feminine hygiene
purposes. [Medium]

§748.4473. What are the requirements for laundry

provisions on a primitive camping excursion?
Subchapter U, Additional Requirements for Operations That Provide Therapeutic Camp
Services
Division 3, Primitive Camping Excursions
January 2017

You must provide the following to a child who participates in a primitive camping excursion
[Medium-Low]:
(1) A way to launder clothes at least weekly; or
(2) Clean clothes at least weekly.

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Subchapter V, Additional Requirements for Operations that
Provide Trafficking Victim Services

Division 1, Definitions and Scope

§748.4501. What does “trafficking victim services” mean

when used in this subchapter?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 1, Definitions and Scope
December 2014

In this subchapter, trafficking victim services means a specialized type of child-care services
designed to treat and support trafficking victims, in addition to basic child care services.

§748.4503. When am I required to meet the additional

rules of this subchapter?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 1, Definitions and Scope
December 2014

You must meet the additional rules of this subchapter if you provide trafficking victim services to
[High]:
(1) 25 or more children; or
(2) More than 30% of the children in your care.

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§748.4505. In addition to the rules in this subchapter,
what other rules in this chapter apply to an operation?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 1, Definitions and Scope
December 2014

An operation that is required to comply with this subchapter must comply with all other rules in
this chapter that apply to all operations, as well as the rules that apply to an operation that
provides treatment services to children with an emotional disorder, unless any such rule is
replaced by a rule in this subchapter, as noted in §748.4507 of this title (relating to What rules
in this subchapter replace other rules in this chapter?).

§748.4507. What rules in this subchapter replace other

rules in this chapter?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 1, Definitions and Scope
December 2014

An operation that is required to comply with the rules in this subchapter is not required to
comply with other rules in this chapter if the rule has been replaced, as specified in the following
chart:

Topic An operation must Instead of this rule:

comply with this rule:
Treatment Director §748.4601 of this title §748.605 of this title
Qualifications (relating to What (relating to What
qualifications must a qualifications must a
treatment director have?) treatment director have?)

Pre-service §748.4651 of this title §748.861 of this title

Experience (relating to What are the pre- (relating to What are the pre-
Requirements for a service experience service experience
Caregiver requirements for a caregiver?) requirements for a
caregiver?)

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 Topic An operation must Instead of this rule:
comply with this rule:
Pre-service Hourly §748.4653 of this title (relating §748.863 of this title
Training to What are the pre-service (relating to What are the
Requirements for hourly training requirements pre-service hourly training
Caregivers and for caregivers and employees?) requirements for caregivers
Employees and employees?)

Annual Training §748.4657 of this title (relating §748.931 of this title (relating
Requirements for to What are the annual training to What are the annual
Caregivers and requirements for caregivers training requirements for
Employees and employees?) caregivers and employees?)

Child/Caregiver Ratio §748.4701 of this title §748.1003 of this title

During Children’s (relating to For purposes of the (relating to For purposes of
Waking Hours child/caregiver ratio, how the child/caregiver ratio, how
many children can a single many children can a single
caregiver care for during the caregiver care for during the
children’s waking hours?) children’s waking hours?)

Child/Caregiver Ratio §748.4703 of this title §748.1007 of this title

During Children’s (relating to For purposes of the (relating to For purposes of
Sleeping Hours child/caregiver ratio, how the child/caregiver ratio, how
many children can a single many children can a single
caregiver care for when caregiver care for when
children are asleep at night?) children are asleep at night?)

Admission of Young §748.4765 of this title §748.1933 of this title

Adults (relating to May I admit a (relating to May I admit a
young adult into care?) young adult into care?)

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Division 2, Policies and Procedures

§748.4551. What additional child-care policies must I

develop?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 2, Policies and Procedures
June 2016

You must develop written policies that address how your operation will:

(1) Provide a variety of engaging activities to help trafficking victims develop their skills
and independence and gain a sense of personal identity, including providing life skills
training for children 14 years of age or older [Medium-Low];

(2) Tailor education to the child’s needs [Medium-Low];

(3) Provide mentoring services [Medium-Low]; and

(4) Prevent and discourage trafficking victims from running away from your operation.
[Medium]

§748.4553. What safety and security policies must I

develop?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 2, Policies and Procedures
December 2022

You must develop written policies that address:

(1) The measures you will implement to ensure the safety and security of trafficking
victims and employees, including measures that address both interior and exterior
security while promoting a comfortable and nurturing environment on the grounds of
your operation [Medium];

(2) Employee protocols and procedures for ensuring a safe environment, including
[Medium]:

(A) An internal and external communication system that addresses emergency

situations [Medium]; and

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 (B) How to handle visitors not allowed on the premises of the operation [Medium];
and

(3) Appropriate safeguards with respect to a trafficking victim’s access to forms of

communication, including telephones, cell phones, computer, internet, mail, and
visitors, which may pose a risk of further victimization of the child. [Medium]

§748.4555. What confidentiality policies must I develop?

Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 2, Policies and Procedures
December 2014

You must develop written policies that address confidentiality, including policies that:
(1) Restrict the disclosure of information, both written and oral, that would identify a child
as a trafficking victim, or describe the nature of the victim’s trafficking history, other
than as needed to serve the victim or comply with other laws [Medium];
(2) Specify to whom and under what circumstances an employee or volunteer may disclose
the location of the operation [Medium]; and
(3) Specify the circumstances under which a visitor may or may not be allowed on the
premises of the operation. [Medium]

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Division 3, Personnel

§748.4601. What qualifications must a treatment director

have?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 3, Personnel
December 2014

A treatment director that provides or oversees treatment services for trafficking victims must
[Medium]:

(1) Be a psychiatrist or psychologist;

(2) Have a master’s degree in a human services field from an accredited college or university
and three years of experience providing treatment services for trafficking victims or
children with an emotional disorder, including one year in a residential setting; or
(3) Be a licensed master social worker, a licensed clinical social worker, a licensed
professional counselor, or a licensed marriage and family therapist, and have three years
of experience providing treatment services for trafficking victims or children with an
emotional disorder, including one year in a residential setting.

§748.4603. Are there additional training requirements for

volunteers who have contact with children receiving
trafficking victim services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 3, Personnel
December 2014

Each volunteer whose responsibilities include working with trafficking victims must have one
hour of training prior to working with the children. The training must include the following
components that explain [Medium]:
(1) The operation’s confidentiality policies [Medium]; and

(2) How the effects of trauma impact working with trafficking victims. [Medium]

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Division 4, Training

§748.4651. What are the pre-service experience

requirements for a caregiver?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 4, Training
December 2014

(a) Before you may assign a caregiver to be the only caregiver responsible for a
child in care, the caregiver must have a minimum of 40 hours of supervised
child-care experience in [Medium]:
(1) Your operation;

(2) Another general residential operation, in which treatment services for

children with an emotional disorder or trafficking victim services are
provided to 25 or more children or 30% or more of the operation’s
children; or
(3) A child-placing agency, in which treatment services for children with an
emotional disorder or trafficking victim services are provided to 30 or
more children or 50% or more of the agency’s children;
(b) Until a caregiver has the minimum amount of supervised child-care experience
as specified in subsection (a) of this section, the caregiver must be supervised
at all times by another caregiver who has already satisfied the minimum
caregiver qualifications described in subsection (a) of this section. [Medium]
(c) The supervised child-care experience must be documented in the appropriate
personnel record. [Medium]

§748.4653. What are the pre-service hourly training

requirements for caregivers and employees?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 4, Training
December 2014

(a) Caregivers and certain employees must complete the following training hours before
the noted time frame:

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Weight Who is What type How many When the
required to of pre- hours of training
receive the service training are must be
training? training is required? completed
required? by?
[Medium] (1) All General pre- 8 hours Before the
caregivers service person can be
training the only
caregiver
responsible for
a child in care.
[Medium- (2) All Pre-service 16 hours; At least half of
High] caregivers training however, if the required
regarding your operation hours of
emergency prohibits the training before
behavior use of the person can
intervention emergency be the only
behavior caregiver
intervention, responsible for
then only 8 a child in care,
hours of and all of the
training are required hours
needed of training
within 90 days
of being
responsible for
a child in care.
[Medium- (3) All Pre-service 5 hours At least two of
High] caregivers training the required
regarding hours of
complex training before
trauma the person can
experienced be the only
by trafficking caregiver
victims responsible for
a child in care,
and all of the
required hours
of training
within 90 days
of being
responsible for
a child in care.

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Weight Who is What type How many When the
required to of pre- hours of training
receive the service training are must be
training? training is required? completed
required? by?
[Medium] (4) Child-care Pre-service 8 hours All 8 hours of
administrators, training training within
treatment regarding 90 days of
directors, emergency beginning job
professional behavior duties.
level service intervention
providers, and
case managers

[Medium] (5) Child-care Pre-service 5 hours All 5 hours of

administrators, training training within
treatment regarding 90 days of
directors, complex beginning job
professional trauma duties.
level service experienced
providers, and by trafficking
case managers victims

(b) You must document the completion of each training requirement in the
appropriate personnel record. [Medium-Low]

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§748.4655. Must I provide pre-service training to a
caregiver or employee who has previously worked in
another operation?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 4, Training
December 2014
(a) An operation does not have to provide additional general pre-service training or pre-
service training regarding emergency behavior intervention to any caregiver or
employee who is exempt from this training by §748.867 of this title (relating to Must I
provide pre- service training to a caregiver or an employee who has previously worked
in an operation?). In addition, a caregiver or employee (child-care administrator,
treatment director, professional level service provider, or case manager) does not have
to complete the five hours of pre-service training regarding complex trauma
experienced by trafficking victims if the caregiver or employee:
(1) During the last 12 months:
(A)Worked in a general residential operation that provides trafficking victim
services to 25 or more children, or 30% or more of the operation’s
children in care; or
(B)Was a caregiver or employee for a child-placing agency that provides
trafficking victim services to 30 or more children, or 50% or more of the
child-placing agency’s children in care; and
(2) Has documentation that the caregiver or employee has previously received
the five hours of pre-service training.
(b) You must document the exemption factors in the appropriate personnel record.
[Medium-Low]

§748.4657. What are the annual training requirements for

caregivers and employees?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 4, Training
December 2014

Caregivers and certain employees must complete the following training hours:

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 Who is required to How many hours of annual training and what types of
receive the annual annual training are needed?
training?
(1) All caregivers 50 hours. [Medium] Of the 50 hours:
(A) Four hours must be completed every six months on training
specific to the emergency behavior intervention techniques
that you allow, and this training must be completed within
180 days from the date that the caregiver last received such
training [Medium-High];
(B) Four hours must be on training specific to trafficking
victims, as further described in §748.4659 of this title
(relating to What areas or topics must the four hours of
annual training regarding trafficking victims include?)
[Medium-High]; and
(C) Two hours must be on training specific to transportation
safety if the caregiver transports a child in care whose
chronological or developmental age is younger than nine
years old. [Medium-High]
(2) Child-care (A) 15 hours. [Medium]
administrators, (B) Of the 15 hours, two hours must be on training specific to
professional level service transportation safety if the person transports a child in
providers, treatment care whose chronological or developmental age is younger
directors, and case than nine years old. [Medium-High]
managers who hold a
(C) There are no annual training requirements for emergency
relevant professional
behavior intervention. However, if there is a substantial
license
change in techniques, types of intervention, or operation
policies regarding emergency behavior intervention, then
the staff must be re-trained in emergency behavior
intervention. [Medium-High]
(D) Annual training hours completed to maintain a person’s
relevant professional license may be used to satisfy all or
part of the 15 hours of annual training required by this
section.
(3) Child-care (A) 20 hours. [Medium]
administrators, (B) Of the 20 hours, two hours must be on training specific to
professional level service transportation safety if the person transports a child in
providers, treatment care whose chronological or developmental age is younger
directors, and case than nine years old. [Medium-High]
managers who do not
(C) There are no annual training requirements for emergency
hold a relevant
behavior intervention. However, if there is a substantial
professional license
change in techniques, types of intervention, or operation
policies regarding emergency behavior intervention, then
the staff must be re-trained in emergency behavior
intervention.

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§748.4659. What areas or topics must the four hours of
training regarding trafficking victims include?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 4, Training
December 2022

The four hours of annual training must include:

(1) One hour of training in preventing compassion fatigue and secondary traumatic stress
[Medium]; and

(2) Three hours of training in areas appropriate to the needs of children for whom the
operation or caregiver will be providing care, which may include [Medium]:
(A) Typology of trafficking victims;
(B) Manifestations of trauma and practice in trauma informed care;
(C)How trafficking victims are manipulated and controlled;
(D)Making informed decisions and setting boundaries for trafficking victims;
(E) Understanding and avoiding the triggers of trafficking victims;
(F) Creating and maintaining nurturing environments for trafficking victims; and

(G)Identifying and responding to internal and external safety and security risks at the
operation, including the grounds of the operation (e.g., high flight risk, potential
self-harm, harm to others, internal recruitment, unapproved visitors, and
intruders).

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Division 5, Child/Caregiver Ratios

§748.4701. For purposes of the child/caregiver ratio, how

many children can a single caregiver care for during the
children’s waking hours?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 5, Child/Caregiver Ratios
January 2017

(a) A single caregiver may care for a maximum of four children during waking hours.
[Medium-High]
(b) A child does not count in the child/caregiver ratio while the child is away from the
operation participating in an approved unsupervised childhood activity.

