Revision 23-2; Effective Sept. 8, 2023

This section assists the grantee in conducting administrative activities such as assuring client access to services and managing client records.

3100 Accessibility

Revision 25-1; Effective Jan. 31, 2025

Maintaining Clinic Information on 2-1-1

Grantees must maintain current and correct clinic information on  211Texas.org for all locations that provide services. Grantees will use the Add or Edit Your 2-1-1 Listing link at the top of the webpage to make any changes to their clinic location information listings. Grantees must accurately maintain the following information in their 2-1-1 listings:

  • clinic phone number,
  • location,
  • hours of operation, and
  • services provided.

Client Access

HHSC contracts require grantees to comply with state and federal antidiscrimination laws. Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights Office webpage.

3200 Abuse and Neglect Reporting

Revision 25-1; Effective Jan. 31, 2025

Grantees must obey state laws that govern reporting of suspected abuse and neglect.

Call the Texas Abuse Hotline at 800-252-5400 or use the secure website to report abuse or neglect. For cases that pose an imminent threat or danger to a person, call 9-1-1 or the appropriate local law enforcement agency.

Grantees must have written policies and procedures to identify and appropriately report abuse, neglect and exploitation of:

  • the elderly and adults with disabilities per Texas Human Resources Code, Chapter 48; and
  • child abuse and neglect per Texas Family Code, Chapter 261.

Grantees also must have written policies and procedures to identify and respond to:

Grantees must provide annual staff training on each separate policy and procedure.

Child Abuse and Neglect

Child Abuse and Neglect Policies must include:

  • Medical professionals to make a report by the 48th hour after first suspecting a child has been abused or neglected or is a victim of an offense.
  • Guidelines to determine, document, report and track instances of abuse, sexual or non-sexual, or neglect for all people 17 years and younger to comply with Texas Family Code, Chapter 261.

For more information on abuse reporting, review the Texas Department of Family and Protective Services webpage.

Human Trafficking

Grantees must comply with all state and federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000, 22 USC Section 7101, et seq., and Texas Occupations Code Sections 116.002 and 116.003, which require health practitioners to complete an HHS-Approved Human Trafficking Course for every licensure renewal period.

Grantee written policies on human trafficking must include:

  • human trafficking definition;
  • how to identify possible situations of human trafficking;
  • the screening tool used to identify possible situations of human trafficking;
  • what to do and who to report to if human trafficking is suspected;
  • mandatory reporting of suspected child human trafficking; and
  • victim support resources.

Resources for Human Trafficking Policy Development:

Domestic and Intimate Partner Violence (IPV)

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 does not require sexual intimacy.

Grantees must comply with all requirements listed in Texas Family Code- Chapter 91 and have a written policy about assessment and prevention of domestic and IPV.

Find more information on IPV on the Centers for Disease Control and Prevention website. The National Domestic Violence Hotline is 800-799-7233. It operates 24/7 and provides interpretation services in more than 200 languages.

3300 Confidentiality

Revision 24-2; Effective Sept. 30, 2024

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

Grantees are required by HIPPA Privacy Rule to develop and distribute a notice that provides a clear explanation of privacy rights and practices.  This Notice of Privacy Practices must be given to clients at the first appointment, upon request, and at minimum, every three years. The notice must also be posted in a clear and easy to find location for clients to view and must be posted on the organization’s website. Review Notice of Privacy Practices for Protected Health Information | HHS.gov, Notice of Privacy Practices | HHS.gov  for more information.

Grantees must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, subrecipients, board members and advisory board members must sign a confidentiality statement during orientation.

A Grantee must document the person’s preferred method of communication such as cell phone, email, work phone or text, and preferred language in the client’s record.

Each client must receive verbal assurance of confidentiality and an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as mandatory reporting.  A health care provider must not require consent for services from the spouse of a married client.  

