3800, Clinic Operations

3810 Personnel Policy and Procedures

Revision 22-2; Effective April 1, 2022

Contractors must develop and maintain personnel policies and procedures to ensure that the clinical staff is hired, trained and evaluated appropriately for clinical job positions. Personnel policies and procedures must include:

  • Job descriptions;
  • A written orientation plan for new staff members that includes a statement of skills and/or competencies that are 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.

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

Contractors shall 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 contracted organization’s HHSC Family Planning Program must be a licensed Texas physician.

Contractors 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 22-2; Effective April 1, 2022

HHSC contractors must maintain a safe environment and must have written policies and procedures that address the handling of hazardous materials, fire safety and medical equipment.

Hazardous Materials 

Contractors must have written policies and procedures that address:

  • 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 

Contractors 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 that provide radiology services must:

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

Smoking Ban

Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must comply with this policy.

Disaster Response Plan

Contractors must have written plans that address how staff is to respond to emergency situations (i.e., fires, flooding, power outage and bomb threats, etc.). 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

Contractors 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; and
  • Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols.