BILL ANALYSIS HUMAN SERVICES C.S.H.B. 413 By: Naishtat 3-18-97 Committee Report (Substituted) BACKGROUND The regulation of nursing facilities is derived from a combination of state and federal law. State law governs the criteria used to determine the competence, character, financial condition and level of compliance with standards of care needed to obtain and retain a license to operate a nursing facility. Federal law governs the criteria used to be "certified" or eligible to receive funds through federal programs such as Medicaid. Nursing facilities must meet all state licensing requirements; otherwise, they are not eligible to participate in the federally funded programs. In this regard, state law is the primary vehicle to assure meaningful protection of current and future residents of nursing facilities. A combination of weaknesses in Texas law limit the effectiveness of current regulation of nursing facilities, placing our most vulnerable population of elderly and disabled at risk of abuse, neglect, exploitation, and inadequate care. Texas law provides inadequate measures to assure that only persons with solid credentials may own, operate and control licensed nursing facilities. Further, Texas law is vague and ambiguous in its delegation of key regulatory authority, including license revocation, application of remedies and rulemaking. PURPOSE House Bill 413 is intended to establish effective state licensure authority over nursing facilities in Texas. To achieve this goal, the bill (1) redefines those persons and entities who are subject to the law; (2) provides the Texas Department of Human Services (the department) authority to exercise discretion to issue and renew licenses for only those facilities that meet the new, more stringent licensing requirements; (3) establishes authority to require relevant background information from those who own, operate and control nursing facilities as a prerequisite for licensure; (4) establishes additional resident protections; (5) establishes a variety of state enforcement measures; (6) clarifies rulemaking authority granted to the Board of Human Services; (7) clarifies the law relating to the use of regulatory reports in civil actions and the use of arbitration proceedings; and (8) enhances the Attorney General's enforcement capabilities. RULEMAKING AUTHORITY House Bill 413 grants rulemaking authority to the Texas Board of Human Services (Board). Those sections of the bill that grant rulemaking authority are intended to provide the board with broad authority to implement each subsection of Chapter 242 of the Health and Safety Code. The rules adopted by the board may be more but not less stringent than the federal laws applicable to nursing facilities. Further, the board's authority to establish rules and standards is expanded to expressly include quality of care standards and residents' rights. It is the opinion of the committee that rulemaking authority is expressly granted to the Texas Board of Human Services in the following sections of the bill: Section 1.06 (Section 242.032(e), Health and Safety Code); Section 1.09 (Section 242.037(a) and (g), Health and Safety Code); Section 1.22 (Section 242.1225, Health and Safety Code); Section 1.23 (Section 242.126(d), Health and Safety Code); Section 1.30 (Section 242.501(a), Health and Safety Code); and Section 1.33. SECTION BY SECTION ANALYSIS ARTICLE 1. REGULATION OF NURSING HOMES AND SIMILAR FACILITIES SECTION 1.01. Amends Health and Safety Code Section 242.001. Replaces the existing purpose statement of Chapter 242 of the Health and Safety Code applicable to nursing facilities. The revised section sets forth the explicit legislative intent that the regulation of nursing facilities in Texas shall be regulated in a manner that protects residents in four basis ways: 1. providing the highest possible quality of care; 2. strictly monitoring all factors relating to the health, safety, welfare and dignity of each resident; 3. imposing prompt and effective penalties for noncompliance with licensing standards; and, 4. providing the public with information concerning the operation of institutions in this state. This section also establishes certain minimum standards for nursing facilities and authorizes the department to establish rules relating to licensure requirements which are more stringent than federal certification regulations. SECTION 1.02. Amends Section 242.002, Health and Safety Code, to define the terms "Commissioner", "Controlling Person," and other terms used in the chapter. SECTION 1.03. Amends Section 242.0021 of the Health and Safety Code. This section defines "controlling person" in order to assure that the licensing requirements and remedies reach the person or entity in actual or legal control of the facility. Section 1.04. Amends Section 242.005, Health and Safety Code to require not only DPS, but also the Office of the Attorney General, to submit an annual performance report to the governor and legislature by October 1. The form and content of the reports shall be prescribed jointly by the Legislative Budget Board and the state auditor. SECTION 1.05. Adds new Sections 242.015 and 242.016 to the Health and Safety Code. New section 