Revision 23-2; Effective Sept. 15, 2023

Grantees that provide clinical services must develop and maintain written clinical prescriptive authority agreements (PAAs), protocols and standing delegation orders (SDOs) in compliance with statutes and rules governing medical, dental, and nursing practice and consistent with national evidence-based clinical guidelines. When HHSC revises a policy, grantees need to incorporate the revised policy into their written procedures.

5310 Prescriptive Authority Agreements

Revision 23-2; Effective Sept. 15, 2023

When services are provided by an advanced practice registered nurse (APRN) or physician assistant (PA), it is the responsibility of the grantee to ensure that a properly executed prescriptive authority agreement (PAA) is in place for each mid-level provider. The PAA must meet all the requirements delineated in Texas Occupations Code,Chapter 157, including, but not limited to, the following criteria:

  • be in writing and signed and dated by the parties to the agreement;
  • be reviewed at least annually (including amendments);
  • kept on-site where the APRN or PA provides care;
  • include the name, address and all professional license numbers of all parties to the agreement;
  • state the nature of the practice, practice locations or practice settings;
  • identify the types or categories of drugs or devices that may be prescribed, or the types or categories of drugs or devices that may not be prescribed;
  • provide a general plan for addressing consultation and referral;
  • provide a plan for addressing patient emergencies;
  • describe the general process for communication and sharing of information between the physician and the APRN or PA to whom the physician has delegated prescriptive authority related to the care and treatment of individuals;
  • if alternate physician supervision will be used, appoint one or more alternate physicians who may:
    • provide appropriate temporary supervision following the requirements established by the PAA and the requirements of this section; and
    • participate in the prescriptive authority quality assurance and improvement plan meetings required under this section;
  • describe a prescriptive authority quality assurance and improvement plan and specify methods for documenting the implementation of the plan that includes:
    • chart review, with the number of charts to be reviewed determined by the physician and APRN or PA; and
    • periodic meetings between the APRN or PA and the physician at a location determined by the physician, APRN or physician assistant.


5320 Protocols

Revision 23-2; Effective Sept. 15, 2023

Grantees that employ advanced practice nurses or physician assistants must have written protocols to delegate authorization to initiate medical aspects of client care. Historically, this delegation has occurred through a protocol or other written authorization. Rather than have two documents, this delegation can now be included in a prescriptive authority agreement (PAA) if both parties agree to do so. The PAA or protocols need not describe the exact steps that an APRN or a PA must take with respect to each specific condition, disease or symptom.

The protocols must be reviewed, agreed upon, signed and dated by the supervising physician and the PA or APRN at least annually and maintained on-site as mandated by Texas Administrative Code, Title 22, Part 11, Chapter 221, Rule 221.13

5330 Standing Delegation Orders

Revision 23-2; Effective Sept. 15, 2023

Per TAC Title 22, Part 9, Chapter 193,when services are provided by unlicensed and licensed personnel other than an APRN or PA whose duties include actions or procedures for a population with specific diseases, disorders, health problems or sets of symptoms, the clinic must have written standing delegation orders (SDOs) in place. SDOs are distinct from specific orders written for an individual. SDOs are instructions, orders, rules, regulations or procedures that specify under what set of conditions and circumstances certain actions may be taken.

The grantee must have SDOs in place for unlicensed and licensed personnel (not APRNs or PAs) that include the following:

  • actions or procedures for a population with specific diseases, disorders, health problems, or sets of symptoms;
  • delineate under what circumstances an RN, LVN or non-licensed health care provider (NLHP) may initiate actions or tasks in the clinical setting; and 
  • provide authority for use with a patient: 
    • when a physician or advance practice provider is not on the premises; and
    • before a patient is examined or evaluated by a physician or advanced practice provider. 

Example: An SDO for assessment of blood pressure and blood-sugar level would name the RN, LVN or NLHP that will perform the task, the steps to complete the task, the ranges for normal and abnormal and the process of reporting abnormal values.

Other applicable SDOs when a physician is not present on-site may include, but are not limited to:

  • obtaining a personal and medical history;
  • performing an appropriate physical exam and the recording of physical findings;
  • initiating and performing laboratory procedures;
  • administering or providing drugs ordered by voice communication with the authorizing physician;
  • providing pre-signed prescriptions for:
    • oral contraceptives;
    • diaphragms;
    • contraceptive creams and jellies;
    • topical anti-infective for vaginal use; or
    • antibiotic drugs for treatment of STIs and STDs;
  • handling medical emergencies to include on-site management, as well as possible transfer of the individual;
  • giving immunizations; or
  • performing pregnancy testing.

The grantee must have a process in place to ensure that SDOs are reviewed, signed and dated at least annually by the supervising physician responsible for the delivery of the medical care covered by the orders and by other appropriate staff. SDOs must be kept on-site.


5340 Client Education

Revision 23-2; Effective Sept. 15, 2023

In addition to the above, grantees must have written plans for client education that include goals and content outlines to ensure consistency and accuracy of information provided. Grantees’ plans for client education must be reviewed and signed by the clinic medical director.