Revision 24-2; Effective Oct. 15, 2024

Grantees must make sure services are provided in a timely and nondiscriminatory manner and must:

• have a policy in place to identify and eliminate possible barriers to client care, including making sure clinic or reception room wait times do not present a barrier to care;
• have a policy in place that describes the timely provision of services as follows:
  • applicants deemed eligible for FPP should be given an appointment as soon as possible and no later than 30 days from the initial request;
  • clients who request a contraceptive method but cannot be given a clinical appointment immediately must be offered a non-prescription method; and
  • minors younger than 18 years old be met with as soon as possible, with every effort made to provide an appointment within two weeks of the request;
• have a policy in place that requires qualified staff to assess and prioritize a person’s needs;
• provide referral sources for services outside the scope of FPP.
• manage funds to make sure established people continue to receive services throughout the budget year, Sept. 1 through Aug. 31;
• inform people of FPP services and encourage them to bring required documentation to the first visit for eligibility processing;
• comply with all laws, regulations and contract terms and conditions, as outlined in Section 3500, Nondiscrimination and Limited English Proficiency.

Grantees may not deny services to a qualifying person based on the person’s inability to pay.  

Revision 24-2; Effective Oct. 15, 2024

Grantees must obey state laws that govern the reporting of suspected abuse and neglect of children, adults with disabilities or people 65 years or older.

The Texas Human Resources Code, Chapter 48, requires 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 about abuse, neglect and exploitation of the elderly and adults with disabilities and must provide annual staff training.

Reporting an Abuse Emergency

To report an emergency that involves the abuse or neglect of children, adults with disabilities, people 65 years or older, or an individual receiving services from certain home and community-based providers, contact the Texas Abuse Hotline at 800-252-5400 or online at TXAbuseHotline.org. For cases that pose an imminent threat or danger to the person, call 9-1-1 or any local or state law enforcement agency.

Call the Texas Abuse Hotline at 800-252-5400 for situations including:

• Serious injuries.
• Any injury to a child 5 years or younger.
• Immediate need for medical treatment, including suicidal thoughts.
• Sexual abuse where the abuser has or will have access to the victim within the next 24 hours.
• Children 5 years and younger who are alone or are likely to be left alone within the next 24 hours.
• Anytime you believe your situation requires action in less than 24 hours.

Reporting a Suspicion of Abuse

For situations that do not require immediate investigation and to report suspicions of abuse, neglect and exploitation of children, adults with disabilities, people 65 years of age or older, or an individual receiving services from certain home and community-based providers, use the Department of Family and Protective Services Texas Abuse Hotline.

3210 Child Abuse Reporting, Compliance and Monitoring

Revision 24-2; Effective Oct. 15, 2024

Grantees and providers must develop policies and procedures that follow the reporting guidelines and requirements in Texas Family Code, Chapter 261. Grantee must develop an internal policy to determine:

• how child abuse reporting requirements will be implemented throughout their agency;
• how staff will be trained; and
• how internal monitoring will be done to make sure reporting is timely.

During quality assurance (QA) monitoring, compliance with the following criteria will be evaluated:

• The grantee's process must make sure staff is reporting abuse as required by Texas Family Code, Chapter 261. To verify compliance, QA monitors examine the grantee to make sure they:
  • have an internal policy which details how the grantee will determine, document, report and track instances of sexual and non-sexual abuse, for all people younger than 18 years in compliance with the Texas Family Code, Chapter 261;
  • follow their own internal policy; and
  • document staff training on child abuse reporting requirements and procedures.
• The grantee’s internal policy must clearly describe the reporting process for child abuse.

Resources for child abuse reporting policy development are found at the Texas Abuse Hotline.

3220 Human Trafficking

Revision 25-3; Effective Oct. 29, 2025

HHSC requires grantees to obey state laws that govern the reporting of abuse and neglect. As part of the requirement that grantees follow applicable federal laws, family planning grantees also must follow anti-trafficking laws, including the Trafficking Victims Protection Act of 2000, 22 USC Section 7101, and all items that follow the item cited.

Grantees must have a written policy on human trafficking which includes the provision of annual staff training.

Grantees must display signage related to human trafficking in areas where clients and the public can easily see them. Such areas include lobbies, waiting rooms, front reception desks and locations where people apply for and receive services.

Resources for Human Trafficking Policy Development

• Texas Health and Human Services Human Trafficking Resource Center webpage
• Texas Health and Human Services Health Care Practitioner Training webpage

Health care professionals and organizations must adhere to reporting requirements per Chapter 91 of the Texas Family Code.

