Administrative Rules Governing Telehealth and Telepractice in Texas

As of May 1, 2018, the Texas Commission of Licensing and Regulation (Commission) has adopted the rule changes proposed by the Texas Department of Licensing and Regulation (TDLR) Speech-Language Pathologists and Audiologists Advisory Board regarding the practice of Telehealth by Speech-Language Pathologists and Audiologists under 16 Texas Administrative Code (TAC), Chapter 111.

The following subchapters of 16 Texas Administrative Code (TAC), Chapter 111 specifically address telepractice:

  • Subchapter V:  Telepractice  (TAC §111. 210 – 111. 216)
  • Subchapter X:  Fitting and dispensing of hearing instruments by telepractice   (TAC § 111.230-111.232)
  • Subchapter F:  Requirements for assistant in speech-language pathology license-supervision via telecommunications technology (TAC § 111.51, g. (1) and (4) )

                     license-supervision via telecommunications technology (TAC § 111.51, g. (1) and (4) )

SUBCHAPTER V. TELEHEALTH.

111.210. Definitions Relating to Telehealth. (New section adopted effective October 1, 2016,41 TexReg 4441)

Unless the context clearly indicates otherwise, the following words and terms, when used in this subchapter, shall have the following meanings. 

(1) Client--A consumer or proposed consumer of speech-language pathology or audiology services. 

(2) Client site--The physical location of the client at the time the services are being furnished via telecommunications. 

(3) Consultant--Any professional who collaborates with a provider of telehealth services to provide services to clients. 

(4) Facilitator--The individual at the client site who assists with the delivery of the telehealth services at the direction of the audiologist or speech-language pathologist. 

(5) Provider--An individual who holds a current, renewable, unrestricted speech-language pathology or audiology license under Texas Occupations Code §401.302 and §401.304; or an individual who holds an audiology intern license under Texas Occupations Code §401.311. 

(6) Provider site--The physical location at which the speech-language pathologist or audiologist delivering the services is located at the time the services are provided via telecommunications which is distant or remote from the client site. 

(7) Telecommunications--Interactive communication at a distance by concurrent two-way transmission, using telecommunications technology, of information, including, without limitation, sound, visual images, and/or computer data, between the client site and the provider site, and required to occur without a change in the form or content of the information, as sent and received, other than through encoding or encryption of the transmission itself for purposes of and to protect the transmission. 

(8) Telecommunications technology--Computers and equipment, other than telephone, email or facsimile technology and equipment, used or capable of use for purposes of telecommunications. For purposes of this subchapter, the term includes, without limitation: 

(A) compressed digital interactive video, audio, or data transmission; 

(B) clinical data transmission using computer imaging by way of still-image capture and storage and forward; and 

(C) other technology that facilitates the delivery of telepractice services. 

(9) Telehealth--The use of telecommunications and information technologies for the exchange of information from one site to another for the provision of speech-language pathology or audiology services to a client from a provider. 

(10) Telehealth services--The application of telecommunication technology to deliver speech-language pathology and/or audiology services at a distance for assessment, intervention, and/or consultation. 

(11) Telepractice--The use of telecommunications technology by a license holder for an assessment, intervention, or consultation regarding a speech-language pathology or audiology client. 

(12) Telepractice services--The rendering of audiology and/or speech-language pathology services through telepractice to a client who is physically located at a site other than the site where the provider is located. 

111.211. Service Delivery Models of Speech-Language Pathologists. (New section adopted effective October 1, 2016,41 TexReg 4441)

(a) Telehealth may be delivered in a variety of ways, including, but not limited to those set out in this section. 

(1) Store-and-forward model/electronic transmission is an asynchronous electronic transmission of stored clinical data from one location to another. 

(2) Clinician interactive model is a synchronous, real time interaction between the provider and client or consultant that may occur via telecommunication links. 

(b) Self-monitoring/testing model refers to when the client or consultant receiving the services provides data to the provider without a facilitator present at the site of the client or consultant. 

(c) Live versus stored data refers to the actual data transmitted during the telepractice. Both live, real-time and stored clinical data may be included during the telepractice

111.212. Requirements for the Use of Telehealth by Speech-Language Pathologists. (New section adopted effective October 1, 2016,41 TexReg 4441; amended effective May 1, 2018, 43 TexReg 2561)

(a) The requirements of this section apply to the use of telehealth by speech-language pathologists. 

(b) A provider shall comply with the commission’s Code of Ethics and Scope of Practice requirements when providing telehealth services. 

(c) The scope, nature, and quality of services provided via telehealth are the same as that provided during in-person sessions by the provider. 

(d) The quality of electronic transmissions shall be equally appropriate for the provision of telehealth services as if those services were provided in person. 

(e) A provider shall only utilize technology which they are competent to use as part of their telehealth services. 

