Subchapter J: Foster Care Services - Medical and Dental

Division 1: Medical and Dental Care

§749.1401. What general medical requirements must my agency meet?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) A child in your care must receive medical care:

Initially, according to the requirements in §749.1151 of this title (relating to What are the medical requirements when I admit a child into care?) [Medium-High];
As needed for injury, illness, and pain [High]; and
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]:

A copy of the results of the medical examination [Medium];
The follow-up treatment recommended and any appointments scheduled [Medium];
A notation of the child's refusal to accept medical treatment, if applicable [Medium];
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
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]

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.

§749.1403. Who determines the need and frequency for ongoing maintenance of medical care and treatment for a child?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental 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]

§749.1405. Who must perform medical care examinations and provide medical treatment for a child?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental 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 care examinations and provide medical treatment for a child. [Medium-High]

§749.1409. What general dental requirements must my agency meet?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) A child in your care must receive dental care:

Initially, according to the requirements in §749.1153 of this title (relating to What are the dental requirements when I admit a child into care?) [Medium];
At as early an age as necessary [Medium];
As needed for relief of pain and infections [Medium-High]; and
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]:

A copy of the results of the dental examination. [Medium-Low]
Follow-up treatment recommended and any appointments scheduled [Medium-Low]; and
A notation of the child's refusal to accept dental treatment, if applicable. [Medium-Low]

(d) You must obtain follow-up dental work indicated by the examination, such as treatment of cavities and cleaning. [Medium-High]

§749.1411. Who must determine the frequency and need for ongoing maintenance of dental health for a child?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2007

A licensed dentist must determine the frequency and need for ongoing maintenance of dental health for a child. You must comply with dentist recommendations for examinations and treatment for each child. [Medium]

§749.1413. Who must perform dental examinations and provide dental treatment?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2007

A health-care professional licensed in the United States to practice dentistry must provide dental care. [Medium]

§749.1415. What health precautions must I take if a person in care, employee, caregiver, someone else in one of my foster homes, or someone else in my agency has a communicable disease?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) You must notify the Department of State Health Services (DSHS) after you become aware that a person in your care, an employee, a contract service provider, a caregiver, someone else in one of your foster homes, 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 has symptoms of a communicable disease that is reportable to the DSHS, you must:

Consult a health-care professional about the person's treatment [Medium-High];
Follow the treating physician's orders, which may include separating the person from others [Medium-High];
Notify the person's parent, if applicable [Medium-Low]; and
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 with a communicable disease that is reportable to DSHS, a health-care professional must authorize the person's participation in any routine activities at the foster home. The authorization must [Medium-High]:

Be in the person's record [Medium];
Include a written statement that the person will not pose a serious threat to the health of others [Medium]; and
Include any specific instructions and precautions to be taken for the protection of others, if necessary. [Medium]

(d) If an employee, a contract service provider, a caregiver, someone else in one of your foster homes, or a volunteer has a communicable disease that is reportable to Department of State Health Services (DSHS), you must obtain written authorization from a health-care professional for the person to be present at the agency or foster home. The written authorization must include a statement that the person will not pose a serious threat to the health of 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.

§749.1417. Who must have a tuberculosis (TB) examination?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
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 (CDC) within 30 days before or after beginning to live, work, or volunteer at your operation unless the person [Medium]:

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
Provides documentation of a tuberculosis screening.

(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:

The person's baseline screening shows positive,

The result shows a mycobacterium tuberculosis infection, or

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.

§749.1421. What immunizations must a child in my care have?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) Each child that you admit must meet and continue to meet 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]:

Be completed by the date of admission; or
Begin within 30 days after admission.

Technical Assistance

The current immunization requirements can be found at http://www.immunizetexas.com, 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".

§749.1423. What exemptions or exceptions are there concerning immunization requirements?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) A child may be exempt from immunization requirements for a medical reason and 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]:

§42.043(d) and (d-1) of the Human Resources Code; or
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 the 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).

Technical Assistance

You can find more information regarding the Department of State Health Services' exemptions at http://www.dshs.state.tx.us/immunize/default.shtm, 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 a CPA, these exemptions may not comply with the school exemption requirements.

§749.1425. What documentation is acceptable for an immunization record?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

Acceptable documentation includes:

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
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]

§749.1427. Must children in my care have a vision and hearing screening?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental 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]

(b) For each child required to be screened, you must keep one of the following in each child's record [Medium-Low]:

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;
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 agency. The statement must be dated and include the name, address, and telephone number of the program or school; or
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: www.dshs.state.tx.us/vhs/.