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

3230 Domestic and Intimate Partner Violence

Revision 25-1; Effective Jan. 29, 2025

The Centers for Disease Control and Prevention Intimate Partner Violence Prevention webpage describes intimate partner violence (IPV) as 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. IPV can exist regardless of the presence of sexual intimacy.

Health care professionals and organizations must adhere to reporting requirements outlined in Chapter 91 of the Texas Family Code.

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

Revision 25-3; Effective Oct. 29, 2025

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

An FPP provider must maintain all health care information as confidential to the extent required by law.

Grantees must make sure all employees and volunteers receive training about client confidentiality during orientation. Employees and volunteers also must understand that violation of the law about confidentiality may result in civil damages and criminal penalties. A health care provider’s paid and unpaid staff must be told during orientation of the importance of keeping client information confidential. Refer to 1 Texas Administrative Code (TAC) Section 382.125(c). Grantees must provide a confidentiality policy that makes sure staff are informed during orientation of the importance of keeping client information confidential. All employees, volunteers, subrecipients and advisory board members must sign a confidentiality statement during orientation.

Grantees must monitor client records to make sure only appropriate staff and HHSC may access the records. A grantee must document the person’s preferred method of follow-up for clinic services, such as by cell phone, email, work phone or text, as well as preferred language, in the client’s record. Each client must receive verbal assurance of confidentiality, an explanation of confidentiality, which means information is kept private and not shared without permission, and any applicable exceptions such as abuse reporting. Grantees must provide clients with a copy of their signed confidentiality policy or agreement and maintain a copy in client's record.

An FPP provider may not require consent for family planning services from the spouse of a married client. Refer to 1 TAC Section 382.125.

For information specific to minors and confidentiality, refer to Responsibilities for Treatment of Minors within the Family Planning Program and Healthy Texas Women Program (PDF).

Revision 25-3; Effective Oct. 29, 2025

Per the HHSC Uniform Terms and Conditions – Grant Version 2.16.1 (PDF), HHSC grantees must comply with state and federal anti-discrimination laws, including:

• Title VI of the Civil Rights Act of 1964
• Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794 (PDF)
• Americans with Disabilities Act of 1990, 42 U.S.C. Section 12101 et seq.
• Age Discrimination Act of 1975, 42 U.S.C. Sections 6101-6107
• Title IX of the Education Amendments of 1972, 20 U.S.C. Sections 1681 et seq.
• Accessible services to persons with limited English proficiency and speech or sensory impairments as noted in Texas Administrative Code (TAC), Title 1, Part 15, Chapter 395, Subchapter B.

HHSC contracts require grantees to comply with state and federal antidiscrimination laws including state rules in TAC Title 1, Part 15, Chapter 395, Subchapter B, Section 395.11.

Find more information about nondiscrimination laws and regulations on the HHSC Civil Rights website and the HHSC Civil Right Office, Requirements for Contractors website.

Grant Terms and Conditions

To ensure compliance with nondiscrimination laws, regulations and policies, grantees must:

• sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations.
• have a written policy that states the agency does not discriminate based on race, color, national origin, sex, age, religion or disability. Grantees also must provide this Civil Rights policy to clients and put a signed copy in the client’s record that shows they have received a copy.
• have a written policy that addresses individual rights and responsibilities that applies to everyone who requests family planning services.
• have procedures to notify the HHSC Civil Rights Office of any program or service-related discrimination allegation or complaint no more than 10 calendar days after the allegation or complaint.
• make sure all grantee staff are trained in the nondiscrimination policies.
• make sure applicants for family planning services are made aware of the grantee’s nondiscrimination policies and complaint procedures.
• prominently display Civil Rights Posters in English and Spanish as applicable in common areas, including lobbies and waiting rooms, the front reception desk and locations where people apply for services. Posters are on the Civil Rights Office website.
• have a Civil Rights policy that includes all the bulleted components, including civil rights posters in Spanish and English as applicable.

More information about nondiscrimination laws and regulations is on the HHSC Civil Rights Office webpage.

Revision 24-2; Effective Oct. 15, 2024

3510 Resolution of Complaints

Revision 24-2; Effective Oct. 15, 2024

Grantees must have a Client Rights policy that explains the process to file complaints and concerns about care received to HHSC, and make sure those complaints and concerns are handled in a consistent and timely 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 requests more help 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.

3520 Termination of Services

Revision 25-2; Effective April 25, 2025

A qualifying person must never be denied services because they are not able 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. Grantees also have the right to terminate services if the client’s behavior jeopardizes their own safety, clinic staff or others. A person has the right to appeal the denial, suspension or termination of services. Refer to 1 TAC Section 382.111.