§748.4703. For purposes of the child/caregiver ratio, how

many children can a single caregiver care for when children
are asleep at night?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 5, Child/Caregiver Ratios
December 2014

(a) A single caregiver may care for a maximum of eight children during night-time
sleeping hours. [Medium-High]
(b) Caregivers must remain awake during night-time sleeping hours. [Medium-High]

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Division 6, Admission and Service Planning

§748.4751. Are there additional medical requirements

when I admit a child for trafficking victim services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

In addition to meeting the requirements under §748.1223 of this title (relating to What are the
medical requirements when I admit a child into care?):

(1) You must ensure that a child receiving trafficking victim services is screened within
72 hours of admission to determine whether there is an immediate need for any of
the following types of medical services [Medium]:

(A) A medical examination by a health-care professional [Medium]; and

(B) Medical tests for pregnancy and the following infectious diseases [Medium]:

(i) Hepatitis B [Medium];

(ii) Hepatitis C [Medium];

(iii)HIV [Medium];

(iv) Sexually transmitted diseases (STDs) [Medium]; and

(v) Tuberculosis. [Medium]

(2) Each individual screening is not required if:

(A) The child was previously placed in a residential child-care operation regulated by
DFPS or a facility operated by the Texas Juvenile Justice Department;

(B) There was a previous screening completed within the last 12 months;
(C)You have documentation of the outcome of the screening;

(D) The child did not run away from the operation or get discharged from the program
since the previous screening; and
(E) There is no clear indication that the child has been injured, victimized, or re-
victimized since the previous screening.

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 (3) If the results of the required screening indicate that there is an immediate need for a
medical examination or medical tests, you must obtain the medical examination and/or
medical tests within five days. [Medium-High]

§748.4753. Must a child I admit for trafficking victim

services have an alcohol and substance abuse screening?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

Yes, you must ensure that a child receiving trafficking victim services is screened for alcohol and
substance abuse within 72 hours of admission. The screening is not required if [Medium]:

(1) You have documentation of:

(A) A child’s alcohol and substance abuse screening that was conducted within the
previous 12 months during the child’s placement at a residential child-care
operation regulated by DFPS or a facility operated by the Texas Juvenile Justice
Department; or
(B) A professional assessment that was conducted within the previous 12 months that
determined whether alcohol and substance abuse services were needed for the
child; and

(2) There is no clear indication that the child has developed an alcohol or substance
abuse dependency since the date of the previous screening or assessment.

§748.4755. What must I do if an alcohol and substance

abuse screening determines that a child receiving
trafficking victim services may need alcohol or substance
abuse treatment?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

If an alcohol and substance abuse screening determines a child receiving trafficking victim
services may need alcohol or substance abuse treatment, you must:

(1) Within 14 days, coordinate and schedule the child for an alcohol and substance
abuse professional assessment [Medium-High];

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 (2) Ensure the professional recommendations are carried out [Medium-High]; and

(3) File documentation of the professional assessment, recommendations, and

follow-up in the child’s record. [Medium-High]

§748.4757. What behavioral health assessments are

required when I admit a child for trafficking victim
services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

(a) Within 30 days of admission, you must ensure that a child receiving trafficking
victim services is assessed for the following [Medium]:
(1) Post-Traumatic Stress Disorder (PTSD) [Medium];
(2) Depression [Medium]; and
(3) Anxiety. [Medium]

(b) The results of all assessments must be documented in the child’s record. [Medium-Low]
(c) Each individual behavioral health assessment is not required if:
(1) The child was previously placed at a residential child-care operation regulated by
DFPS or a facility operated by the Texas Juvenile Justice Department;
(2) There was a previous assessment completed within the last 12 months;
(3) You have documentation of the outcome of the child’s assessment; and
(4) There is no clear indication that the child has developed one of these disorders
since the previous assessment.

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Revised: 12/2024
§748.4759. What mental health services are required for a
child receiving trafficking victim services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
June 2016

(a) A professional service provider must [Medium]:

(1) Provide individual counseling to each child receiving trafficking victim services. The
counseling must address any issues noted in the behavioral health assessment and
whether intervention and additional treatment is needed for sexual assault
[Medium];
(2) Provide family counseling, as appropriate [Medium]; and
(3) Assess the frequency and duration of the counseling. [Medium]
(b) You must document the assessment in the child’s record. [Medium-Low]
(c) If a child refuses counseling, you must document this refusal in the child’s record.
[Medium-Low]
(d) For purposes of this rule, a professional service provider means:
(1) A psychiatrist licensed by the Texas State Board of Medical Examiners;
(2) A psychologist licensed by the Texas State Board of Examiners of Psychologists;
(3) A master’s level social worker or higher licensed by the Texas State Board of Social
Work Examiners;
(4) A professional counselor licensed by the Texas State Board of Examiners and
Professional Counselors;
(5) A marriage and family therapist licensed by the Texas State Board of Examiners of
Marriage and Family Therapists; or
(6) A master’s level or higher nurse licensed as an Advanced Practice Registered Nurse
by the Texas Board of Nursing and board certified in Psychiatric/Mental Health.

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§748.4761. Are there additional requirements for a
preliminary service plan when I admit a child for trafficking
victim services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

In addition to the requirements listed in §748.1331 of this title (relating to What are the
requirements for a preliminary service plan?), the preliminary service plan for a child receiving
trafficking victim services must include a description of the child’s immediate:

(1) Safety needs [Medium]; and

(2) Behavioral health and treatment care needs. [Medium]

§748.4763. What additional items must be included in a

child’s initial service plan?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
June 2016

(a) In addition to the requirements and items noted in §748.1337 of this title (relating to
What must a child’s initial service plan include?), the initial service plan for a child
receiving trafficking victim services must include:
(1) The plans to obtain alcohol treatment, substance abuse treatment, or both, for
children who require it [Medium]; and

(2) Updated plans for behavioral health treatment, including intervention and treatment
services for sexual assault, for children who require it [Medium]; and

(3) A description of any legal services required for the child and how you will assist the
child in meeting those needs. [Medium]

(b) You must document all professional consultations, examinations, recommendations, and
treatment in the child’s record. [Medium-Low]

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§748.4765. May I admit a young adult into care?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

(a) You may admit a young adult into your transitional living program.
(b) For other programs and services for trafficking victims, you may admit a young adult into
your care if the young adult is determined to be a trafficking victim as stated in
§748.61(2)(E) of this title (relating to What types of services does Licensing regulate?)
and [Low]:
(1) Is placed at your operation directly after being discharged from another residential
child-care operation regulated by DFPS or a facility operated by the Texas Juvenile
Justice Department; or
(2) Is placed at your operation within 12 months after being discharged from another
residential child-care operation regulated by DFPS or a facility operated by the
Texas Juvenile Justice Department.
(c) A young adult may remain in your care until the young adult’s 23rd birthday. [Low]

§748.4767. May a young adult in care share a bedroom

with a child in care receiving trafficking victim services?
Subchapter V, Additional Requirements for Operations that Provide Trafficking Victim Services
Division 6, Admission and Service Planning
December 2014

(a) In addition to the requirements listed in §748.1937 of this title (relating to May an adult in
care share a bedroom with a child in care?), a professional level service provider for
operations must complete a re-assessment anytime a child or young adult:
(1) Runs away from the operation and returns to care [Medium-Low]; or

(2) Is discharged from your program and returns to care. [Medium-Low]

(b) The re-assessment and approval by the professional level service provider must
be documented and dated in the child’s record. [Medium-Low]

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Subchapter W, Additional Requirements for Operations that
Provide Psychiatric Health Treatments and Services

Division 1, Definitions and Scope

§748.4801. What do the following terms mean when used

in this subchapter?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 1, Definition and Scope
October 2024
In this subchapter, the following terms have the following meanings unless the context clearly
indicates otherwise:

(1) Individual--A person who is 21 years of age or younger.