§749.1429. What must I do if a child in my care is identified as needing a diagnostic vision or hearing examination?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2007

You must:

Schedule the child for professional examination and needed health services [Medium];
Ensure the professional and medical recommendations are carried out [Medium]; and
Convey the information concerning the child's visual and/or hearing difficulty to the educational and agency caregivers, so the recommended adjustments can be made in programs. [Medium]

§749.1431. What special equipment must I provide for a child with a physical disability?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2007

When recommended by a physician or other health-care professional, you must ensure that a child with a physical disability has any special equipment recommended that can be reasonably obtained. [Medium-High]

§749.1433. How often must the physician review a child's primary medical needs?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2017

(a) A licensed physician must review a child's primary medical needs:

At least every 90 days or on a schedule recommended by the child's physician [Medium-High]; and
Whenever a medical or related problem occurs. [Medium-High]

(b) The review must address:

Whether the child can continue to be cared for appropriately in the foster home [Medium-High]; and
Any new or changed orders regarding the items outlined in §749.1135 of this title (relating to What are the additional admission requirements when I admit a child for treatment services?). [Medium-High]

§749.1435. What are the requirements for using a nasogastric tube?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental Care
January 2007

(a) Only the following may insert a nasogastric tube [High]:

A physician;
A licensed nurse according to a physician's written orders; or
A caregiver instructed by a licensed nurse according to a physician's written orders.

(b) The caregiver must document each insertion in the child's record. The documentation for each insertion must include the [Medium]:

Signature of the nurse or caregiver who inserted the tube [Medium]; and
Date of the insertion. [Medium]

§749.1437. How must a caregiver respond when a child is injured or ill and requires immediate treatment by a health-care professional?

Subchapter J, Foster Care Services: Medical and Dental
Division 1, Medical and Dental 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]

Division 2: Administration of Medication

§749.1461. What consent must I obtain to administer medications?

Subchapter J, Foster Care Services: Medical and Dental
Division 2, Administration of Medication
January 2007

(a) You must obtain a general written consent to administer routine, preventive, and emergency medications. [Medium]

(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 §749.1603 of this title (relating to If my agency 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 §749.1605 of this title (relating to If my agency does not employ or contract with the 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?). [Medium]

§749.1463. What are the requirements for administering prescription medication?

Subchapter J, Foster Care Services: Medical and Dental
Division 2, Administration of Medication
January 2017

(a) To the best of their knowledge, caregivers 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. [Medium]

(b) For prescription medications, caregivers must:

Be informed about possible side effects of medications administered to the child [High];
Store all medication in the original container unless the caregiver has an additional container with the same label and instructions [Medium-High];
Administer all medications according to the instructions on the label or according to a prescribing health-care professional's subsequent signed orders [Medium-High];
Administer each child's medication within one hour of preparation [Medium-High];
Ensure the child has taken the medication as prescribed [High];
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];
Maintain any documentation provided by the health-care professional on the administration of current medication [Medium];
Not physically force a child to take medication [High];
Ensure that a child is not given any medication or treatment except on written orders of a health-care professional [High];
Not borrow or administer medication to a child that is prescribed to another person [High]; and
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. [High]

§749.1469. What are the requirements for administering non-prescription medication and supplements?

Subchapter J, Foster Care Services: Medical and Dental
Division 2, Administration of Medication
April 2022

(a) For non-prescription medications and supplements, you must:

Follow the label instructions for dosage [High]; and
Ensure that the non-prescription medication or supplement is not contraindicated with any other medication prescribed for the child or medical condition that the child has. [Medium-High]

(b) You may give non-prescription 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 3: Self-Administration of Medication

§749.1501. What are the requirements for a self-medication program?

Subchapter J, Foster Care Services: Medical and Dental
Division 3, Self-Administration of Medication
September 2010

For a child to be on a self-medication program:

The child's parent must give written authorization for the child to be on the program [Medium];
The child's service plan must include the self-medication program and any requirements for caregiver supervision [Medium]; and
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]

§749.1503. Who must record the medication dosage if the child is on a self-medication program?

Subchapter J, Foster Care Services: Medical and Dental
Division 3, Self-Administration of Medication
January 2017

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]:

Records the daily dosage; or
Reports the medication to a caregiver, who must then do the actual daily recording.

Division 4: Medication Storage and Destruction

§749.1521. What medication storage and destruction requirements must a foster home meet?

Subchapter J, Foster Care Services: Medical and Dental
Division 4, Medication Storage and Destruction
January 2017

A foster home must:

Store medication in a locked container [High];
Keep medication inaccessible other than to caregivers responsible for stored medication [High];
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 [High];
Make provisions for storing medication that requires refrigeration [Medium-High];
Keep medication storage area(s) clean and orderly [Medium];
Remove discontinued medication immediately and store it in a separate locked area until it is destroyed within 30 days [Medium-High];
Remove medication on or before the expiration date and store it in a separate locked area until it is destroyed within 30 days [Medium-High];
Remove medication of a discharged or deceased child immediately and store it in a separate locked area until it is destroyed within 30 days [Medium-High]; and
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]

Division 5: Medication Records

§749.1541. What records must caregivers maintain for each child receiving medication?

Subchapter J, Foster Care Services: Medical and Dental
Division 5, Medication Records
January 2017

(a) Caregivers must maintain a cumulative medication record of all [Medium-High]:

Prescription medication dispensed to each child; and
Nonprescription medications and supplements that are dispensed to a child under five years old.

(b) The cumulative medication record must be updated within 24 hours of administering medication. [Medium]

Child's full name [Medium-High];
Prescribing health-care professional's name, if applicable [Medium];
Reason medication was prescribed, for prescription medication [Medium];
Medication name, strength, and dosage [Medium-High];
Date (day, month, and year) and the time the medication was administered [Medium-High];
Name and signature of the person who administered the medication [Medium];
Child's refusal to accept medication, if applicable [Medium]; and
Reasons for administering the medication, including the specific symptoms, condition, and/or injuries of the child that the caregiver is treating, only for [Medium-High]:
- A. PRN psychotropic medication; and
- B. Nonprescription medications and supplements for children under five years old.