For more information, refer to Fair and Fraud Hearings page on the HHSC website.

The grantee’s policy manual must include policies for termination of services.

3530 Freedom of Choice

Revision 24-2; Effective Oct. 15, 2024

FPP clients are guaranteed the right to voluntarily choose qualified family planning providers and methods without coercion or intimidation. Acceptance of family planning services may not be required for eligibility for, or receipt of, any other service or assistance from the entity or person who would provide the service or assistance.

3540 Research, Human Subject Clearance

Revision 24-2; Effective Oct. 15, 2024

Grantees must get prior approval from their own internal Institutional Review Board (IRB) and HHSC to participate in proposed research that would involve FPP clients as subjects and the use of client records or any data collected from FPP clients. For information about the process, visit the Institutional Review Board website.

The grantee must have a policy that states approval will be obtained from HHSC before it institutes any research activities. The grantee must make sure all staff members are aware of this policy through staff training. The grantee must keep documentation of training on this topic.

Revision 25-2; Effective April 25, 2025

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

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

The person’s written consent is required to release personally identifiable information, except as may be necessary to provide services to the person, or as required by law, with appropriate safeguards for confidentiality. If the person is a minor, the minor’s parent, managing conservator or guardian must authorize the release per Chapter 32 of the Texas Family Code, federal law or regulations. Emancipated or married minors authorize the release of their own information. HIV information should be handled per state and federal code. Refer to the HHS Law, Rules, and Authorization webpage.

Grantees must release only the specific information requested when information is requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other forms that do not identify individuals. People transferring to other providers must be provided with a copy or summary of their record upon request to ensure continuity of care. Electronic records are acceptable as medical records.

Grantees and sub-grantees must maintain all records of client services, contracts and payments for the time specified by HHSC.

Requirements are in Texas Administrative Code Title 1, Part 15, Section 354.1003, Time Limits for Submitted Claims, Section 354.1004, Retention of Records and in Title 22, Part 9, Chapter 163, Medical Records. Grantees must follow contract provisions, maintain medical records for at least seven years after the contract closes and follow the retention standards of the relevant licensing entity. All records about services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 

Revision 24-2; Effective Oct. 15, 2024

3710 Personnel Policy and Procedures

Revision 25-3; Effective Oct. 29, 2025

Grantees must develop and maintain personnel policies and procedures to make sure all 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 members that includes a statement of skills, competencies appropriate for the position or both; and
• a performance-evaluation process for all staff members.

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

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

Grantees must 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 designated medical director for a grantee must be a licensed Texas physician.

Grantees must establish, annually review and train staff on FPP requirements, including any updates to this manual and required forms that occur during the Grant Term.

Grantees must have a documented plan for organized staff development. The plan must have 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.

Grantees must notify and provide updated contact information in writing within 30 calendar days of a change, whether funded under this contract or not, to HHSC of:

• Any grant-funded positions; and
• chief executive officer (CEO), chief financial officer (CFO), program director or program manager;

Grantees must make sure at least one representative, the capabilities to disseminate information to program administrative and clinic staff:

• attend a minimum of two priority technical assistance webinars offered by HHSC during the fiscal year. These specific webinars will be identified as mandatory or priority in HHSC’s electronic mail. To receive credit for participating, attendees must follow HHSC’s directions including completion of any sign-in sheet, registration, survey within the specified time frame or all three; and
• has access to the HHSC’s web-based applications – SharePoint site. The grantee must sign and submit a Family Clinical Services Extranet and Data Upload Security Agreement form for each grantee staff person accessing HHSC’s web-based applications – SharePoint site. 

Grantees must make sure users of HHSC’s web-based applications have an Outlook or Microsoft Office 365 account.

3720 Facilities and Equipment

Revision 25-3; Effective Oct. 29, 2025

Grantees must maintain a safe environment. Grantee 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 policies and procedures that address hazardous materials and waste, fire safety and medical equipment.

Hazardous Materials and Waste

Grantees must have written policies and procedures to 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. 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 keep documentation of the maintenance, testing and inspection of medical equipment, including automated external defibrillators (AEDs). 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 user 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 that provide radiology services must:

• possess a current Certificate of Registration from the Texas Department of State Health Services (DSHS) Radiation Control Program;
• Comply with Texas Administrative Code, Title 25, Part 1, Chapter 289, Texas Regulations for Control of Radiation; and
• Post Notice to Employees, Texas Regulations for Control of Radiation.

