Texas FEMC
Compliance

The principal authorities governing independently licensed Texas freestanding emergency medical care facilities are:

Texas Health & Safety Code Chapter 254 - Freestanding Emergency Medical Care Facilities

Chapter 254 establishes the statutory licensing framework and authorizes HHSC to regulate Texas FEMCs. Except for statutory exemptions, a facility may not establish or operate a freestanding emergency medical care facility in Texas without the required license. ^[2]

26 Texas Administrative Code Chapter 509 - Freestanding Emergency Medical Care Facilities

Chapter 509 is the primary operational rule set and contains requirements covering:

• General provisions - §§509.1-509.2
• Licensing - §§509.21-509.30
• Operational requirements - §§509.41-509.70
• Inspections and investigations - §§509.81-509.86
• Enforcement - §§509.101-509.108
• Fire prevention and safety requirements
• Physical plant and construction requirements

The former Title 25 Chapter 131 regulatory structure was repealed and replaced by Title 26 Chapter 509. ^{[5], [3]}

Handbook page 3 · Source review September 9, 2026

A survey-ready FEMC should maintain current, immediately retrievable documentation demonstrating that the facility is legally authorized and operationally prepared to provide emergency care.

The facility's compliance file should include, as applicable:

• Current HHSC FEMC license
• Current ownership information
• DBA/assumed-name documentation
• Organizational and ownership chart
• Medical director appointment
• Medical staff leadership documentation
• Director of nursing information
• Governing body structure
• Governing body bylaws
• Medical staff bylaws
• Current policies and procedures
• Fire safety inspection
• Architectural/occupancy approvals
• Pharmacy license
• CLIA certificate
• Radiation/X-ray registration
• Transfer policy
• Memorandum of Transfer
• Hospital transfer agreement
• Applicable accreditation documentation

The original survey guide properly identifies the facility license, fire documentation, CLIA, organizational chart, medical-director documentation and related administrative records as core preparedness documents. ^[1]

Initial Licensure

Current HHSC Form 3226 instructions require an initial applicant to submit its application at least 90 calendar days before the projected opening date. Current instructions list a $14,820 license fee, require patient-transfer documents, a fire-safety survey, Architectural Review Unit approval, and participation in a pre-licensure conference. Annual fire-safety inspections are required for continued licensure. ^[4]

Staffing Affirmation for Licensure

26 TAC §509.24 requires the applicant to affirm that at least:

Handbook pages 3, 4 · Source review September 9, 2026

Governing Body

Under 26 TAC §§509.41-509.42, the governing body is ultimately responsible for the organization, management, control, operation, quality, safety, staffing, policies and services of the facility.

The governing body should be able to demonstrate oversight through documented meetings, approvals, policies, reports and quality review.

Required responsibilities include, among other matters:

• Establishing organizational structure
• Adopting and enforcing bylaws
• Adopting and enforcing operational policies
• Approving staff training
• Ensuring equipment is properly maintained
• Overseeing emergency and disaster preparedness
• Maintaining QAPI
• Approving laboratory, radiology and pharmacy policies
• Maintaining medical-record systems
• Monitoring risk management
• Reviewing deaths, incidents and patient complaints
• Ensuring a safe physical environment

Patient Satisfaction

26 TAC §509.41 requires the facility to assess patient satisfaction with its services and environment and requires governing-body review at least annually. ^[3]

Handbook pages 4, 5 · Source review September 9, 2026

A facility should maintain a controlled policy library with:

Policy title | policy number | original approval date | effective date | most recent review/revision | approving authority

Policies should accurately reflect actual facility operations.