(d) Caregivers must document in the medication record each non-prescription medication or supplement that is given to the child and how often the child receives the medication or supplement. [Medium]

(e) Caregivers must document any prohibited prescription medications (for example, medication allergies or contraindications) or prohibited nonprescription medications and supplements in the medication record. [Medium-High]

(f) 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.

§749.1543. Where must a child's medication records be maintained?

Subchapter J, Foster Care Services: Medical and Dental
Division 5, Medication Records
September 2010

(a) The foster parents must maintain at the foster home the child's medication records for the current month. [Medium-Low]

(b) Foster parents must submit copies of the child's medication records to you each month. You must file these medication records in the child's record. [Medium-Low]

(c) You must maintain copies of all the child's medication records for the length of time that you provide services to the child. [Medium-Low]

§749.1545. What other requirements must I meet regarding medication records?

Subchapter J, Foster Care Services: Medical and Dental
Division 5, Medication Records
January 2007

You must make suitable forms available to caregivers for maintaining adequate records of all medications administered to a child. [Low]

Division 6: Medication and Label Errors

§749.1561. What is a medication error?

Subchapter J, Foster Care Services: Medical and Dental
Division 6, Medication and Label Errors
January 2007

A medication error includes, but is not limited to, the following:

A child receives the wrong medication;
A child receives medication prescribed to someone else;
A child receives the wrong dosage of medication;
A child receives medication at the wrong time;
A medication dose is skipped or missed;
A child receives expired medication;
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
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.

§749.1563. What must a caregiver do if the caregiver finds a medication error?

Subchapter J, Foster Care Services: Medical and Dental
Division 6, Medication and Label Errors
January 2007

(a) If a caregiver finds a medication error regarding a prescribed medication, the caregiver must contact a health-care professional immediately, unless the error is the type described in paragraph (4) or (5) of §749.1561 of this title (relating to What is a medication error?), and follow the health-care professional's recommendations. [Medium-High]

(b) If a caregiver finds a medication error regarding a nonprescription medication, the caregiver must take the appropriate and necessary actions as required by the circumstances. [Medium-High]

The time and date of the error [Medium-High];
The medication error [Medium-High];
The time and date of the call(s) to the licensed health-care professional, if applicable [Medium-High];
The name and title of the health-care professional contacted, if applicable [Medium-High]; and
The health-care professional's medical recommendations for ensuring the child's safety, if applicable. [Medium-High]

§749.1565. What must a caregiver do if the caregiver finds a medication label error?

Subchapter J, Foster Care Services: Medical and Dental
Division 6, Medication and Label Errors
January 2007

If a caregiver finds a medication label error, the caregiver must:

Report the error to the pharmacist [Medium]; and
Have the label on the medication container corrected as soon as possible but no later than the next business day. [Medium]

Division 7: Side Effects and Adverse Reactions to Medication

§749.1581. What must caregivers do if a child has an adverse reaction to a medication?

Subchapter J, Foster Care Services: Medical and Dental
Division 7, Side Effects and Adverse Reactions to Medication
January 2017

If a child has an adverse reaction (unexpected or dangerous reaction) to a medication, the caregiver must:

Immediately report the reaction to a health-care professional and the child's parent [High];
Follow the health-care professional's recommendations [High];
Seek further medical care for the child if the child's condition appears to worsen [High]; and
Document in the child's medical record the [Medium-High]:
- 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]

§749.1583. What must a caregiver do if a child experiences side effects from any medications?

Subchapter J, Foster Care Services: Medical and Dental
Division 7, 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, the caregiver must:

Document the observed and reported side effects [Medium-High];
Immediately report any serious side effects to the child's prescribing health-care professional and the child's parent [Medium-High]; and
Report any other side effect to the prescribing health-care professional within 72 hours. [Medium-High]

Division 8: Use of Psychotropic Medication

§749.1603. If my agency 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 J, Foster Care Services: Medical and Dental
Division 8, 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:

The child's diagnosis [Medium-High];
The nature of the child's mental illness or condition [Medium-High];
An explanation of the purpose of the medication [Medium-High];
A description of the benefits expected [Medium];
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];
A statement of whether the medication is habituating in nature [Medium-High];
Alternative interventions to the use of psychotropic medication that have been attempted and that have been unsuccessful [Medium-High];
Other alternative treatments or procedures to the use of the psychotropic medication [Medium-High];
Risks and benefits of the alternative treatments or procedures [Medium-High];
Risks and benefits of not receiving or undergoing a treatment or procedure [Medium-High];
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
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]

§749.1605. If my agency does not employ or contract with the 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 J, Foster Care Services: Medical and Dental
Division 8, 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:

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:
- 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]
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]
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]

§749.1607. What are the requirements if a physician orders administration of a psychotropic medication to a child in an emergency?

Subchapter J, Foster Care Services: Medical and Dental
Division 8, 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]

§749.1609. What information must be documented about a child's use of psychotropic medication?

