Revision 19-0; Effective July 1, 2019



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.