Core policies should address, as applicable:

• Emergency medical screening
• Stabilization
• Triage
• Patient transfers
• Nursing services
• Physician credentialing and privileging
• Medications and controlled substances
• Pharmacy operations
• Laboratory services
• Radiology
• Respiratory services
• Anesthesia/sedation
• Infection prevention
• Sterilization
• Linen and laundry
• Medical waste
• Patient rights
• Grievances
• Abuse/neglect reporting
• Medical records
• Disaster preparedness
• Workplace violence
• Risk management
• QAPI
• Billing and patient disclosures
• HIPAA/privacy/security

26 TAC §509.41 expressly requires the governing body to adopt, implement and enforce written policies and procedures for the total operation and services of the facility. ^[3]

The uploaded preparedness guide similarly identifies screening/stabilization, triage, medication management, patient rights, infection control and transfer arrangements as essential policy areas. ^[1]

Handbook page 5 · Source review September 9, 2026

Under 26 TAC §509.44, the medical director must be onsite as necessary to perform the responsibilities of the position and, in all cases, must be onsite for at least:

Medical-director responsibilities include:

• Organizing emergency services
• Supervising the infection-control program
• Supervising QAPI
• Participating in infection-control meetings
• Participating in QAPI meetings
• Overseeing or arranging peer-review activities

Facilities should maintain a Medical Director Activity Log demonstrating onsite hours and participation in required oversight functions. ^[3]

Handbook page 6 · Source review September 9, 2026

Medical staff credentialing should demonstrate that every physician has been appropriately evaluated, appointed and privileged by the facility.

26 TAC §§509.41 and 509.45 require medical-staff organization, credential review, governing-body appointment and accountability for the quality of medical care. The medical staff must periodically appraise its members in accordance with its bylaws. ^[3]

A survey-ready credentialing file should include documentation relevant to the facility's credentialing criteria, such as:

• Texas medical license
• DEA registration when applicable
• Board certification/eligibility
• Education and residency
• Emergency-care experience
• Requested and approved privileges
• Current competency
• Peer references
• Required life-support certifications
• Credentialing approval
• Governing-body approval
• Reappointment documentation
• Continuing competence

The uploaded guide likewise emphasizes current professional licenses, certifications, Medical Director qualifications, training documentation and evidence of continuous physician staffing. ^[1]

Important 2026 §509.45 Regulatory Alert

The currently published rule requires physicians privileged at an FEMC to meet specified emergency-experience and life-support-certification requirements.

On July 24, 2026, HHSC published a proposed amendment to §509.45 that would allow physicians currently board certified in Emergency Medicine by ABEM or AOBEM, and meeting the experience requirement, to receive medical-staff privileges without separately maintaining ACLS, PALS and ATLS certifications. The Texas Register identified August 23, 2026 as the earliest possible adoption date. ^{[6], [3]}

Handbook pages 6, 7 · Source review September 9, 2026

Under 26 TAC §509.46, personnel must be qualified for the functions they perform, and sufficient personnel must be available to safely meet patient needs. Nursing services must be organized under qualified registered-nurse leadership.

Surveyors may examine:

• Current RN licenses
• Physician licenses
• Radiology credentials
• Respiratory credentials
• Laboratory qualifications
• Staffing schedules
• Orientation records
• Skills competency
• BLS/ACLS/PALS/ATLS documentation as applicable
• Infection-control training
• HIPAA training
• Emergency-preparedness education
• Workplace-violence training
• Evidence that employees understand facility policies

Remember that §509.63 specifically includes orientation, training, delegation, licensing, certification and policy non-adherence as monthly QAPI indicators. ^[3]

Handbook page 7 · Source review September 9, 2026

Texas FEMC rules independently require emergency screening and stabilization.

Under 26 TAC §509.47, patients presenting for emergency care must receive an appropriate medical screening examination and stabilization within the capabilities of the facility regardless of ability to pay.

Transfers must comply with:

• 26 TAC §509.65 - Patient Transfer Policy
• 26 TAC §509.66 - Patient Transfer Agreements

The transfer policy, Memorandum of Transfer and hospital transfer agreement are specifically required elements of the licensing process. ^[4]

EMTALA - Important Distinction

EMTALA is a federal statute imposing specific emergency-screening and stabilization obligations on Medicare-participating hospitals that offer emergency services. ^[7]

For independent facilities, 26 TAC §509.47 and Chapter 254 provide the core Texas screening and stabilization requirements.

Handbook pages 7, 8 · Source review September 9, 2026

QAPI should be one of the highest-priority survey-preparedness areas.

Under 26 TAC §509.63, every FEMC must maintain an ongoing, facility-wide, data-driven and interdisciplinary QAPI program.