Subchapter J, Foster Care Services: Medical and Dental
Division 8, Use of Psychotropic Medication
January 2007

(a) You must ensure that caregivers maintain a daily record of the child's use of such medication according to the requirements in §749.1541 of this title (relating to What records must caregivers maintain for each child receiving medication?). [Medium-High]

(b) Caregivers must document in the child's record a description of any noticeable change in the child's behavior in response to the medication. [Medium]

(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]

§749.1611. If my agency 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 J, Foster Care Services: Medical and Dental
Division 8, 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 on at least a quarterly basis. 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 the health-care professional does not substantiate effectiveness. A copy of the written rationale must be documented in the child's record. [Medium-High]

Division 9: Protective Devices

§749.1641. What is a protective device?

Subchapter J, Foster Care Services: Medical and Dental
Division 9, Protective Devices
September 2010

(a) A protective device:

Protects a person from involuntary self-injurious behavior or permits wounds to heal; and
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.

§749.1643. What does "involuntary self-injurious behavior" mean when used in this division?

Subchapter J, Foster Care Services: Medical and Dental
Division 9, 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.

§749.1645. May I use protective devices?

Subchapter J, Foster Care Services: Medical and Dental
Division 9, 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. [High]

(b) You may not use protective devices as:

Punishment [High];
Retribution or retaliation [High];
A means to get a child to comply [High];
A convenience for caregivers or other persons [High]; or
A substitute for effective treatment or habilitation. [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-High]:

Clinical justification for continued use of protective devices [Medium-High]; and
Ways to reduce the need for protective devices. [Medium-High]

§749.1647. Who may use PRN orders with respect to protective devices?

Subchapter J, Foster Care Services: Medical and Dental
Division 9, 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]

Division 10: Supportive Devices

§749.1671. What is a supportive device?

Subchapter J, Foster Care Services: Medical and Dental
Division 10, Supportive Devices
January 2007

(a) A supportive device used:

To support a person's posture;
To assist a person who cannot obtain and/or maintain normal physical functioning to improve his mobility and independent functioning; or
As an adjunct to proper care and treatment, for example physical therapy.

(b) The purpose of a supportive device is not to restrict movement.

§749.1673. May I use supportive devices?

Subchapter J, Foster Care Services: Medical and Dental
Division 10, 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. [High]

(b) You may not use a supportive device as a substitute for appropriate nursing care. [High]

(c) You may not use supportive devices that include tying or depriving or limiting the use of a child's hands or feet. [High]

(d) You may not use supportive devices as:

Punishment [High];
Retribution or retaliation [High];
Means to get a child to comply [High];
A convenience for caregivers or other persons [High]; or
A substitute for effective treatment or habilitation. [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]

(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 reviews [Medium-High]:

Clinical justification for continued use of supportive devices [Medium-High]; and
Ways to reduce the need for supportive devices. [Medium-High]

§749.1675. Who may use PRN orders with respect to supportive devices?

Subchapter J, Foster Care Services: Medical and Dental
Division 10, 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]

Subchapter K: Foster Care Services - Daily Care, Problem Management

Division 1: Additional Requirements for Infant Care

§749.1801. What do certain words mean in this division?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
April 2022

These words have the following meanings in this division:

Baby bungee 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.
Baby walker – A baby walker allows an infant to sit inside the walker equipped with rollers or wheels and move across the floor.
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.
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 highchairs.

§749.1803. What are the basic care requirements for an infant?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2017

(a) Each infant must receive individual attention, including playing, talking, cuddling, and holding. [Medium-High]

(b) A caregiver must provide prompt attention to an infant's physical needs, such as feeding and diapering. [Medium-High]

(c) An infant's caregiver must ensure that the environment is safe. For example, 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]

(d) Items necessary for diaper changing must be kept out of the reach of children, but do not need to be in locked storage. [Medium]

(e) An infant's caregiver must never leave the infant unsupervised [High]:

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; and
An awake infant is considered supervised if the caregiver is within eyesight of the infant and is close enough to the infant to intervene as needed. For short periods of time in the course of routine household activities, the infant may be out of the caregiver's eyesight, as long as the:
- A. Infant is within hearing range;
- B. Infant's environment is free of any safety hazards; and
- C. Caregiver is able to intervene immediately, as needed.

Technical Assistance

Best practice for infant care suggests:

Care by the same caregiver on a regular basis, when possible;

Holding and comforting an infant who is upset; and

Talking to infants as they are fed, changed, and held, such as naming objects, singing, or saying rhymes.

When changing diapers, best practice suggests:

Promptly change soiled or wet diapers or clothing;

Thoroughly cleanse infants with individual cloths or disposable towels. Discard disposable towels after use and launder any cloths before using them again;

Ensure that the infant is dry before placing a new diaper on the infant. If the infant must be dried, use a clean, individual cloth or disposable towel to dry the infant. Launder the individual cloth before using it again or discard the disposable towel after its use;

Keep all diaper-changing supplies, including ointments and wipes, out of children's reach;

Wash the infant's hands or see that the infant's hands are washed after each diaper change;

Discard disposable gloves after each diaper change; and

Cover containers used for soiled diapers or keep them in a sanitary manner, such as placing soiled diapers in individual sealed bags.