(2) Psychiatric health treatments and services--In addition to basic child-care services, a
specialized type of child-care services provided by a certified psychiatric residential youth
treatment facility to treat and support individuals who have a severe emotional
disturbance.

(3) Psychiatric Residential Youth Treatment Facility (PYRTF)--As defined at Texas Health and
Safety Code §577A.001(3), a private facility that provides psychiatric health treatments
and services in a residential, non-hospital setting exclusively to individuals and is licensed
as a general residential operation.

(4) Severe emotional disturbance--As defined at Texas Health and Safety Code §577A.001(4),
a mental, behavioral, or emotional disturbance of sufficient duration to result in functional
impairment that substantially interferes with or limits an individual's role or ability to
function in family, school, or community activities.

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§748.4803. When is a general residential operation (GRO)
required to meet the additional rules of this subchapter?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 1, Definition and Scope

October 2024
A GRO that is a certified psychiatric residential youth treatment facility must meet the additional
rules in this subchapter when providing psychiatric health treatments and services to an
individual.

§748.4805. In addition to the rules in this subchapter,

what other rules in this chapter apply to a psychiatric
residential treatment facility (PRYTF)?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 1, Definition and Scope
October 2024

In addition to complying with the rules in this subchapter, a PRYTF must comply with all other
rules in this chapter that apply to all operations, unless any such rule is replaced by a rule in this
subchapter, as noted in §748.4809 of this division (relating to What rules in this subchapter
replace other rules in this chapter?).

§748.4807. How do the rules in this subchapter apply to

the care of a young adult 18 to 21 years of age at a
psychiatric residential treatment facility (PRYTF)?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 1, Definition and Scope

October 2024
The rules in this chapter that apply to a PRYTF as noted in §748.4805 of this division (relating to
In addition to the rules in this subchapter, what other rules in this chapter apply to a psychiatric
residential youth treatment facility (PRYTF)?) also apply to the care of a young adult 18 to 21
years of age whom the PRYTF has admitted for psychiatric health treatments and services.

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§748.4809. What rules in this subchapter replace other
rules in this chapter?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 1, Definition and Scope

October 2024
A psychiatric residential youth treatment facility (PRYTF) is not required to comply with other
rules in this chapter if the rule has been replaced in this subchapter, as specified in this chart:

Figure: 26 TAC §748.4809

Topic A PRYTF must comply Instead of this rule:

with this rule:

Individuals Living in the §748.4863 of this §748.1201 of this chapter

Same Quarters subchapter (relating to May (relating to May children
individuals receiving receiving different types of
different types of service service live in the same
live in the same living living quarters?)
quarters?)

Developing an Initial §748.4869 of this §748.1339 of this chapter

Service Plan subchapter (relating to Who (relating to Who must be
must be involved in involved in developing an
developing an initial service initial service plan?)
plan?)

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Division 2, Policies, Notifications, and Postings

§748.4821. What additional policies must a general

residential operation (GRO) submit as part of the
application process for a psychiatric residential youth
treatment facility (PRYTF) certificate?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 2, Policies, Notifications, and Postings

October 2024

A GRO must develop written policies that address:

(1) How the PRYTF will provide 24-hour medical and emergency services, including 24-hour
nursing services [Medium-High]; and

(2) How caregivers will supervise young adults 18 to 21 years of age receiving psychiatric
health treatments and services and children in the GRO, including the PRYTF, when
sharing restrooms or indoor or outdoor activity areas [Medium-High]. The policy must:

(A) Include a schedule for the young adults and children to use restrooms, for indoor
activity time, including cafeteria usage, and outdoor activity time [Medium-High];
and

(B) Outline the specific staffing schedule caregivers will use and how the caregivers will
maintain supervision, based on the supervision needs in the young adults' and
children's service plans. [Medium-High]

§748.4823. When must a psychiatric residential youth

treatment facility (PRYTF) notify Child Care Regulation
(CCR) about accreditation changes regarding the PRYTF?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 2, Policies, Notifications, and Postings
October 2024

(a) A PRYTF must always meet the accreditation requirement of §745.9053 of this title
(relating to What requirements must a general residential operation meet before applying
for a psychiatric residential youth treatment facility (PRYTF) certificate?). [Medium-High]

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 (b) A PRYTF must notify CCR within two days if the accreditation organization informs the
PRYTF that it has taken or will take an action that will result in the PRYTF no longer
meeting the accreditation requirement of §745.9053 of this title for any period. Such an
action includes revoking, suspending, or refusing to renew the PRYTF's accreditation.
[Medium-High]

§748.4825. Where must a psychiatric residential youth

treatment facility (PRYTF) post the PRYTF certificate?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 2, Policies, Notifications, and Postings

October 2024
The PRYTF must post the PRYTF certificate in a prominent and publicly accessible place where
employees, children, young adults, parents, and others will be able to view it easily. [Medium-
Low]

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Division 3, Personnel

§748.4831. Must a psychiatric residential youth treatment

facility (PRYTF) have a treatment director?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 3, Personnel
October 2024

A PRYTF must have a treatment director that is a full-time employee of the general residential
operation. [Medium-High]

Technical Assistance
Current §748.607 still applies. A GRO that provides more than one type of treatment service
can have only one treatment director if the director meets the required qualifications for the
most prevalent services the GRO offers.

§748.4833. What qualifications must a treatment director

for a psychiatric residential youth treatment facility have?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 3, Personnel
October 2024
A treatment director who provides or oversees psychiatric health treatments and services under
this subchapter must [Medium]:
(1) Be a licensed psychiatrist, psychologist, or physician;

(2) Have a master's degree in a human services field from an accredited college or university
and three years of experience providing treatment services for children or young adults
with an emotional disorder, including one year in a residential setting; or

(3) Be a licensed master social worker, licensed clinical social worker, licensed professional
counselor, or licensed marriage and family therapist, and have three years of experience
providing treatment services for children or young adults with an emotional disorder,
including one year in a residential setting.

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Division 4, Training

§748.4841. What are the pre-service experience

requirements for a caregiver providing psychiatric health
treatments and services?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 4, Training

October 2024
(a) A caregiver responsible for an individual receiving psychiatric health treatments and
services must have a minimum of 40 hours of supervised caregiver experience in
[Medium-High]:

(1) The current general residential operation providing treatment services to children with
an emotional disorder;

(2) Another general residential operation providing treatment services to children with an
emotional disorder;
(3) A psychiatric residential youth treatment facility providing psychiatric health
treatments and services to children or young adults; or
(4) A residential or hospital setting providing direct care, supervision, guidance, and
protection of children or young adults with a severe emotional disturbance.

