Revision 23-4; Effective Nov. 17, 2023

Grantees must ensure services are provided in a timely and nondiscriminatory manner and must:

• have a policy in place to identify and eliminate possible barriers to client care, including ensuring clinic or reception room waiting times do not present a barrier to care;
• have a policy in place that delineates the timely provision of services, as follows:
  • people  who are deemed eligible for FPP should be given an appointment as soon as possible and no later than 30 days from the initial request;
  • clients who request a contraceptive method but cannot be given a clinical appointment immediately must be offered a non-prescription method; and 
  • minors under 18 years old should be seen as soon as possible, with every effort made to provide an appointment within two weeks of the request; 
• have a policy in place that requires qualified staff to assess and prioritize a person’s needs;
• provide referral sources for people who cannot be served or cannot receive a specific service;
• manage funds to ensure established clients continue to receive services throughout the budget year (Sept. 1 through Aug. 31); 
• inform applicants of FPP services and encourage them to bring required documentation to the first visit for eligibility processing; 
• comply with all laws, regulations, and contract terms and conditions, as outlined in Section 3500, Nondiscrimination and Limited English Proficiency.

Grantees may not deny services to a qualifying person based on the person’s inability to pay.
 

Revision 23-4; Effective Nov. 17, 2023

In addition to FPP, people who have served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air Force, Space Force, Coast Guard, Reserves or National Guard, may be eligible for benefits and services under other HHSC programs. For more information, visit the Texas Veterans Portal.

Revision 23-4; Effective Nov. 17, 2023

Grantees must obey state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or people aged 65 years or older. The Texas Human Resources Code, Chapter 48, requires that suspected abuse, neglect or exploitation of an elderly person, a person with a disability or a person  receiving services from certain home and community-based providers be reported. Grantees must have an agency policy regarding abuse and neglect.

Reporting an Abuse Emergency

To report an emergency that involves the abuse or neglect of children, adults with disabilities, people aged 65 years or older, or a person receiving services from certain home and community-based providers, call the Texas Abuse Hotline at 800-252-5400 or online at TXAbuseHotline.org. For cases that pose an imminent threat or danger to the person, call 9-1-1 or any local or state law enforcement agency. 

Call the Texas Abuse Hotline at 1-800-252-5400 for situations including but not limited to:

• Serious injuries.
• Any injury to a child 5 years or younger.
• Immediate need for medical treatment (including suicidal thoughts).
• Sexual abuse where the abuser has or will have access to the victim within the next 24 hours.
• Children aged five and under who are alone or are likely to be left alone within the next 24 hours.
• Anytime you believe your situation requires action in less than 24 hours.

Reporting a Suspicion of Abuse

For situations that do not require immediate investigation and to report suspicions of abuse, neglect and exploitation of children, adults with disabilities, people aged 65 years or older, or a person receiving services from certain home and community-based providers, use the Department of Family and Protective Services Texas Abuse Hotline.

3310 Child Abuse Reporting, Compliance and Monitoring

Revision 23-4; Effective Nov. 17, 2023

Grantees and providers must develop policies and procedures that follow the reporting guidelines and requirements in Texas Family Code, Chapter 261. Grantee must develop an internal policy to determine:

• how child abuse reporting requirements will be implemented throughout their agency;
• how staff will be trained; and
• how internal monitoring will be done to ensure timely reporting.

During quality assurance (QA) monitoring, compliance with the following criteria will be evaluated:

• The grantee's process must ensure staff is reporting abuse as required by Texas Family Code, Chapter 261. To verify compliance, QA monitors examine the grantee to assess whether the they:
  • have an internal policy which details how the grantee will determine, document, report and track instances of abuse, sexual and non-sexual, for all persons under age 18 in compliance with the Texas Family Code, Chapter 261;
  • follow their own internal policy; and
  • document staff training on child abuse reporting requirements and procedures.
• The grantee’s internal policy must clearly describe the reporting process for child abuse.
   

Resources for child abuse reporting policy development are found at the Texas Abuse Hotline.

3320 Human Trafficking

Revision 23-4; Effective Nov. 17, 2023

HHSC requires that grantees obey state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that grantees follow applicable federal laws, family planning grantees must follow anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC Section 7101, et seq.).

Grantees must have a written policy on human trafficking which includes the provision of annual staff training.