§749.1805. What furnishings and equipment must I have in an infant care area?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2007

An infant care area must at a minimum include the following furnishings and equipment:

An individual crib for each infant [Medium]; and
A sufficient number of toys to keep each child engaged in activities. [Medium-Low]

§749.1807. What specific safety requirements must my cribs meet?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2007

(a) All cribs must have:

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];
Sheets that fit snugly and do not present an entanglement hazard [Medium-High];
A mattress that is waterproof or washable [Medium];
Secure mattress support hangers, and no loose hardware or improperly installed or damaged parts [Medium-High];
A maximum of 2 3/8 inches between crib slats or poles [Medium-High];
No corner posts over 1/16 inch above the end panels [Medium-High];
No cutout areas in the headboard or footboard that would entrap a child's head or body [High]; and
Drop rails, if present, which fasten securely and cannot be opened by a child. [Medium-High]

(b) Caregivers must sanitize each crib when soiled and before reassigning the crib to a different child. [Medium-High]

(d) The foster home must not have stackable cribs. [Medium-High]

§749.1809. Are mesh cribs or port-a-cribs allowed?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2007

A foster home may use a full-size, portable, or mesh-side crib if:

Caregivers follow the manufacturer's instructions [Medium];
The crib has:
- A. Mesh that is securely attached to the top rail, side rail, and floor plate [Medium-High]; and
- B. Folded sides that securely latch in place when raised [Medium-High];
Caregivers never leave a child in a mesh-sided crib with a side folded down [Medium-High]; and
If you become aware of a recall for the port-a-crib used, you must discontinue its use. [Medium-High]

Technical Assistance

It is a good idea for the crib to have:

A minimum height of 22 inches from the top of the railing to the mattress support at its lowest level; and

Mesh openings that are 1/4 inch or less.

§749.1811. What equipment must have safety straps before I can use it with an infant?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2007

(a) A high chair, swing, stroller, infant carrier, rocker, bouncer seat, or a similar type of equipment that a foster home uses for an infant must be equipped with safety straps [Medium-High]; and

(b) The safety straps must be fastened whenever the infant is using the equipment. [Medium-High]

§749.1813. What types of equipment may a foster home not use with infants?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2017

(a) A foster home may not use any of the following types of equipment with infants:

Baby walkers [Medium-High];
Baby bungee jumpers [Medium-High];
Accordion safety gates [Medium-High]; and
Toys that are not large enough to prevent swallowing or choking [High];
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]

Be designed specifically for the size and type of crib and crib mattress that it is being used with [Medium-High];
Be tight fitting and thin [Medium-High]; and
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]

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 (a)(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 (a)(2), baby bungee jumpers present a hazard due to increased risk of injury to the infant as a result of spinning, swinging, or bumping into walls while placed in the jumper.

Regarding paragraph (a)(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 infants who try to crawl through or over the gate.

Regarding paragraph (a)(4), examples of items that present a choking hazard for infants and toddlers include coins, balloons, safety pins, marbles, Styrofoam © and similar products, and sponge, rubber or soft plastic toys.

Regarding subsection (b), 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.

§749.1815. What are the specific sleeping requirements for infants?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2017

(a) Caregivers 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]

§749.1817. May I allow an infant to sleep in a restrictive device?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
April 2021

You may not allow an infant to sleep in a restrictive device. If an infant falls asleep in a restrictive device, you must remove the infant from the device and place the infant in a crib as soon as possible. [High]

Technical Assistance

A restrictive device is equipment that places the body of an infant in a position that may restrict air flow or cause strangulation; usually, the infant is placed in a semi-seated position. Examples include car seats, swings, bouncy seats, and high chairs.

Infants sleeping in restrictive devices are at risk for injury and positional asphyxiation.

Placing a car seat containing a sleeping infant in a crib is one example of prohibited use of a restrictive device.

Allowing a sleeping infant to remain in a car seat during transportation is not an example of prohibited use of a restrictive device.

§749.1819. What are the specific requirements for feeding an infant?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, Additional Requirements for Infant Care
January 2017

(a) Caregivers must feed an infant based on the recommendations of the infant's licensed health-care professional. [Medium]

(b) Unless recommendations from the service team are contrary, caregivers must hold the infant while feeding an infant that is [Medium]:

Birth through six months old [Medium-High]; or
Unable to sit unassisted in a high chair or other seating equipment during feeding. [Medium]

(d) A caregiver who cares for more than one infant must:

Sterilize shared bottles or training cups between uses by different infants [Medium]; and
Clean high chair trays before each use. [Medium]

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 infants no longer being held for feeding are fed in a safe manner.

§749.1821. May I swaddle an infant to help the infant sleep?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 1, 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.

Division 2: Additional Requirements for Toddler Care

§749.1841. What are the basic care requirements for a toddler?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 2, Additional Requirements for Toddler Care
September 2010

(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, 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 toddler is considered supervised if the caregiver is within eyesight or hearing range of the child and can intervene as needed, or if the caregiver uses a video camera or an audio monitoring device to monitor the child and is close enough to the child to intervene as needed. [High]

Technical Assistance

Best practice for toddler care suggests:

Care given by the same caregiver on a regular basis, when possible;

Individual attention given to each toddler including playing, talking, and cuddling; and

Holding and comforting a toddler who is upset.