242.015 requires each facility to have a licensed administrator who: 1) works at least 40 hours per week; and 2) is responsible for management of the institution and the delivery of quality care to all residents. New section 242.016 provides that fees or penalties collected by the Department of Human Services under this chapter are to be used by the department to administer and enforce this chapter, except as expressly provided by this chapter. SECTION 1.06. Amends Section 242.032, Health and Safety Code. Allows the department to conduct investigations into the qualifications of all applicants and existing license holders for the purpose of initial licensing and renewal of existing licenses, including review of past compliance or non-compliance with state and federal laws and financial condition. Such compliance information will be required of all owners and other persons who control or manage the facility for at least the past 10 years relating to Texas and all other states. Such information shall be made available to the public. This section places an affirmative burden on the applicant or license holder to establish their ability to comply with all state and federal requirements. This section requires the department to determine what constitutes a satisfactory compliance history by rule. Further, this section authorizes the department to require historical financial information from the applicant or any person required to submit background information to the department as part of a license application or renewal. SECTION 1.07. Amends Section 242.033(a), Health and Safety Code, to place the issuance or renewal of a nursing home license at the discretion of DHS, based upon the results of its evaluation of the applicant and those who control the applicant. SECTION 1.08. Amends Section 242.034, Health and Safety Code. Authorizes the Texas Board of Human Services to establish a background examination fee to be paid by each applicant, including initial licenses, renewals, change of ownership, and increase in bed space. Further, this section increases the license fees for institutions. Any fee increases must be reflected in reimbursement rates. SECTION 1.09. Amends Section 242.037, Health and Safety Code. Grants the department rulemaking authority to implement all of chapter 242 and provides that the rules and standards adopted by the department may be more stringent than the federal requirements for Medicaid certification, and shall not be less stringent that current federal regulations. Further, this section requires the department to coordinate the development and implementation of licensing standards with the federal rules to avoid unnecessary duplication and preserve the efforts made by the department in early 1995 to streamline nursing facility regulations. This section also requires the Board of Human Services to establish rules setting forth a system for prioritizing investigation of and action on complaints relating to institutions. SECTION 1.10. Amends Section 242.042, Health and Safety Code. This section adds the requirement that facilities post the availability of information from the department relating to the facility, including quality of care, recent investigations, and litigation. Further, the section adds the requirement that a notice must be posted on all doors when a facility is ordered to suspend admissions. Finally this section requires each institution to post on all doors that information is available for public inspection in the institution relating to its compliance history and current violations of residents rights. SECTION 1.11. Amends Section 242.061, Health and Safety Code, by amending subsection (a) and adding subsection (c). Provides the department with expanded authority to deny, suspend, or revoke a license to operate an institution. SECTION 1.12. Adds new section 242.0615 which allows the department to exclude a person from eligibility for a license under this chapter if that person has substantially failed to comply with this chapter. The exclusion may be for a period not less than two years and not more than ten. SECTION 1.13 Amends Section 242.063 (a), (b) and (d), by expanding the department's capability to seek temporary restraining orders and injunctions against a person or persons that violate or threaten to violate a standard imposed under this chapter or any other law affecting residents; allowing a district court to provide injunctive relief to prohibit a person or persons from violating or threatening to violate standards or licensing requirements prescribed by this chapter; and, in certain instances, allowing a suit for a temporary restraining order or other injunctive relief to be brought in Travis County or in the county in which the alleged violation occurs. SECTION 1.14 Amends Section 242.065 (a), Health and Safety Code by: further defining who is liable for a civil penalty and increasing the minimum and maximum penalty allowed for each act; by adding new subsection (b) to define what should be considered when determining the amount of a penalty to be awarded under this section; renaming previous subsection (b) to (c) and expanding what constitutes a separate ground for recovery to