Required monthly measurement, analysis and tracking include at least:

• Infection control
• Adverse events
• Mortality
• Complaints and suggestions
• Staffing
• Orientation
• Training
• Delegation
• Licensing and certification
• Policy non-adherence
• Fire/disaster preparedness
• Special-waste disposal
• Clinical-record review
• Treatment errors
• Medication errors

The facility must identify opportunities for improvement, implement corrective action, measure effectiveness and sustain improvement. HHSC inspectors may verify the existence of the program and that core staff understand and can access it. ^[3]

Governing Body Oversight

The governing body must review and monitor QAPI activities quarterly. ^[3]

Recommended QAPI Evidence Folder

Maintain:

• Monthly meeting agendas
• Minutes
• Quality dashboard
• Infection data
• Medication errors
• Treatment errors
• Mortality reviews
• Transfer data
• Complaints
• Patient satisfaction trends
• Staffing/credential findings
• Safety findings
• Peer review
• Performance-improvement projects
• Corrective action plans
• Evidence of sustained improvement

Your original preparedness guide correctly emphasizes QAPI minutes, performance data, peer review, incident summaries, corrective-action plans and patient-satisfaction follow-up. ^[1]

Handbook pages 8, 9 · Source review September 9, 2026

Applicable Chapter 509 provisions include:

• §509.55 - Infection Control
• §509.56 - Sanitary Conditions and Hygienic Practices
• §509.57 - Sterilization
• §509.58 - Linen and Laundry Services
• §509.59 - Waste and Waste Disposal

The facility should be able to demonstrate:

• Designated infection-control responsibility
• Infection surveillance
• Infection logs and trend analysis
• Standard/universal precautions
• Hand hygiene
• PPE
• Sharps safety
• Employee exposure management
• Sterilization/decontamination
• Environmental cleaning
• Isolation procedures
• Waste disposal
• Integration of infection-control findings into QAPI

Chapter 509 specifically treats universal precautions as including handwashing, protective barriers and proper use/disposal of needles and sharps. ^[3]

Handbook pages 9, 10 · Source review September 9, 2026

The governing body must ensure equipment is properly used and maintained according to manufacturer recommendations. ^[3]

A survey-ready facility should maintain logs for:

• crash-cart checks;
• AED/defibrillator checks;
• emergency medication expiration;
• suction equipment;
• oxygen;
• ventilatory equipment;
• monitors;
• infusion pumps;
• preventive maintenance;
• electrical safety;
• calibration; and
• manufacturer-recommended service intervals.

The original guide appropriately identifies crash-cart inventories, defibrillator testing, radiology inspection, environmental cleanliness, PPE, fire drills and evacuation information as critical physical-environment readiness items. ^[1]

Handbook page 10 · Source review September 9, 2026

Texas Requirement

26 TAC §509.49 - Laboratory and Pathology Services

FEMCs providing laboratory services must comply with applicable laboratory requirements.

Federal Requirement

The Clinical Laboratory Improvement Amendments (CLIA) are implemented under 42 CFR Part 493.

CMS states that a facility performing laboratory testing on human specimens to assess health or diagnose, prevent or treat disease generally needs the appropriate CLIA certificate. ^{[8], [24]}

Facilities should maintain:

• current CLIA certificate;
• list of authorized tests;
• test-complexity classification;
• laboratory-director documentation where applicable;
• QC records;
• calibration;
• proficiency testing where applicable;
• competency records; and
• manufacturer instructions.

Handbook pages 10, 11 · Source review September 9, 2026

Texas FEMC Rule

26 TAC §509.50 - Pharmaceutical Services

Texas State Board of Pharmacy

A pharmacy located in a Texas FEMC is generally regulated as a:

Class F - Freestanding Emergency Medical Care Center Pharmacy

Texas State Board of Pharmacy requirements are found principally at:

22 TAC §291.151 - Pharmacies Located in a Freestanding Emergency Medical Care Facility (Class F).

The Board specifically identifies Class F licensure for pharmacy operations in licensed freestanding emergency medical care facilities. ^[9]

Maintain:

• pharmacy license;
• pharmacist-in-charge documentation;
• pharmacy policies;
• medication storage temperatures;
• refrigerator logs;
• controlled-substance records;
• narcotic counts;
• access-control records;
• medication-expiration checks;
• medication-recall process;
• medication-error review;
• emergency medications; and
• required federal/state controlled-substance documentation.