(b) Until a caregiver has the minimum amount of supervised child-care experience as
specified in subsection (a) of this section, the caregiver:
(1) May not be assigned as the only caregiver responsible for a group of individuals if any
individual in the group is receiving psychiatric health treatments and services
[Medium];
(2) Must be always supervised by another caregiver who has already satisfied the 40-hour
experience requirement [Medium]; and
(3) Must have their supervised child-care experience documented in the appropriate
personnel record. [Medium-Low]

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§748.4843. What additional pre-service training
requirements apply to a caregiver or an employee at a
psychiatric residential youth treatment facility (PRYTF)?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 4, Training

October 2024
(a) In addition to the types of pre-service training and hours at §748.863(a) of this chapter
(relating to What are the pre-service training requirements for a caregiver?), a caregiver
must complete four hours of suicide prevention training before the caregiver may be
counted in the child to caregiver ratio if any individual in the group is receiving psychiatric
health treatments and services. [High]
(b) In addition to the types of pre-service training and hours at §748.864(a) of this chapter
(relating to What are the pre-service training requirements for an employee?), a child-
care administrator, professional level service provider, treatment director, and case
manager must complete four hours of suicide prevention training within 90 days of
beginning job duties that include [High]:
(1) Providing services to or planning services for individuals receiving psychiatric health
treatments and services; or

(2) Managing or overseeing employees that provide services to or plans services for
individuals receiving psychiatric health treatments and services.
(c) To meet the pre-service training requirements, the suicide prevention training must meet:

(1) The instructor requirements at §748.869(a) and (b) of this chapter (relating to How
must pre-service training be conducted?); and
(2) The curriculum requirements at §748.125(c)(1) of this chapter (relating to What is the
model suicide prevention, intervention, and postvention policy?).
(d) A caregiver or employee (child-care administrator, professional level service provider,
treatment director, and case manager) does not have to complete the four hours of
suicide prevention training if the caregiver or employee has documentation that it was
completed during the last 12 months.
(e) The PRYTF must document the exemption factor in the appropriate personnel record.
[Medium-Low]

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§748.4845. Who must have first-aid and CPR training in a
psychiatric residential youth treatment facility?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 4, Training
October 2024

(a) Caregivers providing psychiatric health treatments and services to individuals must have a
current certificate of training with an expiration or renewal date in:
(1) First-aid with rescue breathing and choking, which may be through instructor-led
training or self-instructional training [Medium-High]; and
(2) Pediatric and adult cardiopulmonary resuscitation (CPR). [Medium-High]

(b) Each caregiver must be certified in first aid and CPR within 90 days of employment.
[Medium-High]
(c) At least one person counted in the child to caregiver ratio must be certified in first aid and
CPR at all times. [Medium-High]

(d) To meet the first-aid and CPR training requirements, the training must meet:
(1) The CPR training requirements at §748.913 of this chapter (relating to What are the
requirements for CPR training?); and
(2) The documentation requirements at §748.915 of this chapter (relating to What
documentation must I maintain for the first aid and CPR certifications?).

§748.4847. What additional annual training requirements

apply to a caregiver or an employee at a psychiatric
residential youth treatment facility (PRYTF)?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 4, Training

October 2024
(a) A caregiver providing psychiatric health treatments and services to an individual in a
PRYTF must complete 50 annual training hours. [Medium]

(b) In addition to the one hour of annual suicide prevention training required in §748.125(c)
of this chapter (relating to What is the model suicide prevention, intervention, and
postvention policy?):

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 (1) A caregiver must complete four additional hours of annual suicide prevention training
for a total of five hours of annual suicide prevention training if the caregiver provides
care to an individual receiving psychiatric health treatments and services [Medium-
High]; and

(2) A child-care administrator, professional level service provider, treatment director, and
case manager must complete four additional hours of annual suicide prevention
training for a total of five hours of annual suicide prevention training if the employee
is or will be [Medium-High]:

(A) Providing services to or planning services for individuals receiving psychiatric

health treatments and services; or
(B) Managing or overseeing other employees that provide services to or plans
services for individuals receiving psychiatric health treatments and services.
(c) In addition to the specific types of annual training and hours required in §748.930(b) of
this chapter (relating to What are the annual training requirements for a caregiver?), a
caregiver providing psychiatric health treatments and services to an individual must
complete two hours of annual training on administering psychotropic medication.
[Medium-High]

(d) In addition to the specific types of annual training and hours required in §748.931(b) and
(c) of this chapter (relating to What are the annual training requirements for an
employee), a child-care administrator, professional level service provider, treatment
director, and case manager must complete two hours of annual training on administering
psychotropic medication if the employee is or will be [Medium-High]:
(1) Providing services to or planning services for individuals receiving psychiatric health
treatments and services; or

(2) Managing or overseeing other employees that provide services to or plans services for
individuals receiving psychiatric health treatments and services.
(e) To meet the annual training requirements, the annual training must meet the
requirements in:

(1) §748.935 of this chapter (relating to When must an employee or caregiver complete
the annual training?);
(2) §748.937 of this chapter (relating to What types of hours or instruction can be used to
complete the annual training requirements?);
(3) §748.941 of this chapter (relating to How must annual training be conducted?);

(4) §748.945 of this chapter (relating to What curriculum components must be included in
the annual training for administering psychotropic medication?);

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 (5) §748.125(c)(1) of this chapter (relating to What is the model suicide prevention,
intervention, and postvention policy?), relating to the curriculum components for
suicide prevention training; and
(6) §748.949 of this chapter (relating to What documentation must I maintain for annual
training?).

Division 5, Child to Caregiver Ratio

§748.4851. For purposes of the child to caregiver ratio,

how many children can a single caregiver care for when a
child receiving psychiatric health treatments and services
is asleep at night?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 5, Child to Caregiver Ratio

October 2024

(a) If any child in the group is receiving psychiatric health treatments and services, a single
caregiver may care for a maximum of six children during the night-time sleeping hours.
[Medium-High]

(b) Caregivers must remain awake during night-time sleeping hours. [High]

(c) This ratio also applies to any young adults 18 to 21 years of age who are receiving
psychiatric health treatments and services under this subchapter. [Medium-High]

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Division 6, Admission and Service Plans

§748.4861. Whom may a psychiatric residential youth

treatment facility (PRYTF) admit for psychiatric health
treatments and services?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 6, Admission and Service Plans

October 2024
A PRYTF may only admit an individual for psychiatric health treatments and services who
[Medium]:

(1) Is 21 years of age or younger;

(2) Has been diagnosed with a severe emotional disturbance by a licensed mental health
professional;

(3) Requires residential psychiatric treatment under the direction of a licensed physician to
improve the individual's condition; and

(4) Was referred for treatment or services in a PRYTF by a licensed mental health
professional.