Best practice suggests that furnishings and equipment for toddlers include the following:

Age-appropriate seating, tables, and nap or sleep equipment;

Enough popular items available so that toddlers are not forced to compete for them; and

Make items accessible to toddlers by using containers or low shelving, so the items may be used safely and without direct supervision.

Best practices for nap or rest time include the following:

Schedule a supervised sleep or rest period after the noon meal for toddlers according to the child's individual physical needs;

Lighting should allow for visual supervision of the toddlers;

Limit the sleep or rest period to no more than three hours;

Do not force toddlers to sleep and do not put anything in or on a toddler's head or body to force the toddler to rest or sleep;

Allow each toddler 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 toddler awakens.

Division 3: Additional Requirements for Pregnant Children

§749.1861. What information must I provide a pregnant child regarding her pregnancy?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 3, Additional Requirements for Pregnant Children
September 2010

You must:

Ensure information, training, and counseling is available regarding health aspects of pregnancy, preparation for child birth, and recovery from child birth [Medium];
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
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]

§749.1863. Is the use of emergency behavior intervention of a pregnant child permitted in a foster home?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 3, Additional Requirements for Pregnant Children
January 2017

If your policies allow for the use of personal restraints and you have a pregnant child in care:

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
You may not use any emergency behavior intervention that the child's health-care professional attending to her pregnancy finds inadvisable. [High]

§749.1865. If my policies permit the admission of adolescent parents with their child(ren), who is responsible for the care of an adolescent's child?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 3, Additional Requirements for Pregnant Children
January 2007

If your policies permit the admission of adolescent parents with their child(ren):

An adolescent parent must provide most of the care for her child [Medium];
Caregivers must be available to the adolescent parent as a resource and support [Medium-High]; and
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]

Division 4: Educational Services

§749.1891. What responsibilities do I have for the education of a child in care?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 4, Educational Services
January 2017

(a) You must arrange an appropriate education for each child, including:

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, or the Texas Private School Accreditation Commission, unless the child's service planning team approves the child attending another educational facility or program. You must keep documentation of the planning team's justification and approval in the child's record [Medium-Low];
Ensuring a school-age child receives education and training in the least restrictive setting necessary to meet the child's needs and abilities [Low];
For a child attending an accredited educational facility or program, ensuring the facility or program implements a special education student's individual education plan (IEP) [Medium-Low]; and
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]

§749.1893. What responsibilities do caregivers have for the educational needs of a child in their care?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 4, Educational Services
April 2022

Caregivers must:

Review report cards and other information received from teachers or school authorities with the child and provide necessary information to agency staff [Medium-Low];
Counsel and assist the child regarding adequate classroom performance [Medium-Low];
Permit, encourage, and make reasonable efforts to involve the child in extracurricular activities as determined by a reasonable and prudent parent standard and to the extent of the child's interests and abilities and in accordance with the child's service plan [Low];
Provide a quiet, well-lighted space for the child to study and allow regular times for homework and study [Medium-Low];
Know what emergency behavior interventions are permitted and being used with the child [Medium];
Request ARD (admission, review, and dismissal), IEP (individual education plan), and ITP (individual transitional planning) meetings if concerned with the child's educational program or if the child does not appear to be making progress [Medium-Low];
Provide notice to the parent of the child of any scheduled ARD, IEP, or ITP meetings [Medium-Low];
Attend ARD, IEP, ITP meetings, other school staffings, and conferences to represent the child's educational best interests, including the child being evaluated for and provided with services needed for the child to benefit from educational services, and positive behavior supports designed to decrease the need for negative disciplinary techniques or interventions [Medium-Low]; and
Know what is in the child's IEP and support the school's efforts to implement the IEP, if applicable. [Medium-Low]

§749.1895. What are the specific requirements for the educational program of a child diagnosed with an autism spectrum disorder?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 4, Educational Services
January 2017

You must ensure that the educational program for a child with an autism spectrum disorder:

Encourages normalization through appropriate stimulation and by encouraging self-help skills [Medium-Low]; and
Is appropriate to the child's intellectual and social functioning. [Medium-Low]

Division 5: Recreational Services

§749.1921. What responsibilities do foster parents have for providing a child with opportunities for recreational activities?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 5, Recreational Services
January 2017

(a) Caregivers 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) Except for written medical orders to the contrary, your programs for non-ambulatory children must include:

Physical fitness development that prescribes a variety of body positions [Medium]; and
Changes in environment. [Medium-Low]

(d) Caregivers must provide the following types of recreational activities based on each individual child's needs:

Types of Service	The caregivers must:
(1) Child-care services	(A) Ensure that opportunities to participate in community activities, such as school sports or other extracurricular school activities, religious activities, or local social events, are available to the child [Low]; and (B) Organize family activities, religious activities, or local social events that are available to the child. [Low]
(2) Treatment services	(A) Meet the requirements in paragraph (1)(A) of this chart [Low]; (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]

Types of Service

The caregivers must:

(1) Child-care services

(A) Ensure that opportunities to participate in community activities, such as school sports or other extracurricular school activities, religious activities, or local social events, are available to the child [Low]; and (B) Organize family activities, religious activities, or local social events that are available to the child. [Low]

(2) Treatment services

(A) Meet the requirements in paragraph (1)(A) of this chart [Low]; (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]

Technical Assistance

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.