(f) Equipment used for telehealth services at the clinician site shall be maintained in appropriate operational status to provide appropriate quality of services. 

(g) Equipment used at the client/patient site at which the client or consultant is present shall be in appropriate working condition and deemed appropriate by the provider. 

(h) The initial contact between a licensed speech-language pathologist and client may be at the same physical location or through telehealth/telepractice, as determined appropriate by the licensed speech-language pathologist.

(i) A provider shall consider relevant factors including the client’s behavioral, physical, and cognitive abilities in determining the appropriateness of providing services via telehealth/telepractice

(j) A provider shall be aware of the client or consultant level of comfort with the technology being used as part of the telehealth services and adjust their practice to maximize the client or consultant level of comfort. 

(k) When a provider collaborates with a consultant from another state in which the telepractice services are delivered, the consultant in the state in which the client receives services shall be the primary care provider for the client. 

(l) As pertaining to liability and malpractice issues, a provider shall be held to the same standards of practice as if the telehealth services were provided in person. 

(m) A provider shall be sensitive to cultural and linguistic variables that affect the identification, assessment, treatment, and management of the clients. 

(n) Upon request, a provider shall submit to the department data which evaluates effectiveness of services provided via telehealth including, but not limited to, outcome measures. 

(o) Telehealth providers shall comply with all laws, rules, and regulations governing the maintenance of client records, including client confidentiality requirements, regardless of the state where the records of any client within this state are maintained. 

(p) Notification of telehealth services shall be provided to the client, the guardian, the caregiver, and the multi-disciplinary team, if appropriate. The notification shall include, but not be limited to: the right to refuse telehealth services, options for service delivery, and instructions on filing and resolving complaints. 

111.213. Limitations on the Use of Telecommunications Technology by Speech-Language Pathologists. (New section adopted effective October 1, 2016,41 TexReg 4441; amended effective May 1, 2018, 43 TexReg 2544)

(a) The limitations of this section apply to the use of telecommunications technology by speech-language pathologists. 

(b) Supervision of a licensed assistant in speech-language pathology may be undertaken through the use of telecommunications technology as described under §111.51 and as follows:

(1) no more than two (2) hours of direct supervision per month shall be undertaken through the use of telecommunications technology; and

(2) no more than six (6) total hours of supervision per month shall be undertaken through the use of telecommunications technology.

(c) Direct supervision of a licensed intern in speech-language pathology shall not be undertaken through the use of telecommunications technology. 

(d) Telehealth services may not be provided by correspondence only, e.g., mail, email, faxes, although they may be adjuncts to telepractice

111.214. Requirements for Providing Telehealth Services in Speech-Language Pathology. (New section adopted effective October 1, 2016,41 TexReg 4441)

(a) A provider of telehealth services who practices in the State of Texas shall be licensed by the department. 

(b) A provider of telehealth services shall be competent in both the type of services provided and the methodology and equipment used to provide the service. 

111.215. Requirements for Providing Telepractice Services in Audiology. (New section adopted effective October 1, 2016,41 TexReg 4441)

(a) Unless otherwise legally authorized to do so, an individual shall not render telepractice services in audiology from the State of Texas or to a client in the State of Texas, unless the individual qualifies as a provider as that term is defined in this subchapter and renders only those telepractice services that are within the course and scope of the provider's licensure and competence, and delivered in accordance with the requirements of that licensure and pursuant to the terms and conditions set forth in this section. 

(b) The provider shall use only telecommunications technology that meets the definition of that term, as defined in this subchapter, to render telepractice services. Modes of communication that do not utilize such telecommunications technology, including facsimile and email, may be used only as adjuncts. 

(c) Subject to the requirements and limitations of this section, a provider may utilize a facilitator at the client site to assist the provider in rendering telepractice services. 

(d) The provider shall be present at the provider site and shall be visible and audible to, and able to see and hear the client and the facilitator via telecommunications technology in synchronous, real-time interactions, even when receiving or sending data and other telecommunication transmissions in carrying out the telepractice services. The provider is responsible for the actions of the facilitator and shall monitor the client and oversee and direct the facilitator at all times during the telepractice session. 

(e) The provider of telepractice services, prior to allowing a facilitator to assist the provider in rendering telepractice services, shall verify and document the facilitator’s qualifications, training, and competence in each task the provider directs the facilitator to perform at the client site, and in the methodology and equipment the facilitator is to use at the client site. 

(f) The facilitator may perform at the client site only the following tasks: 

(1) those physical, administrative, and other tasks for which the provider has trained the facilitator in connection with the rendering of audiology services for which no form of license, permit, authorization or exemption under the Texas Occupations Code is required; and 

(2) a task for which the facilitator holds and acts in accordance with any license, permit, authorization or exemption required under the Texas Occupations Code to perform the task. 