include each resident who suffers directly because of the violation; and adding subsection (d) to define "affiliate". SECTION 1.15 Amends Section 242.066, Health and Safety Code, by amending subsections (a) and (b) and adding subsections (f), (g), and (h), revising the reasons for assessing administrative penalties assessed by the department. Six reasons are provided for administrative penalties: 1) violation of any department rule, order or standard; 2) making a false statement on an application or in an investigation; 3) refusing access to the department to inspect records or premises; 4) willful interference with department functions; 5) willful interference with department representatives; and 6) failing to pay a penalty within 10 days of the assessment. The penalty for these types of offenses may not be less than $500 or more than $15,000 per day for each violation. This section permits the penalty to be assessed against either the applicant, license holder or anyone who owns or controls the institution. This section also establishes a separate level of fines for violations of resident rights, failure to post notice of suspension of admissions and rules requiring the reporting of conduct or conditions resulting in the exploitation of residents and accidental injury to or hospitalization of residents.. These types of violations will be limited to $1000 a day for each violation, unless the violation of a resident's right also violates a standard of care. In such cases, the $15,000 limit applies. SECTION 1.16. Amends Subchapter C, Chapter 242, Health and Safety Code, by adding new section 242.0665. Allows a facility up to 30 days to correct certain violations to avoid the assessment of administrative penalties. To avoid the penalty, the facility must maintain compliance for at least one year. Failure to maintain compliance results in an increase in the amount of the fine, up to $30,000 a day per violation with a minimum fine established as $500 per day per violation. Facilities, however, that have violations that result in serious harm, constitute a serious threat to the health or safety of a resident, or limit the institution's capacity to provide care, are excluded from the avoidance of penalties. SECTION 1.17. Amends Section 242.068(d), Health and Safety Code, to clarify the distinction between civil penalties and administrative penalties. SECTION 1.18. This section amends the existing Health and Safety Code regarding enforcement. Section 242.067 is amended to incorporate provisions implementing the right to correct violations. Section 242.069 is amended to satisfy constitutional requirements of administrative penalty adjudication. Notice must be given to the person charged and the notice must include the findings, the amount of the penalty, the rate of interest payable, the date on which interest begins to accrue, whether payment is required, and the person's right to judicial review. The person charged is directed to pay the full amount or file a petition for judicial review. The department, notwithstanding subsection (b), may permit the person to pay the penalty in installments or to use the penalty to ameliorate the violation to improve services affected by the violation. Penalties not collected within 30 days are subject to interest and in such situations the department may refer matters to the Attorney General for collection. Reduced or unassessed penalties will be remitted with interest to charged persons. Interest accrued on amounts collected after the 30 day period will be paid at rate set by the New York Federal Reserve Bank for the period beginning on the day the order is received by the person and ending on the date on which the penalty is paid. Section 242.070 states that a penalty may not be assessed for the same act under both this chapter and for violations of Chapter 32, Human Resources Code unless a facility violates contractual obligations under Chapter 32 of the Human Resources Code. Not more than one penalty authorized by this chapter may be assessed under this subsection. SECTION 1.19. Amends Subchapter C, Chapter 242, Health and Safety Code, by adding Section 242.071, Amelioration of Violation. Authorizes the Commissioner of the department to require a facility to use, under the supervision of the department, all or part of the dollars fined to enhance care in lieu of paying the fine to the state. Section 242.072 is added to define when the Attorney General and the Department may recover costs and provides for how the costs shall be appropriated. New section 242.073 provides authority to immediately suspend admissions to a facility, coupled with the requirement that a notice of the suspension be posted on all doors of the facility. New section 242.074 is added to authorize the Attorney General to conduct additional investigations and defines under which circumstances those investigations may be conducted. New section 242.075 authorizes a demand for a civil investigation and defines the parameters of such, including disclosure and procedure involved with documentary material, the delivery of a civil investigation demands, and the role of the Attorney General. New section 242.076 prohibits an institution from