§748.4863. May individuals receiving different types of

service live in the same living quarters?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 6, Admission and Service Plans

October 2024
(a) Except as provided by subsections (c) and (d) of this section, children receiving different
types of service may reside in the same living quarters as long as:
(1) A professional level service provider completes an evaluation of the living quarters for
each child that the psychiatric residential youth treatment facility (PRYTF) places in
the living quarters [Medium]; and
(2) In each evaluation, the professional level service provider ensures that:

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 (A) There is no conflict of care with the best interests of any of the children placed in
the living quarters [Medium];

(B) Placing the child with different service or treatment needs in the living quarters will
not adversely impact the other children in the living quarters [Medium];

(C)The number of children in the living quarters is appropriate at all times based on
the needs of all children in the living quarters [Medium];
(D)Caregivers can appropriately supervise all children in the living quarters at all
times [Medium]; and

(E) The PRYTF can meet the needs of all children in the living quarters. [Medium]
(b) If the treatment or service needs of any child in the living quarters changes, the
professional level service provider must evaluate the needs of each child in the living
quarters to ensure there is no conflict of care. [Medium-Low]
(c) Children admitted for emergency care services must receive any therapeutic services
(such as group therapy or art therapy) separately from children admitted for non-
emergency care and must have separate living quarters, such as a separate wing of an
operation, or a separate cottage. The PRYTF may combine children admitted for
emergency care services with children in non-emergency care for meals, recreation, and
transportation. [Medium-Low]

(d) Young adults 18 to 21 years of age receiving psychiatric health treatments and services
that are not in the care of the Texas Department of Family and Protective Services and did
not come immediately from another residential child-care operation:
(1) Must receive therapeutic services (such as group therapy or art therapy) separately
from children admitted to the operation, including the PRYTF [Medium-High];
(2) Must have separate living quarters, such as a separate wing of an operation, or a
separate cottage [Medium-High]; and
(3) Must not use an area of the general residential operation's building or grounds at the
same time with children admitted to the operation, including the PRYTF, except
restrooms and indoor and outdoor activity areas may be shared under a policy
required by §748.4821 of this subchapter (relating to What additional policies must a
general residential operation (GRO) submit as part of the application process for a
psychiatric residential youth treatment facility (PRYTF) certificate?). [Medium-High]

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§748.4865. Are there additional requirements for a
preliminary service plan when a psychiatric residential
youth treatment facility (PRYTF) admits an individual for
psychiatric health treatments and services?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services

Division 6, Admission and Service Plans

October 2024

When a PRYTF admits an individual for psychiatric health treatments and services, in addition to
the requirements listed in §748.1331 of this chapter (relating to What are the requirements for a
preliminary service plan?), the preliminary service plan for an individual receiving psychiatric
health treatments and services must include:

(1) Therapeutic needs, including plans for psychiatric evaluation, the use of psychotropic
medications, and one-to-one therapy [Medium];

(2) Family engagement activities [Medium-Low];

(3) Plans to consult with qualified professionals, including case managers, primary care
professionals, community-based mental health providers, school staff, and other support
planners [Medium-Low]; and

(4) Nursing care. [Medium]

§748.4867. Are there additional requirements for an initial

service plan when a psychiatric residential youth treatment
facility (PRYTF) admits an individual for psychiatric health
treatments and services?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 6, Admission and Service Plans

October 2024
(a) In addition to the requirements listed in (b)(2) in Figure: 26 TAC §748.1337(b) of this
chapter (relating to What must a child's initial service plan include?), the initial service
plan for an individual receiving psychiatric health treatments and services must include:
(1) One-to-one therapy [Medium-High];
(2) Family engagement activities [Medium-Low];

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 (3) Consultation services with qualified professionals, including case managers, primary
care professionals, community-based mental health providers, school staff, and other
support planners [Medium];
(4) 24-hour nursing services, though services do not need to be onsite [Medium-High];
and
(5) Direct care and supervision services, supportive services for daily living and safety,
and positive behavior management services. [Medium]

(b) A PRYTF must document all professional consultations, examinations, recommendations,

and treatment in the individual's record. [Medium]

§748.4869. Who must be involved in developing an initial

service plan?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 6, Admission and Service Plans
October 2024
(a) A service planning team must develop the service plan. The team must consist of:

(1) At least one of the individual's current caregivers [Low];

(2) For a child, a person designated to make decisions regarding a child's participation in
childhood activities [Low]; and
(3) At least one professional level service provider who provides direct services to the
individual. [Low]

(b) Except as provided by subsection (c) of this section, if a general residential operation is
providing treatment services to a child, the team must also include two of the following
professions [Low]:

(1) A licensed professional counselor;

(2) A psychologist;
(3) A psychiatrist or physician;

(4) A licensed registered nurse;

(5) A licensed masters level social worker;
(6) A licensed or registered occupational therapist; or

(7) Any other person in a related discipline or profession that is licensed or regulated in
accordance with state law.

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(c) If a psychiatric residential youth treatment facility is providing psychiatric health
treatments and services to an individual, the team must also include a licensed
psychiatrist or physician and one of the following professionals [Medium]:
(1) A licensed professional counselor;

(2) A psychologist;
(3) A licensed registered nurse;
(4) A licensed masters level social worker; or

(5) Any other person in a related discipline or profession that is licensed or regulated in
accordance with state law.

(d) The individual and parents or guardian must be invited to a service planning meeting, so
that they may participate and provide input into the development of the service plan.
[Low]

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Division 7, Providing Care to Children and Adults

§748.4881. After a child in the care of a psychiatric

residential youth treatment facility (PRYTF) turns 18 years
old, may the young adult remain in care?
Subchapter W, Additional Requirements for Operations that Provide Psychiatric Health
Treatments and Services
Division 7. Providing Care to Children and Adults

October 2024
A child who turns 18 years old in the care of a PRYTF may remain in care until the young adult's
22nd birthday. [Low]

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Appendix A: Definitions

Texas Administrative Code, Title 26 Health and Human Services

Part 1, Health and Human Services Commission
Chapter 745, Licensing Subchapter A. Precedence and Definitions Division 2. Definitions for
Licensing

§745.21. What words must I know to understand this

subchapter?
The following words and terms, when used in this chapter, have the following meanings
unless the context clearly indicates otherwise:

(1) Abuse--As defined in the Texas Family Code, §261.001(1) (relating to Definitions) and
Texas Administrative Code, Title 40, Chapter 707, Subchapter C, Division 5 (relating to
Abuse, Neglect, and Exploitation).
(2) Affinity--Related by marriage as set forth in Texas Government Code, §573.024 (relating
to Determination of Affinity).
(3) Business entity--May be an association, corporation, nonprofit association, nonprofit
corporation, nonprofit association with religious affiliation, nonprofit corporation with
religious affiliation, or limited liability company.
(4) Capacity--The maximum number of children that a permit holder may care for at one
time.
(5) Caregiver--A person who is counted in the child to caregiver ratio, whose duties include
the supervision, guidance, and protection of a child.
(6) Child--A person under 18 years old.