(g) A provider shall not render telepractice services to a client in those situations in which the presence of a facilitator is required for safe and effective service to the client and no qualified facilitator is available to the client during the telepractice session. 

(h) The scope, nature, and quality of the telepractice services provided, including the assistance provided by the facilitator, shall be commensurate with the services the provider renders in person at the same physical location as the client. 

(i) The provider shall not render telepractice services unless the telecommunications technology and equipment located at the client site and at the provider site are appropriate to the telepractice services to be rendered; are properly calibrated and in good working order; and are of sufficient quality to allow the provider to deliver equivalent audiology service and quality to the client as if those services were provided in person at the same physical location. The provider shall only utilize telecommunications technology and other equipment for the provider’s telepractice which the provider is competent to use. 

(j) Providers and facilitators involved in the provider’s delivery of telepractice services shall comply with all laws, rules, and regulations governing the maintenance of client records, including client confidentiality requirements. Documentation of telepractice services shall include documentation of the date and nature of services performed by the provider by telepractice and of the assistive tasks of the facilitator. 

(k) Except to the extent it imposes additional or more stringent requirements, this section does not affect the applicability of any other requirement or provision of law to which an individual is otherwise subject under this chapter or other law. 

111.216. Limitations on the Use of Telecommunications Technology by Audiologists. (New section adopted effective May 1, 2018, 43 TexReg 2544)

(a) The limitations of this section apply to the use of telecommunications technology by audiologists. 

(b) Supervision of a licensed assistant in audiology may be undertaken through the use of telecommunications technology as described under §111.91, except for duties described under §§111.92(c)(1) - (4) where the supervisor must provide in-person, direct supervision.

(c) Telehealth services may not be provided by correspondence only, e.g., mail, email, faxes, although they may be adjuncts to telepractice

SUBCHAPTER X. JOINT RULES FOR FITTING AND DISPENSING OF
HEARING INSTRUMENTS BY TELEPRACTICE.

111.230. Purpose. (New section adopted effective October 1, 2016,41 TexReg 4441)

Pursuant to Texas Occupations Code §401.2022 and §402.1023, the commission, with the assistance of the Speech-Language Pathologists and Audiologists Advisory Board and the Hearing Instrument Fitters and Dispensers Advisory Board, shall adopt rules to establish requirements for the fitting and dispensing of hearing instruments through the use of telepractice. This subchapter contains rules that set forth the requirements for the fitting and dispensing of hearing instruments through the use of telepractice

111.231. Definitions. (New section adopted effective October 1, 2016,41 TexReg 4441)

Unless the context clearly indicates otherwise, the following words and terms, when used in this subchapter, shall have the following meanings: 

(1) Acts--Texas Occupations Code, Chapter 401, relating to Speech-Language Pathologists and Audiologists, and Texas Occupations Code, Chapter 402, relating to Hearing Instrument Fitters and Dispensers. 

(2) Client--A consumer or proposed consumer of services. 

(3) Client site--The site at which the client is physically located. 

(4) Facilitator--The individual at the client site who assists with the delivery of telehealth services. 

(5) Fitting and dispensing hearing instruments--The measurement of human hearing by the use of an audiometer or other means to make selections, adaptations, or sales of hearing instruments. The term includes the making of impressions for earmolds to be used as a part of the hearing instruments and any necessary post fitting counseling for the purpose of fitting and dispensing hearing instruments. 

(6) Hearing instrument--Any wearable instrument or device designed for, or represented as, aiding, improving or correcting defective human hearing. This includes the instrument's parts and any attachment, including an earmold, or accessory to the instrument. The term does not include a battery or cord. 

(7) Provider--An individual who holds a current, renewable, unrestricted audiology license under Texas Occupations Code, §401.302 and §401.304; an individual who holds an audiology intern license under Texas Occupations Code, §401.311; or an individual who holds a current, renewable, unrestricted license under Texas Occupations Code, Chapter 402, that authorizes the individual to fit and dispense hearing instruments without supervision. 

(8) Provider site--The physical location of the provider of telehealth services which is distant or remote from the client site. 

(9) Telecommunications--Interactive communication at a distance by concurrent two-way transmission, using telecommunications technology, of information, including, without limitation, sound, visual images, and/or computer data, between the client site and the provider site, and required to occur without a change in the form or content of the information, as sent and received, other than through encoding or encryption of the transmission itself for purposes of and to protect the transmission. 

(10) Telecommunications technology--Computers and equipment, other than telephone, email or facsimile technology and equipment, used or capable of use for purposes of telecommunications. For purposes of this subchapter, the term includes, without limitation: 

(A) compressed digital interactive video, audio, or data transmission; 

(B) clinical data transmission using computer imaging by way of still-image capture and storage and forward; and 

(C) other technology that facilitates the delivery of telehealth services. 