Minors and Confidentiality

Except as permitted by law, a provider is legally required to maintain the confidentiality of care provided to a minor. Confidential care does not apply when the law requires parental notification or consent or when the law requires the provider to report health information, such as in the cases of contagious disease or abuse. The definition of privacy is the ability of the person to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider not to disclose protected information. While confidentiality is implicit in maintaining a patient's privacy, confidentiality between provider and patient is not an absolute right.

The HIPAA privacy rule requires a covered entity to treat a personal representative the same as the individual with respect to uses and disclosures of the individual’s protected health information. In most cases, parents are the personal representatives for their minor children and they can exercise individual rights, such as access to medical records, on behalf of their minor children. Review Code of Federal Regulations - 45 CFR Section 164.502(g).

Review Adolescent Health – A Guide for Providers for more information (PDF).

3310 Civil Rights

Revision 25-1; Effective Jan. 31, 2025

Grantees must comply with state and federal anti-discrimination laws per contracts with HHSC.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website.

3320 Required Signage

Revision 24-2; Effective Sept. 30, 2024

Grantees providing direct services to clients must display certain HHS posters related to civil rights.  The posters must be displayed in areas where clients and the public can easily view them, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive HHS services. The following posters are required:  

Grantees are encouraged to display signage about suicide prevention, including the 988 Suicide and Crisis Lifeline. If grantee elects to display such signage, it must be displayed in areas where it is easily viewed by clients and the public, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services. Examples of a suitable flyers are available here: 

Additional mental health and suicide prevention resources are available here:  

3330 Complaints and Termination of Services

Revision 24-2; Effective Sept. 30, 2024

Termination of Services

A grantee must never deny services to an eligible client 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’s ability to effectively and safely provide services; or
  • the client’s behavior jeopardizes their own safety, or the safety of clinic staff or others. 

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

If a grantee denies, modifies, suspends, or terminates services to a client, an explanation must be documented in the client’s record. A client has the right to appeal the denial, modification, suspension, or termination of services by following the Resolution of Complaints process.

Resolution of Complaints

Grantees must ensure that clients can express concerns about care received and that those complaints are handled in a consistent manner. Grantees’ policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received. 

1. Grantees must investigate and resolve a complaint or concern within 30 business days, beginning on the day they are notified by the aggrieved client.

2. Clients may contact the grantee during and after the resolution of an investigation to receive more information on the grantee's decision or help to correct the issue. 

3. Grantees must provide the client with contact information to the HHS Office of the Ombudsman. If a client has requested additional assistance from the Ombudsman, a grantee must not terminate services to that client until a final decision is rendered by HHSC, unless there is a viable risk to the safety of the aggrieved client, clinic staff, or others.

4. All complaints and concerns must be documented in the client's record.

3340 Research (Human Subjects Clearance)

Revision 24-2; Effective Sept. 30, 2024

Grantees considering clinical or sociological research using TVFFS funded clients as subjects must get prior approval from their own internal Institutional Review Board (IRB) and HHSC.

The grantee must have a policy in place indicating prior approval will be obtained from the HHSC TVFFS Program, as well as the IRB, before instituting any research activities. The grantee must also ensure that all staff are made aware of this policy through staff training. Documentation of training on this topic must be maintained.

3400 Client Records Management

Revision 24-2; Effective Sept. 30, 2024

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

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

Written consent is required for the release of personally identifiable information, except when necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years or younger, the client’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. HIV information should be handled per federal and state law.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may be only disclosed in summary, statistically or in a format that does not identify individuals. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care.

Grantees, providers, and subrecipients must maintain all records pertaining to client services, contracts and payments, for the time specified by HHSC. 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 appropriate 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. 

3500 Personnel Policies and Procedures

Revision 24-2; Effective Sept. 30, 2024

Grantees must develop and maintain personnel policies and procedures to ensure that clinical staff are hired, trained and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated per their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. Grantees should follow the Advisory Committee on Immunization Practices (ACIP) for immunization of health care workers. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

  • job descriptions, including those for contracted personnel;
  • a written orientation plan for new staff including skills evaluation or competencies appropriate for the position; and
  • a performance evaluation process for all staff.

