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 Administrative Policies

Revision 23-2; Effective Sept. 8, 2023

Maintaining Clinic Information on 2-1-1

Grantees must maintain current and correct clinic information on for all locations providing services. Grantees will use the Add or Edit Your 2-1-1 Listing link found at the top of the webpage to make any changes to their clinic location information listings. The information that grantees shall accurately maintain in their 2-1-1 listings includes, but is not limited to, clinic phone number, location, hours of operation and services provided.  

Client Access

Grantee must observe all Texas Health and Human Services (HHS) policies and federal and state civil rights laws and treat clients and the public with dignity and respect. Grantees must ensure that clients are provided services in a timely and nondiscriminatory manner. The grantee must:

  • Have a policy in place that delineates the timely provision of services.
  • Have policies in place to identify and eliminate possible barriers to client care.
  • Comply with all applicable civil rights laws and regulations including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act (ADA) of 1990, the Age Discrimination Act of 1975, Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to people with Limited English Proficiency (LEP) and speech or sensory impairments.
  • Have a policy in place that requires qualified staff to assess and prioritize client needs.
  • Provide referral resources for people who cannot be served or cannot receive a specific needed service.
  • Maintain appropriate exterior signage identifying the entity as a healthcare facility.
  • Ensure clinic or reception room wait times are reasonable and do not present a barrier to care.

Important Information for Former Military Service Members

Women and men who served in any branch of the United States Armed Force, including Army, Navy, Marines, Air Forces, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services. Visit the Texas Veterans Portal for more information. 

3200 Abuse and Neglect Reporting

Revision 23-2; Effective Sept. 8, 2023

Abuse and Neglect 

Grantees must obey state laws governing the reporting of suspected abuse and neglect of children, adults with disabilities, or individuals 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 an individual receiving services from certain home and community-based providers be reported. Grantees must have an agency policy regarding abuse and neglect.

To report abuse or neglect, call the Texas Abuse Hotline at 800-252-5400, or use the secure Texas Abuse Hotline Website. For cases that pose an imminent threat or danger to an individual, call 9-1-1, or any local or state law enforcement agency.

Child Abuse Reporting, Compliance and Monitoring

Grantees are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261 of the Texas Family Code.

Grantees must develop an internal policy specific to:

  • Determining, documenting, reporting, and tracking instances of abuse, sexual or non-sexual, for all individuals age 17 and younger in compliance with Texas Family Code, Chapter 261; and 
  • Annual staff training requirement, including how staff will be trained. 

Additional information for abuse reporting: Texas Department of Family and Protective Services.

Human Trafficking

HHSC mandates that grantees comply with state laws governing the reporting of abuse and neglect. Additionally, as part of the requirement that grantees comply with all applicable federal laws, grantees must comply with the federal 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.

References 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. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

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

Additional information on IPV can be found on the Centers for Disease Control and Prevention website.

3300 Confidentiality

Revision 23-2; Effective Sept. 8, 2023

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

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, subgrantees, board members and advisory board members must sign a confidentiality statement during orientation.

The client’s preferred method of follow-up to clinic services (cell phone, email, work phone or text) and preferred language must be documented 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 abuse reporting.

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 (Code of Federal Regulations - 45 CFR Section 164.502(g)).

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

Nondiscrimination and Limited English Proficiency (LEP)

As outlined in the HHSC Uniform Terms and Conditions – Grant Version 2.16 (PDF), grantees must comply with state and federal anti-discrimination laws, including but not limited to:

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

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

  • Americans with Disabilities Act  
  • Know Your Rights – Clients and Applicants 
  • Need a Sign Language Interpreter?  
  • Need an Interpreter? 

Termination of Services

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’s ability to provide services effectively and safely, or if the client’s behavior jeopardizes his or her own safety, clinic staff or others. A person has the right to appeal the denial, modification, suspension or termination of services. If an aggrieved client requests a hearing, a grantee shall not terminate services to the client until a final decision is rendered by HHSC. Any policy related to termination of services must be included in the grantee’s policy manual.

Resolution of Complaints

Grantees must ensure that clients can express concerns about care received and to further ensure 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.

If a client remains unsatisfied with how the complaint was handled, they can appeal to the HHSC Title V MCH FFS Office at, or mail PO Box 149030, Austin TX 78714-9347. More information may be needed. 

Any client complaint must be documented in the client’s record.

Research (Human Subjects Clearance)

Grantees considering clinical or sociological research using Title V MCH FFS Program funded clients as subjects must obtain 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 Title V Program, as well as the IRB, prior to 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 23-2; Effective Sept. 8, 2023

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 as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 17 years old 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 according to 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, subrecipients and subgrantees must maintain for the time specified by HHSC all records pertaining to client services, contracts and payments. 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 23-2; Effective Sept. 8, 2023

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 according to 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 healthcare 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 to include skills evaluation and/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 are provided 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 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. All dental services must be provided under the supervision, direction and responsibility of a qualified licensed dentist.

The Title V MCH FFS medical director for the clinic must be a licensed Texas physician and the Title V MCH FFS dental director for the clinic must be a U.S. 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/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 23-2; Effective Sept. 8, 2023

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. 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 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.

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

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment including 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:

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

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 obtain 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 23-2; Effective Sept. 8, 2023

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. Staff trained in CPR must be present during all hours of clinic operations.
  • There must be written protocols to address vaso-vagal 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 has been trained regarding these 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 can be found at the Texas State Board of Dental Examiners website and in the Texas rule for Minimum Standard of Care

Emergency Preparedness

There must be a written safety plan that includes 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 (i.e., fires, flooding, power outage, bomb threats, etc.). 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. For an employer with 10 or fewer employees, the plan may be communicated orally to employees. 

For additional resources on facilities and equipment, see the  Occupational Safety and Health Administration website

3800 Quality Management

Revision 23-2; Effective Sept. 8, 2023

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor Title V MCH FFS 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 such 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 at a minimum must:

  • 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 individuals 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 providing 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, order, etc. 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.