using, in any action brought by the department or the Attorney General, any evidence withheld from the department or the Attorney General during an inspection or investigation under this chapter, if the evidence was requested by the department or the attorney general and is not privileged under the law of this state. SECTION 1.20 Amends Section 242.096(e), Health and Safety Code, by stating that any moneys in the nursing and convalescent home trust fund in excess of $500,000 at the end of the fiscal year shall be transferred to the credit of the general revenue fund and may be appropriated only to DHS for use in administering and enforcing this chapter. SECTION 1.21 Amends Section 242.097, Health and Safety Code. Subsection (a) is amended to require the department to adopt, if the amount of the nursing and convalescent home trust fund is less than $500,000, an annual fee to be deposited in that fund. Subsection (b) is amended to require the department to set a fee of $1 per unit or bed space, or an amount necessary to provide $500,000 in the trust fund. SECTION 1.22. Amends Subchapter E, Chapter 242, Health and Safety Code, by adding a new Section 242.1225. Directs the board to adopt rules requiring the reporting of conduct or conditions that result in exploitation of residents, accidental injury and hospitalization of residents. SECTION 1.23. Amends Section 242.126, Health and Safety Code, to provide parameters and time lines for the initiation and completion of investigations relating to abuse and neglect allegations. The department shall begin its investigation within twenty-four hours of the receipt of a report which alleges any of the following three circumstances: 1. the health or safety of a resident is in imminent danger; 2. a resident has recently died because of the reported conduct; or 3. a resident has been hospitalized because of reported conduct. This section further provides a one working day response time for other complaints of abuse or neglect that could place a resident in imminent danger. The department is required to adopt rules governing the conduct of investigations to ensure that the complainant and resident receive periodic information regarding the investigation. If, during an investigation, immediate removal of a resident is necessary to protect the resident, the department must file a petition for temporary care and protection of the resident. Ultimately, the department or designated agency must file a final written report with the district attorney and the appropriate law enforcement agency, if necessary. SECTION 1.24. Amends Section 242.127, Health and Safety Code, to require the department to maintain the confidentiality of the names of persons making complaints or reports of abuse and neglect. SECTION 1.25. Amends Section 242.133 (a), Health and Safety Code, to provide a private cause of action against an institution by a person (employee) who is retaliated against for making any report of abuse or neglect or for initiating or cooperating in investigations of the institution. Further, this cause of action is broadened to specifically include retaliation for reporting any complaint to the person's supervisor. SECTION 1.26. Amends Section 242.1335 (a), Health and Safety Code, to broaden the protection of residents from retaliation for making any type of compliant report or grievance or reports made in accordance with this subchapter. SECTION 1.27. Redesignates Subchapter H, Chapter 242, Health and Safety Code, to Subchapter J, relating to arbitration. SECTION 1.28. Amends Section 242.253 (c), Health and Safety Code, to require that the party that elects arbitration to pay the costs of the arbitration. Additionally, this section limits fees and expenses to be paid to an arbitrator to a maximum of $500 per day. SECTION 1.29. Amends Section 242.267, Health and Safety Code, to provide the department and institutions equal standing to file applications to vacate an arbitrator's order. Amends Section 242.268, Health and Safety Code, to prohibit the use of arbitration in cases involving suspension of a license, suspension of admissions or closing orders. SECTION 1.30. Amends Chapter 242, Health and Safety Code, by redesignating Subchapter F to Subchapter N. Adds to Chapter 242, Health and Safety Code, a new Subchapter F, entitled Medical, Nursing, and Dental Services Other Than Administration of Medication, to provide the statutory authority for requiring institutions to maintain the following types of services: 1. Physician Services. Section 242.151: Each institution is to have a state-licensed medical director responsible for residents' assessment and a comprehensive plan of care. Specifically stated is the right of each resident to choose a personal attending physician. 2. Physician Services for Residents Younger Than 18 Years of Age, Sec. 242.152: Each institution shall use pediatric consultative services in accordance with the assessment and that a pediatrician or other physician with expertise with children with complex medical needs shall participate in all aspects of the child's care. 3. Director of Nursing Services, Section 242.153: Each institution shall have a director who is responsible for coordinating the residents' comprehensive plan of care and ensuring the proper administration of medication. This person must be a registered nurse. 