§749.1923. What physical fitness activities must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 5, Recreational Services
January 2017

(a) A child receiving treatment services for primary medical needs or intellectual disability must have a minimum of one hour of physical stimulation each day. [Medium]

(b) Training programs for non-mobile children must include development of physical fitness. This must include a variety of body positions and changes in environment. [Medium]

§749.1925. What type of daily schedule must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 5, Recreational Services
January 2017

A child receiving treatment services for primary medical needs or intellectual disability must have a schedule that is based on the normalization principle. In order to help the child obtain an existence as normal as possible, the daily schedule must [Medium-Low]:

Demonstrate an understanding of normal child development [Medium-Low]; and
Enhance the child's physical, emotional, and social development. [Medium]

§749.1927. To what extent must a child receiving treatment services for primary medical needs or intellectual disabilities have normal life experiences?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 5, Recreational Services
December 2014

A child receiving treatment services for primary medical needs or intellectual disabilities should experience normalcy as much as possible and as appropriate for the child's special needs. This means that the child's foster parents must be routinely and personally involved with the child. This involvement must include [Medium]:

Daily one-on-one interaction between the child and the foster parent primarily responsible for the child's care [Medium];
Participation in everyday family activities to the extent the child is able, such as having meals together, participating in family time, and participating in family outings [Medium];
Sensory stimulation for the child, such as the child being held, being read to, being played with, and being talked to, and the foster family watching television and listening to music together [Medium];
Actively participating in the child's medical care, including appointments and hospitalizations [Medium]; and
Actively participating in the child's educational needs. [Medium]

Division 6: Discipline and Punishment

§749.1951. What are the requirements for disciplinary measures?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, 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:

Be consistent with your policies and procedures [Medium];
Not be physically or emotionally damaging to the child [High];
Be individualized to meet each child's needs [Medium];
Be appropriate to the child's level of understanding, age, and developmental level [Medium-High]; and
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]

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.

§749.1953. May I use corporal punishment for children in care?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, 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 means of controlling or managing the child's behavior. It includes:

Hitting or spanking a child with a hand or instrument; or
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
- C. Do any form of "unproductive work."

§749.1955. What is "unproductive work"?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, 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 an acceptable behavior management tool.

§749.1957. What other methods of punishment are prohibited?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, Discipline and Punishment
April 2022

In addition to corporal punishment, prohibited discipline techniques include, but are not limited to:

Any harsh, cruel, unusual, unnecessary, demeaning, or humiliating discipline or punishment [High];
Denial of mail or visits with their families as discipline or punishment [Medium];
Threatening with the loss of placement as discipline or punishment [Medium];
Using sarcastic or cruel humor [Medium-High];
Maintaining an uncomfortable physical position, such as kneeling, or holding his arms out [Medium-High];
Pinching, pulling hair, biting, or shaking a child [High];
Putting anything in or on a child's mouth [High];
Humiliating, shaming, ridiculing, rejecting, or yelling at a child [Medium-High];
Subjecting a child to abusive or profane language [Medium-High];
Placing a child in a dark room, bathroom, or closet [High];
Requiring a child to remain silent or inactive for inappropriately long periods of time for the child's age [Medium-High];
Confining a child to a highchair, box, or other similar furniture or equipment as discipline or punishment [Medium-High];
Denying basic child rights as a form of discipline or punishment [High];
Withholding food that meets the child's nutritional requirements [High]; and
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.

§749.1959. To what extent may a caregiver restrict a child's activities as a behavior management tool?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, Discipline and Punishment
January 2017

(a) Within limits, a foster parent 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 14 days, must be reviewed with and approved by the child placement management staff or treatment director prior to or within 24 hours of imposing the restriction. [Medium-Low]

(c) Restrictions to a particular room or building that will be imposed on a child for more than 24 hours must have approval from the service planning team, a professional service provider, or treatment director prior to or within 24 hours of imposing the restriction. [Medium-Low]

(d) You must inform the child and parent about any such restrictions you place on the child. [Medium-Low]

(e) Documentation of all approvals, justification for the restriction, and informing the child and parents must be in the child's record. [Medium-Low]

§749.1961. May a person in care discipline or punish another person in care?

Subchapter K, Foster Care Services: Daily Care, Problem Management
Division 6, Discipline and Punishment
January 2017

No. A person in care must not discipline or punish another person in care except when babysitting under §749.2599 of this title (relating to Can a child serve as a babysitter?). [Medium-High]

Document Information:

Part: 6 of 13
Pages: 213-264 (52 pages)
Version: November 2025
Conversion Date: November 22, 2025
Source: Texas HHSC Chapter 749 - Minimum Standards for Child Placing Agencies

Related Parts:

Part 05: Foster Care Services - Admission and Service Planning
Part 07: Foster Care Services - Emergency Behavior Intervention
Part 08: Foster Homes - Screenings and Verifications

Section Coverage: This document covers comprehensive medical and dental care requirements, medication administration protocols, infant and toddler care standards, requirements for pregnant children, educational services, recreational activities, and discipline policies for Child Placing Agencies in Texas.

tac-749-part-06-foster-medical-care

Subchapter J: Foster Care Services - Medical and Dental

Division 1: Medical and Dental Care

§749.1401. What general medical requirements must my agency meet?