Handbook page 11 · Source review September 9, 2026

Radiology is regulated under:

26 TAC §509.51 - Radiology

and applicable Texas DSHS Radiation Control rules in 25 TAC Chapter 289.

Texas DSHS identifies §289.227 among the applicable medical X-ray rules and requires registrants to maintain and implement written operating and safety procedures. ^{[11], [10]}

Survey documentation should include:

• current X-ray registration;
• equipment inventory;
• physicist/inspection reports as applicable;
• shielding documentation;
• preventive maintenance;
• radiation-safety program;
• dosimetry records where required;
• employee training; and
• operating and safety procedures.

26 TAC §509.51 also addresses radiation precautions, shielding, monitoring and documentation. ^[3]

Handbook page 12 · Source review September 9, 2026

26 TAC §509.54 - Medical Records establishes extensive documentation and retention requirements.

Among other requirements:

Adult Medical Records

Retain for at least 10 years.

Films, Scans and Other Image Records

Retain for at least 5 years.

Minor Records

Generally retain until the later of:

• the patient's 20th birthday; or
• 10 years following the patient's last treatment.

Medical-record entries must be legible, accurate, complete, dated, timed and authenticated within the timeframe prescribed by the rule. ^[3]

Facilities should include medical-record audits within QAPI.

Handbook page 12 · Source review September 9, 2026

Relevant provisions include:

• 26 TAC §509.60 - Patient Rights
• §509.61 - Abuse and Neglect
• Texas Health & Safety Code Chapter 254 consumer protections
• applicable HIPAA requirements

Patients must receive required information regarding rights, services, charges/payment expectations and complaint mechanisms.

Facilities should maintain:

• patient-rights notice;
• grievance policy;
• complaint log;
• investigation records;
• written responses;
• corrective actions;
• HHSC complaint information;
• abuse/neglect reporting signage; and
• evidence that complaints feed into QAPI.

Handbook pages 12, 13 · Source review September 9, 2026

If the facility is a HIPAA-covered entity, the HIPAA Privacy Rule applies under:

45 CFR Part 160 and Part 164, Subparts A and E.

The Privacy Rule establishes requirements governing use, disclosure and protection of protected health information and patient rights. ^[12]

The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information. ^[13]

Survey/compliance documentation should include, as applicable:

• Notice of Privacy Practices;
• HIPAA policies;
• workforce privacy training;
• security-risk assessment;
• access controls;
• incident-response process;
• breach procedures;
• Business Associate Agreements; and
• physical safeguards for PHI/ePHI.

Handbook page 13 · Source review September 9, 2026

Healthcare facilities must also consider applicable federal OSHA standards.

Particularly important is:

29 CFR §1910.1030 - Bloodborne Pathogens

which includes requirements involving:

• exposure-control plans;
• universal precautions;
• engineering controls;
• PPE;
• hepatitis B vaccination;
• post-exposure evaluation;
• training; and
• recordkeeping. ^[14]

Other potentially applicable healthcare standards include respiratory protection, hazard communication and occupational exposure requirements. ^[15]

Handbook pages 13, 14 · Source review September 9, 2026

26 TAC §509.64 - Safety and Preparedness, together with §509.42 and applicable fire-safety requirements, should drive the facility emergency-preparedness program.

The governing body must review the disaster preparedness plan at least annually. ^[3]

Maintain:

• all-hazards emergency operations plan;
• staff responsibilities;
• emergency contact lists;
• communication plan;
• fire response;
• severe-weather response;
• utility failure plan;
• active-shooter/workplace-violence procedures;
• evacuation procedures;
• emergency power procedures;
• drill documentation;
• after-action reviews; and
• corrective actions.

The original guide appropriately recommends documented drills and after-action/corrective-action review. ^[1]

Handbook page 14 · Source review September 9, 2026

Effective October 21, 2024, 26 TAC §509.70 requires Texas FEMCs to address workplace violence prevention.

The regulation implements Texas Health & Safety Code Chapter 331 and requires an FEMC to establish or designate a workplace violence prevention committee and adopt, implement and enforce a written workplace violence prevention policy and plan.