4. Nursing Services, Section 242.154: Each institution shall maintain sufficient staff to obtain and maintain the physical, mental, and psychosocial functions of each resident at the highest practicable level. 5. Pediatric Nursing Services, Section 242.155: Each institution must ensure that nursing services are provided by staff with demonstrated competence in care of children and must use consultative pediatric nursing services. 6. Required Medical Examination, Section 242.156: Requires a minimum of one medical examination each year, the details of which should be specified by the department, unless other requirements are made by federal law. 7. Dental Examination, Section 242.157: Requires the facility to ask the residents or custodians if they desire a dental exam at their own expense. Adds a new Subchapter K to Chapter 242, Health and Safety Code, Subchapter K, which includes: 1. Quality of Life, Section 242.401: Facilities must provide care in a way that promotes maintenance or enhancement of the quality of life and to meet unique needs of those under 18 years of age. 2. Quality of Care, Section 242.402: The care must enable the resident to attain and maintain the highest practicable level of physical, emotional and social well-being. 3. Standards for Quality of Life and Quality of Care, Section 242.403: The department shall adopt standards which, at a minimum, address: (1) admissions (2) care for residents under 18 years of age (3) assessment and comprehensive plan of care (4) transfer and discharge (5) clinical records (6) infection control (7) rehabilitation services (8) food services (9) social services and activities (10) prevention of pressure sores (11) bladder/bowel retraining (12) tube feeding (13) relocation of residents (14) postmortem procedures (15) appropriate use of restraints The department may also adopt additional standards to implement Sections 242.401 and 242.402. 4. Policies, Procedures and Practices for Quality of Care and Quality of Life, Section 242.404: This section requires institutions to comply with the standards and to develop written operating policies to implement them. The content of such policies and procedures will be the subject of standards adopted by the department, and must be made available to the public, including physicians, staff resident's next of kin, or anyone making a request. Adds to Chapter 242, Health and Safety Code, Subchapter L, entitled Rights of Residents, which includes: 1. Resident's Rights, Section 242.501: Instructs the department to adopt a statement of resident rights. At a minimum, the statement of rights must contain provisions relating to the 21 specific rights listed in the statute. Such rights may only be restricted to protect the rights of other residents, particularly matters of privacy and confidentiality. The department may adopt resident rights in addition to those required. 2. Rights Cumulative, Section 242.502: Assures that the resident rights are cumulative with all other rights established by this chapter or any other law. 3. Duties of Institution, Section 242.503: Requires institutions to develop and implement policies to protect resident rights and determines that these rights may not be violated. 4. Information About Resident's Rights and Violations, Section 242.504: Establishes the duty on the institution to explain the resident's rights to residents and next of kin, and to provide a written statement of rights, any policies of the facility related to implementing the rights and the duty to post written statements. Further, as part of the proposed enforcement of rights, any time the institution has been cited for violation of resident rights by the department, the institution must include a notice of the citation in the informational materials required by 242.042(a)(8). Also, the institution must include its written statement of rights in this informational material. Adds to Chapter 242, Health and Safety Code, Subchapter M entitled Complaint Inspections which includes: 1. Complaint Requesting Inspection, Section 242.551: Any person may request the department to conduct an inspection of an institution by making a complaint when there is an alleged violation of law in the institution. All such complaints are encouraged to be in writing. 2. Disclosure of Substance of Complaint, Section 242.552: The department is prohibited from providing the institution with information about the substance of the complaint until it makes an on-site inspection. 3. Confidentiality, Section 242.553: The name of the person making the complaint is confidential, unless the person requests their name to be released. 4. Preliminary Review of Complaint: Inspection, Section 242.554: Requires the department to inspect or otherwise respond within a reasonable time unless they determine that the complaint is made to harass the institution or has no reasonable basis or they find corrective action by the institution. The department shall notify the person making the complaint of the proposed course of action. Adds to Chapter 242, Health and Safety Code, Subchapter N entitled Administration of Medication which includes: 1. Medication Administration, Section 242.601: Requires institutions to set up procedures which comply with all department rules. 