The Texas Health and Human Services Commission (HHSC) is the primary agency that regulates nursing homes in Texas. HHSC handles licensing, inspections, enforcement, and complaint investigations for all nursing facilities in the state. It also acts as the designated state survey agency for the federal Centers for Medicare and Medicaid Services (CMS), meaning it carries out federal oversight responsibilities on the ground in Texas.
Several other entities play supporting roles, from a federal agency that sets baseline standards to an independent ombudsman program that advocates for residents. Here’s how the full regulatory picture fits together.
HHSC: The Primary State Regulator
HHSC oversees nursing homes through its Health Care Facilities Regulation division. This division licenses facilities, sets staffing and safety standards, conducts inspections, and takes enforcement action when a facility falls short. The legal authority for all of this comes from Chapter 242 of the Texas Health and Safety Code, which covers convalescent and nursing facilities and spells out rules for licensing, general enforcement, quality of care, and residents’ rights.
HHSC also licenses the individual administrators who run nursing homes. The agency’s Nursing Facility Administrators Licensing Branch validates education requirements, issues and renews licenses, and can revoke a license when an administrator fails to meet professional standards.
The Federal Role: CMS
Any nursing home that accepts Medicare or Medicaid (which is most of them) must also meet federal standards set by the Centers for Medicare and Medicaid Services. CMS doesn’t send its own inspectors to every facility. Instead, it contracts with state agencies through what’s called an 1864 Agreement. Under that agreement, HHSC conducts surveys and inspections on behalf of CMS, and CMS holds the state agency accountable for the quality and consistency of that oversight.
CMS also sets certain nationwide requirements that Texas facilities must follow. A recent federal rule, for example, established a minimum staffing standard of 3.48 total nursing hours per resident per day, including at least 0.55 hours of registered nurse care and 2.45 hours of nurse aide care. The rule also requires a registered nurse on site 24 hours a day, seven days a week. These federal floors apply on top of any state requirements.
How Inspections Work
Texas law requires HHSC to conduct at least three unannounced inspections of each nursing facility during every three-year licensing period. These inspections are always unannounced so that surveyors see the facility as it actually operates, not as it looks when staff know someone is coming.
Beyond routine inspections, HHSC can send special teams to conduct validation surveys or verify findings from earlier visits. The agency uses record reviews, random sampling, and other criteria to decide when a deeper look is warranted. Complaint-triggered investigations can also happen at any time outside the regular inspection cycle.
Enforcement Tools
When a nursing home violates state rules, HHSC has a range of enforcement options that escalate with the severity of the problem.
- Administrative penalties: HHSC can assess fines for each individual violation found during a single survey. For facilities that also participate in Medicare or Medicaid, CMS can impose civil money penalties of up to $10,000 per day of noncompliance.
- Trusteeships: If a facility poses an immediate threat to residents, is operating without a license, or is closing without a relocation plan for residents, HHSC can petition the court (through the Texas Attorney General) to appoint a trustee to take over operations.
- License denial or revocation: HHSC can revoke a facility’s license for repeated or substantial violations, and it can deny a license to any facility without a satisfactory compliance history. Revocation can happen at the same time as other enforcement actions.
For serious cases involving health and safety threats, HHSC refers matters to the Office of the Attorney General, which can pursue injunctive relief or civil penalties in court.
The Long-Term Care Ombudsman Program
Texas also runs a State Long-Term Care Ombudsman program that operates independently of nursing facilities. Ombudsmen are advocates for residents’ rights, not regulators in the traditional sense, but they play an important oversight role. They listen to concerns from residents and family members, inform residents of their legal rights, work to resolve problems, and help ensure that state laws and regulations are actually protecting the people they’re meant to protect. The program uses both paid staff and trained volunteers.
How to File a Complaint
If you have concerns about a nursing home in Texas, complaints go directly to HHSC. The fastest option is the Texas Unified Licensure Portal (TULIP), an online system available around the clock. You can also call the complaint hotline at 1-800-458-9858, or send a written complaint by mail to: Health and Human Services Commission, Complaint and Incident Intake, Mail Code E-249, P.O. Box 149030, Austin, Texas 78714-9030.
Once HHSC receives a complaint, the Health Facility Compliance Unit evaluates the allegations and decides whether to authorize a formal investigation. If the complaint points to a potential regulatory violation, investigators are dispatched to the facility. After the investigation, HHSC notifies the person who filed the complaint about what they found.