The committee must evaluate the plan annually and report its evaluation to the facility governing body. ^{[16], [17]}

Maintain:

• committee membership;
• committee minutes;
• written prevention plan;
• annual evaluation;
• governing-body report;
• employee education;
• incident reporting; and
• follow-up/corrective actions.

Handbook pages 14, 15 · Source review September 9, 2026

26 TAC §509.62 - Reporting Requirements

and current HHSC Form 6104 - Freestanding Emergency Medical Care Facility Incident Report establish important incident-reporting obligations.

Current Form 6104 instructions identify reporting timeframes including:

Immediately

• abuse;
• neglect; and
• exploitation.

As Soon as Possible

• illegal, unethical or unprofessional conduct.

Within One Business Day

• fire causing injury.

No Later than the 10th Business Day

• death of a patient under facility care;
• fire;
• patient stay exceeding 23 hours;
• 911 activation; or
• emergency transfer to a hospital by ambulance. ^[18]

This is a particularly important survey-readiness item because reportable events should also connect back to facility risk management and QAPI.

Handbook page 15 · Source review September 9, 2026

Maintain readily available evidence demonstrating compliance with:

26 TAC §509.65 - Patient Transfer Policy

and

26 TAC §509.66 - Patient Transfer Agreements

Current HHSC licensing instructions require:

• 1. Patient Transfer Policy;
• 2. Memorandum of Transfer; and
• 3. written Patient Transfer Agreement with a general hospital. ^[4]

Clinical records should show that actual transfers follow the facility's approved policies.

Handbook page 16 · Source review September 9, 2026

This area is particularly important for Texas FEMCs.

Relevant authorities include:

• Texas Health & Safety Code Chapter 254
• 26 TAC §509.60 - Patient Rights
• §509.67 - Billing Requirements
• §509.69 - Fees and Prices
• Texas Health & Safety Code Chapter 185 - Health Care Billing
• applicable Texas Insurance Code provisions
• federal No Surprises Act requirements

Itemized Billing

Texas Health & Safety Code §185.002 requires a health care provider requesting payment from a patient after providing services or supplies to provide a written itemized bill meeting statutory requirements. ^[19]

26 TAC §509.67 was amended specifically to require FEMCs to comply with Chapter 185's itemized-billing requirements. ^{[3], [19]}

Texas Facility-Fee / Network Disclosures

Texas Health & Safety Code Chapter 254 contains specific requirements governing:

• notice of fees;
• insurance-network representations;
• facility/physician billing disclosures;
• required written disclosure statements; and
• advertising.

Facilities should routinely audit signs, registration paperwork, website statements and marketing materials against these requirements. ^[2]

Advertising

26 TAC §509.41 restricts an FEMC from advertising that it "takes" or "accepts" an insurer or health plan unless the facility actually participates in the applicable provider network. It also limits use of insurer names/logos where the facility is out-of-network for all of that issuer's plans. ^[3]

Handbook pages 16, 17 · Source review September 9, 2026

Independent freestanding emergency departments are expressly included within federal No Surprises Act protections for applicable emergency services. ^{[20], [21]}

Facilities should maintain procedures addressing:

• applicable balance-billing prohibitions;
• patient disclosures;
• emergency-service cost-sharing protections;
• payer-provider dispute processes; and
• uninsured/self-pay requirements.

CMS states that qualifying patients receiving emergency care generally cannot be charged more than the applicable in-network cost-sharing amount for protected emergency services. ^{[21], [20]}

Handbook page 17 · Source review September 9, 2026

For uninsured or self-pay patients, federal rules generally require a Good Faith Estimate when care is scheduled sufficiently in advance or when the patient requests an estimate.

CMS specifically states:

"You won't get an estimate during emergency care." ^[22]

Therefore, facilities should distinguish:

Emergency Care

No Surprises Act emergency billing protections.

Scheduled/Requested Non-Emergency Services for Uninsured/Self-Pay Patients

Good Faith Estimate requirements where applicable.

This distinction improves upon the original guide's general reference to Good Faith Estimate procedures. ^[1]

Handbook page 17 · Source review September 9, 2026

Facilities must comply with applicable Chapter 509:

• fire-prevention requirements;
• life-safety requirements;
• physical-plant requirements; and
• construction standards.