For information on X-ray machine registration, review the DSHS Radiation Control Program webpage.

Smoking and Vaping Ban

Grantees must have written policies that prohibit smoking and vaping in any portion of their indoor facilities. If a grantee contracts with another entity to provide health services, the subgrantee must uphold this policy.

Disaster Response Plan

Grantees must have written plans that address how staff will respond to emergencies such as fires, flooding, power outages and bomb threats. The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position 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 verbally.

For resources on facilities and equipment, review the Occupational Safety and Health Administration Compliance Assistance Guide.

Clinical Emergencies

Grantees must be adequately prepared to handle clinical emergencies as follows:

• There must be a written plan for the management of on-site medical emergencies, emergencies that require 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 vasovagal 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; and
• Documentation must be maintained in personnel files that staff have been trained on these written plans or protocols.

Suicide Prevention Signage

Grantees are encouraged to display signage related to suicide prevention, including the 988 Suicide and Crisis Lifeline. If a grantee elects to display such signage, it must be displayed in areas where clients and the public can easily see it, such as lobbies, waiting rooms, front reception desks and locations where people apply for and receive services.

Examples of suitable flyers are available on the Substance Abuse and Mental Health Services Administration (SAMHSA) webpages:

• 988 Suicide & Crisis Lifeline Poster, English
• 988 Suicide & Crisis Lifeline Poster, Spanish
• Suicide Warning Signs for Youth Poster
• Texting 988 Poster 1, Spanish
• Texting 988 Poster 2, English
• 988 Partner Toolkit

More mental health and suicide prevention resources are at the:

• Texas Health and Human Services (HHS) Behavioral Health Services Provider webpage
• HHS Suicide Prevention webpage
• Find Resources or a Provider, You're Not Alone Mental Health Texas webpage

Revision 25-3; Effective Oct. 29, 2025

Quality assurance and quality improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal QA/QI systems and processes to monitor FPP services. Grantees must have a quality management (QM) program based on their organizational structure and on the services they provide. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care. Grantees should integrate QM concepts and methods into the organization’s structure 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 written, 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 subaward 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 subgrantees.

An important part of the QM program is the QM committee, whose members are key leaders of the organization, including the executive director or chief executive officer, medical director and other appropriate staff where applicable. The committee must annually review and approve a 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 QI actions to be implemented; and
• reassess outcomes and goal achievement.

Meeting dates, minutes of the discussion, actions taken by the committee and a list of the attendees must be maintained and made available during QA/QI reviews. The comprehensive quality work plan, at a minimum, must:

• be reviewed annually;
• include clinical and administrative standards that will be used to monitor services;
• include the process for credentialing and peer review of clinicians;
• identify people responsible for implementing, monitoring, evaluating and reporting;
• establish timelines for QM activities;
• identify tools and forms to be used; and
• outline reporting to the QM committee.

Although each organization’s QM program is unique, the following activities must be undertaken by all agencies that provide client services:

• ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• tracking and reporting of adverse outcomes;
• client satisfaction surveys and reporting survey data to HHSC in the frequency, manner and format defined by HHSC;
• annual review of facilities to maintain a safe environment, including an emergency safety plan;
• annual review and update of all prescriptive authority agreements (PAAs) for mid-level providers;
• annual review of all standing delegation orders and clinical protocols used;
• annual review of all policies and forms; and
• up-to-date personnel performance evaluations to include primary license verification, Drug Enforcement Administration and immunization status.

The review or revision date must be clearly noted on each policy, form, agreement, order, etc. used.

Grantees who subaward 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 subgrantee, to include at a minimum:

• annual license verification, the primary source verification;
• clinical record review;
• billing and eligibility review;
• utilization review;
• facility on-site review;
• annual client satisfaction evaluation process; and
• child abuse training and reporting for subgrantee staff.

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 committee and should be documented.

Revision 25-3; Effective Oct. 29, 2025

Grantees must regularly collect and maintain data that measures the performance and effectiveness of program activities as specified in their grant agreement. The following outcome measures are acceptable:

1. Improving health outcomes:
   1. Increased screening rates; and
   2. Managing chronic disease.
2. Reducing health care costs:
   1. Avoidable emergency department visits;
   2. Hospitalizations and hospital readmission rates;
   3. Symptom-free days; and
   4. Quality-adjusted life years.
3. Other outcome measures proposed by applicant and approved by HHSC.

Grantees must submit a quarterly narrative in the Performance Measures Report that addresses their progress toward their specific goals. More information about frequency and submission is in 8000, Quality Management.