Revision 24-2; Effective Sept. 16, 2024
HHSC grantees are required to always maintain a safe environment. Grantees 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. Clinic sites must be geographically close to the target population(s) the grantee intends to serve. Grantees must have written policies and procedures that address the forementioned requirements, and include a policy that discusses hazardous materials, fire safety and medical equipment.
3610 Hazardous Materials
Revision 23-2; Effective Sept. 15, 2023
Grantees must have written policies and procedures that address:
- the handling, storage and disposal of hazardous materials and waste, according to applicable laws and regulations;
- the handling, storage and disposal 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.
3620 Fire Safety
Revision 23-2; Effective Sept. 15, 2023
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.
3630 Medical Equipment
Revision 23-2; Effective Sept. 15, 2023
Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an Automated External Defibrillator (AED). 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 errors;
- an orientation and education program for personnel who use medical equipment; and
- manufacturer recommendations for the care and use of medical equipment.
3640 Radiology Equipment and Standards
Revision 23-2; Effective Sept. 15, 2023
All facilities providing radiology services, including dental X-rays, must:
- possess a current Certificate of Registration from the Texas Department of State Health Services Radiation Control Program;
- have operating and safety procedures, as required by 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 Texas Department of State Health Services, Radiation Control Program.
3645 Laboratory Standards
Revision 23-2; Effective Sept. 15, 2023
All facilities providing laboratory services must possess a current Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver. CLIA requires that any facility examining human specimens for diagnosis, prevention, treatment of a disease, or for assessment of health must register with the federal Centers for Medicare & Medicaid Services (CMS) and obtain CLIA certification.
3650 Smoking Ban
Revision 24-2; Effective Sept. 16, 2024
Grantees must have written policies that prohibit smoking in any portion of their indoor facilities. If a grantee subcontracts with another entity for the provision of health services, the subrecipient also comply with this policy.