Revision 19-0; Effective July 1, 2019



HHSC contractors must have an organized and secure client record system. The contractor must ensure that the record is organized, readily accessible and available to the client upon request with a signed release of information. The record must be kept confidential and secure, as follows:

  • Safeguarded against loss or use by unauthorized persons;
  • Secured by lock when not in use and 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.

The written consent of the individual is required for the release of personally identifiable information, except as may be necessary to provide services to the individual, or as required by law, with appropriate safeguards for confidentiality. If the individual is 17 years of age or younger, the individual’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, contractors should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify particular individuals. Upon request, individuals transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.

Contractors, providers, subrecipients and subcontractors must maintain for the time period specified by HHSC all records pertaining to client services, contracts and payments. Record retention requirements are found in Title 1, Part 15 TAC §354.1003 (relating to time limits for submitted claims) and Title 22, Part 9 TAC §165 (relating to medical records). Contractors 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. 

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

  • job descriptions;
  • 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.

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 FPP medical director 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.