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(7) Child-care facility--An establishment subject to regulation by Licensing that provides
assessment, care, training, education, custody, treatment, or supervision for a child who
is not related by blood, marriage, or adoption to the owner or operator of the facility, for
all or part of the 24-hour day, whether or not the establishment operates for profit or
charges for its services. A child-care facility includes the people, administration,
governing body, activities on or off the premises, operations, buildings, grounds,
equipment, furnishings, and materials. A child-care facility does not include child-placing
agencies, listed family homes, employer-based child care operations, or shelter care
operations.
(8) Child day care--As defined in §745.33 of this chapter (relating to What is child day
care?).
(9) Child-placing agency (CPA)--A person, including a sole proprietor, partnership, or
business or governmental entity, other than the parents of a child, who plans for the
placement of or places a child in a child care operation or adoptive home.
(10) Children related to the caregiver--Children who are the children, grandchildren, siblings,
great-grandchildren, first cousins, nieces, or nephews of the caregiver, whether by
affinity or consanguinity or as the result of a relationship created by court decree.
(11) Consanguinity--Two individuals are related to each other by consanguinity if one is a
descendant of the other; or they share a common ancestor. An adopted child is related
by consanguinity for this purpose. Consanguinity is defined in Texas Government Code,
§573.022 (relating to Determination of Consanguinity).
(12) Contiguous operations--Two or more operations that touch at a point on a common
border or located in the same building.
(13) Controlling person--As defined in §745.901 of this chapter (relating to Who is a
controlling person at a child-care operation?).
(14) Deficiency--Any failure to comply with a minimum standard, rule, statute, specific term
of your permit, or condition of your probation.
(15) Designated perpetrator--As defined in §745.731 of this chapter (relating to What are
designated perpetrators and sustained perpetrators of child abuse or neglect?).
(16) Designee--The person named on the application as the designated representative of the
operation who is officially authorized by the owner to speak for and act on the
operations’ behalf.

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(17) Employee--Any person employed by or that contracts with the permit holder, including
caregivers, drivers, kitchen personnel, maintenance and administrative personnel, and
the center or program director.
(18) Endanger--To expose a child to a situation where physical or mental injury to a child is
likely to occur.
(19) Exploitation--As defined in Texas Family Code, §261.001(3) and Texas Administrative
Code, Title 40, Chapter 707, Subchapter C, Division 5.
(20) Finding--The conclusion of a Licensing investigation or inspection indicating compliance
or deficiency with one or more minimum standards, rules, or statutes.
(21) Full license--The type of full permit that is issued to an operation that requires a
license. See also §745.341 of this chapter (relating to What type of permit does
Licensing issue?) and §745.343 of this chapter (relating to What is the difference
between an initial license and a full license?).
(22) Full permit--A full permit includes a listing, registration, compliance certificate, or a full
license. See also §745.341 and §745.343 of this chapter.
(23) Governing body--A group of persons or officers of a business or governmental entity
that has ultimate control over the entity.
(24) Governmental entity--A political subdivision or state agency of Texas.
(25) Household member--An individual, other than the caregivers, who resides in an
operation.
(26) Initial license--A time-limited license that we issue to certain applicants for a full license
in situations described in §745.345 of this chapter (relating to When does Licensing
issue an initial license?).
(27) Licensed administrator--As defined in §745.8905 of this chapter (relating to What is a
licensed administrator?).
(28) Minimum standards-- Minimum requirements for permit holders that are enforced by
Licensing to protect the health, safety, and well-being of children. The minimum
standards consist of the rules contained in:
(A) Chapter 742 of this title (relating to Minimum Standards for Listed Family Homes;
(B) Chapter 743 of this title (relating to Minimum Standards for Shelter Care);
(C)Chapter 744 of this title (relating to Minimum Standards for School-Age and Before
or After-School Programs);
(D) Chapter 746 of this title (relating to Minimum Standards for Child-Care Centers);
(E) Chapter 747 of this title (relating to Minimum Standards for Child-Care Homes);

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 (F) Chapter 748 of this title (relating to Minimum Standards for General Residential
Operations);
(G) Chapter 749 of this title (relating to Minimum Standards for Child-Placing
Agencies);
(H) Chapter 750 of this title (relating to Minimum Standards for Independent Foster
Homes); and
(I) Subchapter D, Division 11 of this chapter (relating to Employer-Based Child Care).
(29) Neglect--As defined in the Texas Family Code, §261.001(4) and Texas Administrative
Code, Title 40, Chapter 707, Subchapter C, Division 5.
(30) Operation (also known as a child care operation)--A sole proprietor, partnership, or
business or governmental entity offering a program that is subject to Licensing's
regulation, including day-care operations and residential child care operations. An
operation includes the building and grounds where the program is offered, any person
involved in providing the program, and any equipment used in providing the program.
An operation includes a child-care facility, child-placing agency, listed family home,
employer-based child care operation, shelter care operation, or any operation that
requires a permit under Chapter 42, Texas Human Resources Code.
(31) Owner—The sole proprietor, partnership, or business or governmental entity that owns
an operation that is subject to regulation by Licensing.
(32) Parent--A person who has legal responsibility for or legal custody of a child, including
the managing conservator or legal guardian.
(33) Permit--A license, certification, registration, listing, compliance certificate, or any other
written authorization granted by Licensing to operate a child care operation. This also
includes an administrator's license.
(34) Permit holder--The owner of the operation that is granted the permit.
(35) Pre-kindergarten age child--A child who is three or four years of age before the
beginning of the current school year.
(36) Program--Activities and services provided by an operation.

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(37) Regulation--Includes the following:
(A) The development of rules, including minimum standards, as provided by statutory
authority; and
(B) The enforcement of requirements that are minimum standards, rules, statutes, or
any condition or restriction we have placed on a permit. Anyone providing or
seeking to provide care or a service that is subject to regulation must comply with
the applicable requirements. This includes a permit holder, an applicant for a
permit, and anyone providing care or a service without the appropriate permit.
(38) Report--A communication to Licensing or the Department of Family and Protective
Services (DFPS), including the Statewide Intake division of DFPS, of:
(A) An allegation of a deficiency in a minimum standard, rule, or statute; or
(B) Any other possible risk to a child in the care of an operation that is subject to
regulation by Licensing.
(39) Residential child care--As defined in §745.35 of this chapter (relating to What is
residential child care?).
(40) School-age child--A child who is five years of age or older and is enrolled in or has
completed kindergarten.
(41) State Office of Administrative Hearings (SOAH)--See §745.8831 of this chapter (relating
to What is a due process hearing?).
(42) Sustained perpetrator--See §745.731 of this chapter (relating to Who are designated
perpetrators and sustained perpetrators of child abuse or neglect?).

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Appendix B, Vaccine-Preventable Diseases

This guide is intended to provide you with more information to assist in the development and
implementation of a vaccine-preventable disease policy for your program.

What must the policy for protecting children from vaccine-

preventable diseases include?
Your operation is responsible for developing a policy that includes all areas addressed in
§748.241.

How will Licensing evaluate for compliance?

Licensing will review your program’s policy to ensure that it covers each of the eight required
areas. Licensing staff will ensure that your operation outlines how you will maintain either
written or electronic records for each employee’s compliance with your policy as well as any
exemptions. We will not evaluate based on the content of each policy item.