§749.1403. Who determines the need and frequency for ongoing maintenance of medical care and treatment for a child?

§749.1405. Who must perform medical care examinations and provide medical treatment for a child?

§749.1409. What general dental requirements must my agency meet?

§749.1411. Who must determine the frequency and need for ongoing maintenance of dental health for a child?

§749.1413. Who must perform dental examinations and provide dental treatment?

§749.1415. What health precautions must I take if a person in care, employee, caregiver, someone else in one of my foster homes, or someone else in my agency has a communicable disease?

§749.1417. Who must have a tuberculosis (TB) examination?

§749.1421. What immunizations must a child in my care have?

§749.1423. What exemptions or exceptions are there concerning immunization requirements?

§749.1425. What documentation is acceptable for an immunization record?

§749.1427. Must children in my care have a vision and hearing screening?

§749.1429. What must I do if a child in my care is identified as needing a diagnostic vision or hearing examination?

§749.1431. What special equipment must I provide for a child with a physical disability?

§749.1433. How often must the physician review a child's primary medical needs?

§749.1435. What are the requirements for using a nasogastric tube?

§749.1437. How must a caregiver respond when a child is injured or ill and requires immediate treatment by a health-care professional?

Division 2: Administration of Medication

§749.1461. What consent must I obtain to administer medications?

§749.1463. What are the requirements for administering prescription medication?

§749.1469. What are the requirements for administering non-prescription medication and supplements?

Division 3: Self-Administration of Medication

§749.1501. What are the requirements for a self-medication program?

§749.1503. Who must record the medication dosage if the child is on a self-medication program?

Division 4: Medication Storage and Destruction

§749.1521. What medication storage and destruction requirements must a foster home meet?

Division 5: Medication Records

§749.1541. What records must caregivers maintain for each child receiving medication?

§749.1543. Where must a child's medication records be maintained?

§749.1545. What other requirements must I meet regarding medication records?

Division 6: Medication and Label Errors

§749.1561. What is a medication error?

§749.1563. What must a caregiver do if the caregiver finds a medication error?

§749.1565. What must a caregiver do if the caregiver finds a medication label error?

Division 7: Side Effects and Adverse Reactions to Medication

§749.1581. What must caregivers do if a child has an adverse reaction to a medication?

§749.1583. What must a caregiver do if a child experiences side effects from any medications?

Division 8: Use of Psychotropic Medication

§749.1607. What are the requirements if a physician orders administration of a psychotropic medication to a child in an emergency?

§749.1609. What information must be documented about a child's use of psychotropic medication?

§749.1611. If my agency 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?

Division 9: Protective Devices

§749.1641. What is a protective device?

§749.1643. What does "involuntary self-injurious behavior" mean when used in this division?

§749.1645. May I use protective devices?

§749.1647. Who may use PRN orders with respect to protective devices?

Division 10: Supportive Devices

§749.1671. What is a supportive device?

§749.1673. May I use supportive devices?

§749.1675. Who may use PRN orders with respect to supportive devices?

Subchapter K: Foster Care Services - Daily Care, Problem Management

Division 1: Additional Requirements for Infant Care

§749.1801. What do certain words mean in this division?

§749.1803. What are the basic care requirements for an infant?

§749.1805. What furnishings and equipment must I have in an infant care area?

§749.1807. What specific safety requirements must my cribs meet?

§749.1809. Are mesh cribs or port-a-cribs allowed?

§749.1811. What equipment must have safety straps before I can use it with an infant?

§749.1813. What types of equipment may a foster home not use with infants?

§749.1815. What are the specific sleeping requirements for infants?

§749.1817. May I allow an infant to sleep in a restrictive device?

§749.1819. What are the specific requirements for feeding an infant?

§749.1821. May I swaddle an infant to help the infant sleep?

Division 2: Additional Requirements for Toddler Care

§749.1841. What are the basic care requirements for a toddler?

Division 3: Additional Requirements for Pregnant Children

§749.1861. What information must I provide a pregnant child regarding her pregnancy?

§749.1863. Is the use of emergency behavior intervention of a pregnant child permitted in a foster home?

§749.1865. If my policies permit the admission of adolescent parents with their child(ren), who is responsible for the care of an adolescent's child?

Division 4: Educational Services

§749.1891. What responsibilities do I have for the education of a child in care?

§749.1893. What responsibilities do caregivers have for the educational needs of a child in their care?

§749.1895. What are the specific requirements for the educational program of a child diagnosed with an autism spectrum disorder?

Division 5: Recreational Services

§749.1921. What responsibilities do foster parents have for providing a child with opportunities for recreational activities?

§749.1923. What physical fitness activities must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability?

§749.1925. What type of daily schedule must caregivers provide for a child receiving treatment services for primary medical needs or intellectual disability?