2. Pharmacist Services, Section 242.602: Requires certain services to be performed by licensed pharmacist, and establishes right of resident to choose their pharmacy provider. 3. Storage and Disposal of Medications, 242.603: Establishes standards for storage and disposal. 4. Reports of Medication Errors and Adverse Reactions, Section 242.604: Establishes reporting requirements for errors and adverse reactions. 5. Medication Reference Sources, Section 242.605: Requires facilities to maintain proper reference books, including pediatric medications if they have children in the institution. 6. Sections 242.606 through 242.610: Conforming amendments. 7. Section 242.611. Amended to allow the department greater flexibility in the use of medication permit fees by removing the requirement that fees received under this section may only be appropriated to the department to defray costs incurred under this section. 8. Section 242.612 through 242.615. Conforming amendments. Existing requirements under Section 242.159 (regarding medical examinations) and Section 242.160 (regarding dental examinations) are deleted. SECTION 1.31. Amends section 222.0255 of the Health and Safety Code to clarify that the licensing standards must be adopted by rule in accordance with Chapter 242, including the provisions of 242.037 providing that the rules and standards may be more stringent than the standards imposed by federal law for certification for participation in the state Medicaid program, but may not be less stringent than the Medicaid certification standards and regulations imposed under the Omnibus Budget Reconciliation Act of 1987 (OBRA), Pub. L. No. 100-203. SECTION 1.32. This section repeals the existing "rights of residents" provision (242.012). The repeal is to take effect January 1, 1998. SECTION 1.33. Requires the Board of Human Services to adopt rules necessary to implement this law not later than January 1, 1998. SECTION 1.34. Specifies that the additional license fee set forth in section 1.21 applies only to fees due on or after the effective date on this Act. SECTION 1.35 Applies the new law to conduct occurring on and after January 1, 1998. ARTICLE 2. GOVERNMENT FUNDING OF NURSING SERVICES SECTION 2.01 Amends section 32.021, Human Resources Code, to eliminate the sanctions advisory committee, to remove the restriction on state rulemaking being tied to federal certification standards, and provide that certification standards adopted by the department for participation in the state Medicaid program must comply with the more stringent of state or federal law. This section also bolsters authority to impose appropriate remedies. This section also clarifies the procedure for admissibility of surveys, complaint investigations, incident investigations and other documents in civil actions; and prohibits any reimbursement for penalties paid. Also, the "3-strikes" rule promulgated by the department is codified. ARTICLE 3. EFFECTIVE DATE; EMERGENCY SECTION 3.01 Effective date is September 1, 1997. SECTION 3.02 Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE Section 1.01 is changed to provide that a violation of a minimum acceptable level of care established under this chapter is prohibited by law, to provide that all rules and standards adopted under this chapter are designed to protect a class of persons that includes residents of institutions. Section 1.02 is changed to delete the definition of the term "restraints" and add new definitions of the terms "commissioner", "controlling person", "facility", and "home", and to modify the definition of "person". Section 1.03 is changed to establish a definition of "controlling person" rather than "control". Section 1.04 is changed to delete new section 242.015 entitled Documents Public and to add amendments to section 242.005 requiring performance reports. Also, new section 242.016 entitled Licensed Administrator contained in the original bill has been renumbered without other changes and appears as 242.015 in section 1.05 of the Committee Substitute. Section 1.05 has been changed to include new section 242.015 and new section 242.016 entitled Fees and Penalties. The amendments to 242.032 contained in Section 1.05 in the original bill have been modified and moved to Section 1.06 of the Committee Substitute. Section 1.06 has been changed to no longer amend 242.033. This Section provides new amendments to 242.032 entitled License or Renewal Application. The Committee Substitute contains amendments to 242.032 that are not contained in the original bill, including the requirement that the department determine by rule what constitutes a satisfactory compliance history, and greater specificity regarding historical financial information to be filed as part of a license application. Section 1.07 of the Committee Substitute contains the amendments to 242.034 contained in section 1.06 of the original bill. Section 1.08 of the Committee Substitute amends 242.034 to increase the license fees for institutions and