What would be an example of how licensing will evaluate

my operation’s compliance with the new rule?
The new rule requires you to specify any vaccines that you have determined an employee must
have based on the level of risk the employee presents. Licensing staff will review your policy to
ensure you have specified any vaccines an employee must have. For example, if your policy
outlines that all employees must only obtain a flu vaccine once every 12 months then we would
only review compliance with the employee’s requirement to obtain a flu vaccine.

What immunizations are recommended for adults?

The Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention (CDC) develops the recommendations and they are listed on the CDC website at
[Link]

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Do I have to require employees to obtain all immunizations
recommended by the CDC?
No, employees at your program will only need to obtain immunizations that are required in your
policy. It is up to you to determine what immunizations will be required and which employees
are required to obtain them based on their level of risk as determined by their routine and direct
exposure with children.

How do I determine an employee’s level of risk?

An employee’s level of risk is determined by the policy you develop. The basis for determining
an employee’s level of risk must be outlined in your policy and must be based on the employee’s
routine and direct exposure to children. Items to consider when you develop policy include:

● What are the employee’s primary duties?

● How closely does the employee work with children? (For example, does the employee
change diapers, assist with toileting, prepare or serve food)
● How often does the employee work with children? (Regular contact vs. substitute basis)
● What are the ages of children the employee works with?

Can an employee be exempt from immunizations that my

program’s policy requires?
Yes, an employee may be exempt from one or more of your program’s required immunizations
for:

● Medical conditions identified as contraindications or precautions by the CDC; or

● Reasons of conscience, including a religious belief.

What procedures must an employee follow to be exempt

from having a required vaccine?
Your policy must address exemption procedures an employee must follow in order for you to
determine the employee’s qualification of an exemption.

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What are some examples of acceptable documentation for
exemptions?

● For medical conditions, acceptable documentation may include a note from the employee’s
health care professional providing a statement that the required vaccine is medically
contraindicated or poses a significant risk to the health and well-being of the individual.
● For reasons of conscience, acceptable documentation may include a signed and dated
statement from the employee that states the employee is exempt for reasons of
conscience, including the person’s religious beliefs.

What are some examples of procedures that an exempt

employee must follow to protect children in care from
exposure to disease?
It is up to your operation to determine what and when protective procedures will be required.
Examples of protective procedures include:

● Wearing gloves when handling or cleaning body fluids, such as after wiping noses,
mouths, or bottoms, and tending sores;
● Specifying that an employee with open wounds and/or any injury that inhibits hand
washing, such as casts, bandages, or braces, must not prepare food or have close contact
with children in care;
● Wearing masks when the employee has respiratory symptoms to reduce the spread of
droplets to surrounding areas;
● Wearing masks when taking care of children with respiratory symptoms;
● Removing gloves and washing hands immediately after each task to prevent cross-
contamination to other children;
● Excluding the employee from direct care when the employee has signs of illness.

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How can I determine that an employee has complied with
my operation’s policy?
You must specify in your policy how you will verify that an employee has complied with your
policy. This must include what written and/or electronic documentation you will accept.
Examples of documentation may include:

● Copy of the employee’s current immunization record;

● Receipt that includes date a required immunization was received;
● Letter signed by a health care professional that lists the date an immunization was
received;
● Documentation of exemption for medical reasons from a health care professional;
● Signed and dated statement from the employee for exemption based on a reason of
conscience.

Where can my employees get the recommended

immunizations?
Individuals should start with their health care provider. Other resources in your area include
pharmacies, the health department, and public or community health clinics. For a list of local
health departments in Texas visit the Texas Department of State Health Services (DSHS)
website at: [Link]

Are there any other resources available for employees to

receive the recommended immunizations?
Yes, the Adult Safety Net program created by The Texas Department of State Health Services
(DSHS) to increase access to vaccination services in Texas for uninsured adults.

What is the Adult Safety Net program?

The Adult Safety Net (ASN) program provides vaccine purchased with public funds to
participating clinics to be used for immunizing uninsured adults.

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How do I find an Adult Safety Net provider in my area?
Visit the ASN website at [Link]/ASN and click on the search page to locate an
ASN clinic near you. (Please check with the clinic before visiting to make sure they can see you.)

Who is eligible to receive vaccinations from the ASN

program?
Adults ages 19 years and older that do not have health insurance are eligible to receive ASN
vaccines.

Who is not eligible to receive ASN vaccines?

Individuals who do not qualify for ASN vaccines include:

● Adults who have Medicare, Medicaid, or any other insurance, including private insurance.
● Adults who are underinsured for adult vaccines (e.g., those who have healthcare
insurance that does not cover adult vaccines).
● Individuals younger than 19 years of age.

What vaccines are offered through the ASN program?

The following is a list of vaccines currently offered through the ASN program and a description of
the diseases they prevent.

● Hepatitis B Vaccine — prevents infection of the liver by the hepatitis B virus, which can
lead to liver cancer, cirrhosis of the liver, liver failure, and death.
● Hepatitis A Vaccine — prevents infection of the liver by the hepatitis A virus. Symptoms of
hepatitis A include lack of energy, diarrhea, fever, nausea and jaundice (yellow color to
the whites of the eyes or skin).
● Hepatitis A and Hepatitis B Combination Vaccine—see above.
● Human Papillomavirus (HPV) Vaccine — prevents infection from several strains of HPV,
including those that cause genital warts and several types of cancer, such as cervical,
anal, penile, and throat cancer.

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 ● Measles/Mumps/Rubella (MMR) Vaccine — prevents infection from the measles virus,
which can lead to rash, ear infection, brain damage, and death. Prevents infection from
the mumps virus, which can cause fever, swollen glands, headache, and can lead to
deafness and meningitis. Prevents infection from rubella virus, which can cause rash,
arthritis, and miscarriage in pregnant women.
● Pneumococcal Polysaccharide (PPSV23) Vaccine — prevents infection by the Streptococcus
pneumoniae bacterium, which is one of the most common causes of severe pneumonia
and can lead to other types of infections, such as ear infections, sinus infections,
meningitis (infection of the lining of the brain and spinal cord), and blood stream
infections (bacteremia).
● Tetanus, Diphtheria, and Pertussis (Tdap) Vaccine — prevents tetanus, which can cause
muscle spasms, lockjaw, paralysis, and death. Prevents diphtheria, which can cause
suffocation and heart failure. Prevents pertussis (known as “whooping cough”), which can
cause severe coughing that can lead to rib fractures, pneumonia, and death. The CDC
recommends* one dose for all pregnant women during every pregnancy and all other
adults who have not yet received Tdap vaccination, especially those who come in contact
with infants.
● Tetanus and Diphtheria (Td) Vaccine — similar to Tdap vaccine (see above), but protects
against tetanus and diphtheria only, without the pertussis component.

If I qualify for ASN vaccine, do I have to pay anything?

ASN vaccines are supplied to participating medical providers at no cost. This means that ASN
providers cannot charge a fee for the vaccine itself. However, providers are allowed to charge an
administration fee of up to $25 for each vaccine that is administered. Although ASN providers
may charge this administration fee, they cannot deny the vaccine because of an inability to pay
it.

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Revised: 12/2024