Resources for Human Trafficking Policy Development  

• Texas Health and Human Services Human Trafficking Resource Center: https://hhs.texas.gov/services/safety/texas-human-trafficking-resource-center
• Texas Health and Human Services Health Care Practitioner Training Page:   https://hhs.texas.gov/services/safety/texas-human-trafficking-resource-center/health-care-practitioner-human-trafficking-training

3330 Domestic and Intimate Partner Violence

Revision 23-4; Effective Nov. 17, 2023

Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. Per Texas Human Resources Code, Chapter 51, family violence may also include emotional harm and a threat of harm. This type of violence can occur among heterosexual or same-sex couples. IPV can exist regardless of the presence of sexual intimacy.

Grantees must have a written policy related to assessment and prevention of domestic and intimate partner violence, including the provision of annual staff training.
 

Revision 23-4; Effective Nov. 17, 2023

All contracting agencies must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards for protection of privacy.

Grantees must ensure all employees and volunteers receive training about client confidentiality during orientation and understand violation of the law regarding confidentiality may result in civil damages and criminal penalties. A health care provider’s staff (paid and unpaid) must be informed during orientation of the importance of keeping client information confidential (1 Texas Administrative Code Section 382.125(c)). All employees, volunteers, subgrantees and advisory board members must sign a confidentiality statement during orientation.

A grantee must document the client’s  preferred method of follow-up for clinic services (cell phone, email, work phone or text) and preferred language in the client’s record. Each client must receive verbal assurance of confidentiality, an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting. 

Additionally, grantees may not require consent for family planning services from the spouse of a married client (1 TAC Section 382.125).

For information specific to minors and confidentiality, refer to Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program.
 

Revision 23-4; Effective Nov. 17, 2023

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16.1, HHSC grantees must comply with state and federal anti-discrimination laws, including but not limited to:

• Title VI of the Civil Rights Act of 1964
• Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Section 794)
• Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.) 
• Age Discrimination Act of 1975 (42 U.S.C. Sections 6101-6107) 
• Title IX of the Education Amendments of 1972 (20 U.S.C. Sections 1681 et seq.)
• Administrative rules, to the extent applicable to HHSC grantees, are set forth in the Texas Administrative Code (TAC) Title 1 Part 15 Section 395.32.  

Additionally, grantees must comply with Article IX, Section 9.21 (a-f) Civil Rights, the HHSC Special Conditions Version 1.1, Article V, Section 5.06 Services, and Information for Persons with Limited English Proficiency. These are part of a grant with the state. 

It is highly recommended that grantees comply with Texas Government Code, Section 2054.457, Access to Electronic and Information Resources.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website and the HHSC Civil Right Office, Requirements for Contractors website.

Grant Terms and Conditions 

To ensure compliance with nondiscrimination laws, regulations and policies,
grantees must:

• sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
• have a written policy   that states the agency does not discriminate on the basis of race, color, national origin, including limited English proficiency (LEP), sex, age, religion or disability;
• have a policy that addresses individual rights and responsibilities applicable to all persons requesting family planning services;
• have procedures for notifying the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint no more than 10 calendar days after the allegation or complaint;
• ensure all grantee staff is trained in the discrimination policies, including policies for serving people with LEP and people with disabilities, and HHSC complaint procedures;
• notify all applicants who are applying for family planning services of the grantee’s nondiscrimination policies and complaint procedures; and
• prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desk and locations where people apply for services (posters can be found on the Civil Rights Office website).

More information about nondiscrimination laws and regulations can be found on the HHSC Civil Rights Office page.
 

3610 Resolution of Complaint

Revision 23-4; Effective Nov. 17, 2023

Grantees must ensure clients have a means to express complaints and concerns about care received to HHSC, and ensure those complaints and concerns are handled in a consistent manner. Grantee’s policy manuals must explain the process clients may follow if they are not satisfied with the care received. If an aggrieved client makes a request for a hearing, a grantee shall not terminate the client until a final decision is rendered by HHSC. Any client complaint must be documented in the client’s record.

3620 Termination of Services 

Revision 23-4; Effective Nov. 17, 2023

A qualifying person must never be denied services due to an inability to pay.

Grantees have the right to terminate services to a client if the client is disruptive, unruly, threatening or uncooperative to the extent that the client seriously impairs the grantee to provide services effectively and safely, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. A client has the right to appeal the denial, suspension or termination of services (1 TAC Section 382.111). 