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

Grantees shall establish safeguards to prohibit employees from using their positions in ways 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. All dental services must be provided under the supervision, direction and responsibility of a qualified licensed dentist.

The TVFFS medical director for the clinic must be a Texas-licensed physician and the TVFFS dental director for the clinic must be a  Texas licensed dentist.

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

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

3600 Facilities and Equipment

Revision 24-2; Effective Sept. 30, 2024

Grantees must always maintain a safe environment and provide clean and well-maintained facilities where services are 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 hazardous materials, fire safety and medical equipment.

Hazardous Materials

Grantees must have written policies and procedures that address:

  • the handling, storage, and disposal of hazardous materials and waste per 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.

Fire Safety

Grantees must have a written fire safety policy that includes a schedule for testing and maintenance of fire safety equipment. Clearly post evacuation plans for the premises. They must be visible to all staff and clients.

Medical Equipment

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment. This includes the 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 care and use of medical equipment.

Radiology Equipment and Standards

All facilities providing radiology services, including dental X-rays, must:

Review the Texas Department of State Health Services, Radiation Control Program for information on X-ray machine registration.

Laboratory Standards 

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 get CLIA certification.  

Smoking Ban

Grantees 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 also comply with this policy. 

3700 Emergency Responsiveness

Revision 25-1; Effective Jan. 31, 2025

Clinical Emergencies

Grantees must adequately prepare to handle clinical emergency situations. Each site must:

  • have a written plan for the management of on-site medical emergencies, emergencies that require ambulance services and hospital admission.
  • have staff trained in basic cardiopulmonary resuscitation (CPR) and emergency medical action. Staff trained in CPR must be present during all hours of clinic operations.
  • maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site and have appropriately trained staff when clients are present.
  • maintain documents in personnel files that confirm staff are trained in the written plans or protocols.

Dental Emergencies

The dental office or clinic must have a written emergency plan that includes criteria for management of emergencies. The plan must be reviewed annually and as needed. Requirements for emergencies are at the Texas State Board of Dental Examiners website and in the Texas rule for Minimum Standard of Care. 

Emergency Preparedness

A written safety plan must include maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.

Disaster Response Plan

Grantees must have written disaster response plans that address how staff must respond to emergency situations such as:

  • fires,
  • flooding,
  • power outage and
  • bomb threats.

The disaster plan must identify the procedures and processes that will be initiated during a disaster and the staff position(s) 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. An employer with 10 or fewer employees may communicate the plan to them verbally. 

Review the  Occupational Safety and Health Administration website for more resources on facilities and equipment.  

3800 Quality Management

Revision 24-2; Effective Sept. 30, 2024

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor TVFFS 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 methodologies 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 a way that provides for ongoing evaluation of services. Grantees should have a 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.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, the medical director and dental director, and other appropriate staff where applicable, annually reviews and approves the 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 quality improvement actions to be implemented; and
  • reassess outcomes and goal achievement.

Minutes of the discussion and actions taken by the committee and a list of the attendees must be maintained.

The comprehensive quality work plan must, at minimum:

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

Although each organization’s QA program is unique, the following activities are required by all agencies that provide client services:

  • ongoing eligibility, billing, and clinical record reviews to assure compliance with program requirements and clinical standards of care;
  • utilization review:
  • client satisfaction surveys;
  • defining, reporting, tracking, and follow-up of adverse outcomes;
  • annual performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications;
  • annual review of facilities to maintain a safe environment, including an emergency safety plan; 
  • annual review and update of all prescriptive authority agreements (PAAs), including protocols, for mid-level providers;
  • annual review of all standing delegation orders (SDOs) and clinical protocols; and
  • annual review of all policies and forms. 

The review or revision date must be clearly noted on each policy, form, agreement, and order that is in use. 

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 subcontracting entities, including:

  • annual license verification (primary source verification);
  • clinical record review;
  • eligibility and billing review;
  • utilization review;
  • on-site facility review;
  • annual client satisfaction evaluation process; and
  • compliance with all abuse and neglect, and civil rights requirements.

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 QM Committee and should be documented.