strikes language appearing as subsection (g) of 242.034 as provided in Section 1.07 of the original bill. Section 1.09 establishes amendments to 242.037, most of which were contained in Section 1.08 in the original bill. Changes in the committee substitute include specific rule-making authority relating to care and treatment of residents and any other matter related to resident health, safety, and welfare, quality of life, quality of care, residents' rights, and licensure of institutions. Further, the committee substitute clarifies rule-making authority relating to geriatric care training, and requires the Board to adopt rules establishing a system for prioritizing investigation and action on complaints relating to institutions. Section 1.10 amends 242.042 as provided in Section 1.09 of the original bill, with changes including the elimination of the requirement that a notice of resident rights violations be posted on all doors, while adding the requirement that all institutions maintain an up to date one year compliance history and post notice of the availability of that information on all doors providing ingress to and egress from the institution. Section 1.11 amends 242.061 with changes to the provisions contained in Section 1.10 of the original bill. These changes include the expansion of the authority to deny, suspend or revoke a license based upon the actions of any person required to submit background information as part of the license application or renewal process. Other changes include the addition of the requirement that violations of law or rule be found to be either repeated or substantial prior to license denial, suspension or revocation in 242.061(a)(1) while the requirement of substantial failure to comply was removed from 242.061(a)(3). A new basis for license denial, suspension or revocation was created on the basis of having been excluded from holding a license as established under 242.0615. Section 1.12 amends subchapter C, chapter 242, by adding section 242.0615, which allows DHS to exclude from license eligibility, under this chapter, for a period of 2 to 10 years, a person that has substantially failed to comply with this chapter. This provision was not in the original bill. Section 1.13 Amends section 242.063 (a), (b) and (d), by expanding the departments capability to seek a temporary restraining orders and injunctions against a person or persons that violate or threaten to violate a a standard imposed under this chapter or any other law affecting residents; allowing a district court to provide injunctive relief to prohibit a person or persons from violating or threatening to violate standards or licensing requirements prescribed by this chapter; and ; in certain instances allowing a suit for a temporary restraining order or other injunctive relief to be brought in Travis County or in the county in which the alleged violation occurs. Section 1.14 Amends section 242.065 of the Health and Safety Code as follows: 1. to further define who is liable for a civil penalty and increases the minimum and maximum penalty allowed for each act by: a. providing a minimum civil penalty of $2,000 in comparison to the removal of minimum for a civil penalty in the introduced version, and b. providing a maximum civil penalty amount of $15,000 in comparison to the $25,000 maximum amount in the introduced version; 2. by adding new subsection (b) which defines what should be considered when determining the amount of a penalty to be awarded under this section; 3. renames previous subsection (b) to (c) and expands what constitutes a separate ground for recovery to include each resident who suffers directly because of the violation; 4. and adds subsection (d) to define "affiliate". Section 1.15 amends 242.066 relating to administrative penalties with changes to the provisions of law contained in Section 1.12 of the original bill. These changes include the elimination of administrative penalties against persons acting without a license due to lack of jurisdiction, the reduction of maximum penalties from $25,000 a day per violation to $15,000 per day per violation, with the minimum penalty established at $500. Section 1.16 adds a new section 242.0665 with changes to the provisions of law contained in Section 1.13 of the original bill. These changes include a reduction in the amount of time given an institution to correct certain violations from 60 days to 30 days. The fines for violations of this section were reduced from a maximum of $75,000 per day per violation to $30,000 per day per violation, with the minimum fines set at $500. Section 1.18 This section amends 242.067 with changes to the provisions contained in Section 1.15 of the original bill. These changes include shifting the burden of developing a plan of correction on the institution rather than the department, clarifying that an institution has 20 days consent to the report of violation, request a hearing or submit a plan of correction, deletes the default hearing in (g)(2) Section 242.069 is amended, with changes from the provisions in Section 1.15 of the original bill that streamlines the collection of administrative penalties by eliminating a process for staying the enforcement