Current HHSC licensing instructions require a passing local fire-safety survey and state that annual fire-safety inspections are required for continued licensure. ^[4]

Survey readiness should cover:

• fire inspection;
• alarm system;
• extinguishers;
• emergency lighting;
• generator/emergency power;
• evacuation routes;
• exit accessibility;
• fire drills;
• medical gases;
• preventive maintenance;
• environmental safety rounds; and
• physical-plant deficiencies.

Handbook pages 17, 18 · Source review September 9, 2026

A facility should be capable of producing relevant documentation promptly, including:

Licensing

Current licenses, registrations and certificates.

Governance

Bylaws, governing-body oversight and meeting documentation.

Credentialing

Physician and clinical staff files with approved privileges.

Staffing

Schedules demonstrating required coverage.

Policies

Current approved policies that match actual practice.

QAPI

Monthly meetings, indicators, data, corrective action and outcomes.

Medical Director

Evidence of required onsite participation and quality/infection-control oversight.

Patient Records

Complete clinical documentation and retention compliance.

Infection Prevention

Surveillance, training, PPE and environmental controls.

Emergency Preparedness

Plans, drills and corrective actions.

Pharmacy

Class F pharmacy compliance and medication management.

Laboratory

CLIA compliance.

Radiology

DSHS registration and radiation-safety records.

Transfers

Transfer policy, agreements and actual transfer documentation.

Reportable Events

Evidence that required incidents were submitted timely.

Billing

Required patient disclosures, signage and itemized billing procedures.

Workplace Violence

Committee, plan and annual review.

Handbook pages 18, 19 · Source review September 9, 2026

A practical compliance repository can be organized into the following tabs:

• Tab 1 - Facility Licensing & Corporate Documents
• Tab 2 - Governing Body & Administration
• Tab 3 - Medical Staff Bylaws
• Tab 4 - Physician Credentialing & Privileging
• Tab 5 - Nursing / Staff Credentials
• Tab 6 - Policies & Procedures
• Tab 7 - QAPI
• Tab 8 - Peer Review & Risk Management
• Tab 9 - Infection Prevention
• Tab 10 - Pharmacy
• Tab 11 - Laboratory / CLIA
• Tab 12 - Radiology / Radiation Safety
• Tab 13 - Medical Records Audits
• Tab 14 - Emergency Preparedness
• Tab 15 - Fire / Life Safety
• Tab 16 - Equipment Maintenance
• Tab 17 - Transfer Agreements
• Tab 18 - HHSC Incident Reporting
• Tab 19 - Patient Rights & Complaints
• Tab 20 - Billing & Required Disclosures
• Tab 21 - HIPAA / Privacy / Security
• Tab 22 - OSHA / Employee Safety
• Tab 23 - Workplace Violence Prevention
• Tab 24 - Survey Findings & Corrective Action Plans

Maintaining an organized survey binder or electronic repository and assigning responsibility for survey readiness were also recommendations in the original preparedness guide. ^[1]

Handbook pages 19, 20 · Source review September 9, 2026

At Least Every Six Months

and targeted readiness audits monthly or quarterly.

Mock surveys should include:

• patient tracer;
• medication tracer;
• credential-file tracer;
• employee-file tracer;
• transfer tracer;
• infection-control tracer;
• QAPI tracer;
• billing/disclosure tracer;
• environment-of-care round;
• emergency-preparedness review; and
• document-retrieval drill.

Deficiencies should generate:

Finding → Root Cause → Corrective Action → Owner → Due Date → Validation → QAPI Closure

Handbook page 20 · Source review September 9, 2026

The Joint Commission's Ambulatory Health Care Accreditation Program specifically includes Freestanding Emergency Care. ^[23]

Joint Commission readiness can add an additional layer of expectations involving:

• leadership;
• quality/performance improvement;
• credentialing;
• medication management;
• infection prevention;
• environment of care;
• emergency management;
• patient safety;
• record of care;
• rights and responsibilities; and
• competency.

Facilities seeking or maintaining Joint Commission accreditation should integrate those standards with—not substitute them for—Texas Chapter 509 requirements.

Handbook pages 20, 21 · Source review September 9, 2026