For more information, see Fair and Fraud Hearings on the HHSC website.

Policies for termination of services must be included in the grantee’s policy manual.
 

3630 Freedom of Choice

Revision 23-4; Effective Nov. 17, 2023

FPP clients are guaranteed the right to voluntarily choose qualified family planning providers and methods without coercion or intimidation. Acceptance of family planning services may not be required for eligibility for, or receipt of, any other service or assistance from the entity or individual that would provide the service or assistance.

3640 Research (Human Subject Clearance)

Revision 23-4; Effective Nov. 17, 2023

To participate in proposed research that would involve the use of FPP clients as subjects, the use of clients’ records or any data collected from FPP clients, grantees must get prior approval from their own internal Institutional Review Board (IRB) and from HHSC. For information about the process, grantees may visit the Institutional Review Board website. 

The grantee must have a policy that states that approval will be obtained from HHSC before instituting any research activities. The grantee must ensure all staff members are aware of this policy through staff training. The grantee must keep documentation of training on this topic.
 

Revision 23-4; Effective Nov. 17, 2023

Grantees must have an organized and secure client record system. The grantee must ensure records are organized, readily accessible and available to the client upon request with a signed release of information. Records must be kept confidential and secure, as follows:

• safeguarded against loss or use by unauthorized persons;
• secured by lock when not in use and inaccessible to unauthorized persons; and
• maintained in a secure environment in the facility, as well as during transfer between clinics and between home and office visits.

The written consent of the client is required for the release of personally identifiable information, except as may be necessary to provide services to the client, or as required by law, with appropriate safeguards for confidentiality. If the client is a minor, the minor’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. Emancipated or married minors authorize the release of their own information. HIV information should be handled according to state and federal Law, Rules, and Authorization.

When information is requested, grantees must release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify clients. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to ensure continuity of care. Electronic records are acceptable as medical records.

Grantees and subgrantees must maintain for the time specified by HHSC all records of client services, contracts and payments. 

Requirements are found in Title 1, Part 15 TAC Section 354.1003, relating to time limits for submitted claims, and in Title 22, Part 9 TAC Section 165, relating to maintenance of medical records. Grantees must follow contract provisions, maintain medical records for at least seven years after the close of the contract and follow the retention standards of the relevant licensing entity. All records relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 
 

3810 Personnel Policy and Procedures

Revision 23-4; Effective Nov. 17, 2023

Grantees must develop and maintain personnel policies and procedures to ensure all staff are hired, trained and evaluated appropriately for their job position. Personnel policies and procedures must include:

• job descriptions;
• a written orientation plan for new staff members that includes a statement of skills and competencies appropriate for the position; and
• a performance evaluation process for all staff members.

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

Grantees must show evidence employees meet all required qualifications and receive annual training. Job evaluations should include observation of staff-client interactions during clinical, counseling and educational services.

Grantees must establish safeguards to prohibit employees from using their positions for a purpose that constitutes or presents the appearance of personal or organizational conflict of interest or personal gain. All employees and board members must complete a conflict-of-interest statement during orientation. All medical care must be provided under the supervision, direction and responsibility of a qualified medical director. The designated medical director for a grantee must be a licensed Texas physician.

Grantees must have a documented plan for organized staff development. There must be an assessment of:

• training needs;
• quality assurance indicators; and
• changing regulations and requirements.

Staff development must include orientation and in-service training for all personnel and volunteers. Nonprofit entities must provide orientation for board members and government entities must provide orientation for their advisory committees. Employee orientation and continuing education must be documented in agency personnel files. 

3820 Facilities and Equipment

Revision 23-4; Effective Nov. 17, 2023

Grantees are required to always maintain a safe environment. Grantee must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas and space for clinical and administrative staff. Grantees must have policies and procedures addressing hazardous materials, fire safety and medical equipment.

Hazardous Materials 

Grantees must have written policies and procedures addressing:

• the handling, storage and disposing of hazardous materials and waste according to applicable laws and regulations;
• the handling, storage and disposing of chemical and infectious waste, including sharps; and
• an orientation and education program for personnel who manage or have contact with hazardous materials and waste.
   