of a penalty. Section 242.070 is amended with changes from the provisions deleted in Section 1.15 of the original bill. These changes include language that prevents the department from pursuing two separate penalties under this Chapter and Chapter 32 of the Human Resource Code for a violation arising out of the same act or failure to act unless a facility violates contractual obligations under Chapter 32 of the Human Resource Code. Section 1.19 adds new section 242.072 relating to the recovery of costs by the attorney general. This Section also adds 242.073 with changes to the provisions contained in Section 1.16 of the original bill. These changes includes the elimination of the requirement for notice and hearing prior to the suspension of admissions while requiring the department to provide the institution with an opportunity for a hearing within 14 days of the effective date of the suspension. This Section also adds new section 242.074, Health and Safety Code, authorizing the Attorney General to conduct additional investigations and defining under which circumstances those investigations may be conducted. New section 242.075 authorizes a demand for a civil investigation and defines the parameters of such, including disclosure and procedure involved with documentary material, the delivery of a civil investigation demands, and the role of the Attorney General. New section 242.076 prohibits an institution from using, in any action brought by the department or the Attorney General, any evidence withheld from the department or the Attorney General during an inspection or investigation under this chapter if the evidence was requested by the department or the attorney general and is not privileged under the law of this state. Section 1.20 amends 242.096(e) Health and Safety Code, by raising the threshold amount of the nursing and convalescent trust fund to $500,000. Section 242.096 (e) is not addressed in the introduced version. Section 1.21 amends section 242.097 (a) and (b), Health and Safety Code, by increasing the nursing and convalescent home trust fund threshold to $500,000. Section 242.097 is not addressed in the introduced version. Section 1.22 adds new section 242.1225 with changes to the provisions contained in Section 1.17 of the original bill. These changes include the requirement that the department establish rules to report require the reporting of conditions in institutions causing exploitation or injury and other conditions as required by the department. Section 1.23 amends section 242.126 with changes to the provisions contained in Section 1.20 in the original bill. These changes include changing the two hour response time to 24 hours, elimination of the initial status report, elimination of the 45 day period for the completion of the written investigation report, requiring the department to adopt rules governing the conduct of investigations. Section 1.24 amends 242.127 with changes to the provisions contained in Section 1.21 of the original bill. These changes provide that working papers and related records used or developed in an investigation are confidential in the same manner as under current law and regulation. Section 1.25 amends 242.133(a) with changes from the version provided in Section 1.22 of the original bill. These changes broaden the prohibition against retaliation. Section 1.26 amends 242.1335(a) with changes from the version provided in Section 1.23 of the original bill. These changes broaden the prohibition against retaliation. Section 1.28 amends 242.253(c) which was not amended in the original bill . Section 1.29 amends 242.068 with changes from the provisions provided under Section 1.25 of the original bill. These changes include additional limitations on the use of arbitration. Section 1.30 provides new subchapters of the Health and Safety Code with changes from the version provided under Section 1.26 of the original bill. These changes include clarification of terminology in 242.151, removing specific nurse to resident ratio replaced with a new standard applicable to nursing and related services, changes to 242.156 to avoid conflict with federal law, elimination of prescriptive language in 242.403 providing the department with broader rule-making authority, changes to 242.501 relating to the rights of residents to eliminate reference to Chapter 102 of the Human Resources Code, changes to 242.504 to eliminate the posting of a notice on all doors of the institution relating to violations of resident rights while making such information available to the public at the institution. Other changes include the elimination of 242.555 contained in the original bill , changes to 242.611 delete existing law relating to fees appropriated back to the department to defray only the costs incurred under this section. Section 1.31 amends section 222.0255, Health and Safety Code, with changes to the provisions provided in Section 1.27 of the original bill. These changes include the elimination of separate rules for licensure and certification. Section 2.01 is changed to remove the fair rental value reimbursement system, and to reinstate arbitration of monetary penalties assessed under the Human Resources Code.