(11) Telehealth services--The fitting and dispensing of hearing instruments through telepractice to a client who is physically located at a site other than the site where the provider is located. 

(12) Telepractice--The use of telecommunications technology for the fitting and dispensing of hearing instruments. 

111.232. Requirements for Providing Telehealth Services for the Fitting and Dispensing of Hearing Instruments. (New section adopted effective October 1, 2016,41 TexReg 4441)

(a) Unless otherwise legally authorized to do so, an individual shall not render telehealth services from the State of Texas or to a client in the State of Texas, unless the individual qualifies as a provider as that term is defined in this subchapter and renders only those telehealth services that are within the course and scope of the provider's licensure and competence, and delivered in accordance with the requirements of that licensure and pursuant to the terms and conditions set forth in this section. 

(b) The provider shall use only telecommunications technology that meets the definition of that term, as defined in this subchapter, to render telehealth services. Modes of communication that do not utilize such telecommunications technology, including telephone, facsimile, and email, may be used only as adjuncts. 

(c) Subject to the requirements and limitations of this section, a provider may utilize a facilitator at the client site to assist the provider in rendering telehealth services. 

(d) The provider shall be present at the provider site and shall be visible and audible to, and able to see and hear the client and the facilitator via telecommunications technology in synchronous, real-time interactions, even when receiving or sending data and other telecommunication transmissions in carrying out the telehealth services. The provider is responsible for the actions of the facilitator and shall monitor the client and oversee and direct the facilitator at all times during the telehealth session. 

(e) The provider of telehealth services, prior to allowing a facilitator to assist the provider in rendering telehealth services, shall verify and document the facilitator's qualifications, training, and competence in each task the provider directs the facilitator to perform at the client site, and in the methodology and equipment the facilitator is to use at the client site. 

(f) The facilitator may perform at the client site only the following tasks: 

(1) those physical, administrative, and other tasks for which the provider has trained the facilitator in connection with the fitting or dispensing of hearing instruments for which no form of license, permit, authorization or exemption is required by law; and 

(2) those tasks for which the individual who is acting as a facilitator otherwise holds and acts in accordance with any license, permit, authorization or exemption required by law to perform the tasks. 

(g) A provider shall not render telehealth services to a client in those situations in which the presence of a facilitator is required for safe and effective service to the client and no qualified facilitator is available to the client during the telepractice session. 

(h) The scope, nature, and quality of the telehealth services provided, including the assistance provided by the facilitator, shall be commensurate with the services the provider renders in person at the same physical location as the client. 

(i) The provider shall not render telehealth services unless the telecommunications technology and equipment located at the client site and at the provider site are appropriate to the telehealth services to be rendered; are properly calibrated and in good working order; and are of sufficient quality to allow the provider to deliver equivalent fitting and dispensing service and quality to the client as if those services were provided in person at the same physical location. The provider shall only utilize telecommunications technology and other equipment for the provider's telepractice which the provider is competent to use. 

(j) A client's initial professional contact with a provider shall be in person at the same physical location. 

(k) Providers and facilitators involved in the provider's delivery of telehealth services shall comply with all laws, rules, and regulations governing the maintenance of client records, including client confidentiality requirements. Documentation of telehealth services shall include documentation of the date and nature of services performed by the provider by telepractice and of the assistive tasks of the facilitator. 

(l) Except to the extent it imposes additional or more stringent requirements, this section does not affect the applicability of any other requirement or provision of law to which an individual is otherwise subject under this chapter or other law.

SUBCHAPTER F. REQUIREMENTS FOR ASSISTANT IN SPEECH-LANGUAGE
PATHOLOGY LICENSE.

111.51. Assistant in Speech-Language Pathology License--Supervision Requirements. (New section adopted effective May 1, 2018, 43 TexReg 2544)

(g) Amount and Type of Supervision. Each supervisor shall provide a minimum of eight (8) hours per calendar month of supervision to the assistant. This subsection applies whether the assistant is employed full-time or part-time. 

(1) At least four (4) hours must be direct supervision. At least two (2) of the direct supervision hours must be in-person. The other two (2) hours may be in-person or by telehealth/telepractice

(2) The remaining hours may be performed using indirect supervision.

(3) If fewer than four (4) weeks are worked in a calendar month, then the number of hours of supervision provided will be based on the number of weeks worked. Two (2) hours of supervision must be provided for each week worked, including one (1) hour of direct supervision and one (1) hour of indirect supervision. 

(4) For the purposes of this subsection the telehealth/telepractice provisions allowed by Subchapter V may be used for up to six (6) hours of supervision (two (2) hours of direct supervision and four (4) hours of indirect supervision).

View the TDLR Administrative Rules governing the practice of speech-language pathology and audiology in Texas