Fire Safety 

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment 

Contractors must have a written policy and keep documentation of the maintenance, testing and inspection of medical equipment, including automated external defibrillators (AEDs). Documentation must include:

• assessments of the clinical and physical risks of equipment through inspection, testing and maintenance;
• reports of any equipment management problems, failures and use of errors;
• an orientation and education program for personnel who use medical equipment; and
• manufacturer recommendations for care and use of medical equipment.

Radiology Equipment and Standards 

All facilities providing radiology services must:

• possess a current Certificate of Registration from the Texas Department of State Health Services (DSHS) Radiation Control Program;
• comply with Title 25, Texas Administrative Code, Chapter 289, Texas Regulations for Control of Radiation; and
• post “Notice to Employees,” Texas Regulations for Control of Radiation.

For information on X-ray machine registration, see the DSHS Radiation Control Program.

Smoking and Vaping Ban

Grantees must have written policies prohibiting smoking and vaping in any portion of their indoor facilities. If a grantee contracts with another entity for the provision of health services, the subgrantee must uphold this policy.

Disaster Response Plan

Grantees must have written plans addressing how staff is to respond to emergency situations (i.e., fires, flooding, power outages, bomb threats, etc.). The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position responsible for each activity. A disaster response plan must be in writing, formally communicated to staff and kept in the workplace available to employees for review. For an employer with 10 or fewer employees, the plan may be communicated orally to employees.

For resources on facilities and equipment, see the Occupational Safety and Health Administration Compliance Assistance Guide.

Clinical Emergencies

Grantees must be adequately prepared to handle clinical emergency situations, as follows:

• There must be a written plan for the management of on-site medical emergencies, emergencies requiring ambulance services and hospital admission.
• Each site must have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action, and staff trained in CPR must be present during all hours of clinic operations.
• There must be written protocols to address vasovagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties.
• Each site must maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present.
• Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols. 

Revision 23-4; Effective Nov. 17, 2023

Quality assurance and quality improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal quality assurance and quality improvement (QA/QI) systems and processes to monitor FPP services. Grantees must have a quality management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care. Grantees should integrate QM concepts and methods into the structure of the organization and day-to-day operations. 

Grantees are expected to develop quality processes based on four core QM principles that focus on:

• the client;
• systems and processes;
• measurement; and
• teamwork.

The QM program must be developed and implemented in such a way that provides for ongoing evaluation of services. Grantees should have a written , comprehensive plan for the internal review, measurement and evaluation of services, the analysis of monitoring data, and the development of strategies for improvement and sustainability.

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities.

An important part of the QM program is the QM committee, whose membership consists of key leadership of the organization, including the executive director or chief executive officer, medical director and other appropriate staff, where applicable. The committee must annually review and approve a quality work plan for the organization.

The QM committee must meet at least quarterly to:

• receive reports of monitoring activities;
• make decisions based on the analysis of data collected;
• determine QI actions to be implemented; and
• reassess outcomes and goal achievement.

Meeting dates, minutes of the discussion, actions taken by the committee and a list of the attendees must be maintained and made available during QA/QI reviews.

The comprehensive quality work plan, at a minimum, must:

• be reviewed annually;
• include clinical and administrative standards by which services will be monitored;
• include the process for credentialing and peer review of clinicians;
• identify persons  responsible for implementing, monitoring, evaluating and reporting;
• establish timelines for QM activities;
• identify tools and forms to be used; and
• outline reporting to the QM committee.

Although each organization’s QM program is unique, the following activities must be undertaken by all agencies providing client services:

• ongoing eligibility, billing, and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• tracking and reporting of adverse outcomes;
• annual review of facilities to maintain a safe environment, including an emergency safety plan;
• annual review and update of all prescriptive authority agreements (PAAs) for mid-level providers; 
• annual review of all standing delegation orders and clinical protocols used;  
• annual review of all policies and forms; and 
• up-to-date performance evaluations to include primary license verification, Drug Enforcement Administration and immunization status 

The review or revision date must be clearly noted on each policy, form, agreement, order, etc. used. 

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subgrantee, to include at a minimum:

• annual license verification (primary source verification);
• clinical record review;
• billing and eligibility review;
• utilization review;
• facility on-site review;
• annual client satisfaction evaluation process; and
• child abuse training and reporting for subgrantee staff.

Data from these activities must be presented to the QM committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented.