3000, Administrative Policy

Revision 26-2; Effective Sept. 1, 2026

This section provides guidance to grantees on conducting administrative activities, including ensuring client access to services and managing client records.

Grantees must maintain current and accurate information on 211Texas.org for all clinic locations providing PHC services. Grantees may use the Add or Edit Your 2-1-1 Listing link at the top of the webpage to add a new listing or update their active clinic location information.

In the comment box for 2-1-1 staff review, first-time grantees without an existing listing must note that they are a Primary Health Care (PHC) Program grantee and specify which clinic locations will serve PHC clients.

Grantees with existing listing(s) may update their PHC designations by contacting their local 2-1-1 resource manager or by selecting Service Revision Request on their listing(s) on the 2-1-1 website.

At a minimum, grantees must maintain current information on each clinic, including its:

phone number
physical location
hours of operation
services provided

At the beginning of each fiscal year, grantees will receive a notification from their HHSC program contact of any active 2-1-1 listings servicing PHC clients. Grantees will be asked to confirm all listed information is current or indicate any needed changes to:

clinic location(s)
hours of operation
contact information
services provided

Grantees will have 10 calendar days to respond from the date HHSC requests the information.

Grantees must notify HHSC of any changes made to their clinic information within 30 days of the change throughout the grant year.

3110 Client Access

Revision 26-2; Effective Sept. 1, 2026

Grantees must make sure clients are provided services in a timely and non-discriminatory manner per all Texas Health and Human Services (HHS) policies. Grantees must adhere to the following guidelines:

Have a policy in place to identify and reduce barriers to client care, including making sure clinic or reception room wait times are reasonable.
Have a policy in place that delineates the timely provision of services, including:
- Applicants deemed eligible for PHC 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 contraceptive method.
Have a policy in place that requires qualified staff to assess and prioritize a client’s needs.
Provide referral sources for services outside the scope of PHC.
Manage funds to make sure established clients continue to receive services throughout the budget year, including after allocated funds are expended.
Inform people of PHC services and encourage them to bring required documents to the first visit for eligibility processing.
Comply with all applicable civil rights and anti-discrimination laws, regulations, and contract terms and conditions as outlined in the Requirements for Contractors.
Display appropriate exterior signage that identifies the entity as a health care facility.

3200, Abuse and Neglect Reporting

Revision 26-2; Effective Sept. 1, 2026

Grantees must obey state laws that govern the reporting of suspected abuse and neglect. Grantees must have written policies and procedures in place for the detection and appropriate reporting of abuse, neglect and exploitation of:

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

Grantees must provide annual training that includes the requirements outlined in the following sections:

Reporting an Emergency or Suspicion of Abuse
Child Abuse and Neglect Reporting, Compliance and Monitoring
Human Trafficking, and Domestic and Intimate Partner Violence.

Reporting an Emergency or Suspicion of Abuse

For cases that pose an immediate threat to a person, call 9-1-1 or the appropriate local law enforcement agency.

For situations that do not pose an immediate threat, or to report suspected abuse or neglect, grantees should use the secure Texas Abuse Hotline website or call the Texas Abuse Hotline at 800-252-5400.

3210 Child Abuse and Neglect Reporting, Compliance and Monitoring

Revision 26-2; Effective Sept. 1, 2026

A grantee’s policies must include:

How child abuse reporting requirements will be implemented throughout their agency, including how staff will be trained and how internal monitoring will be done to ensure timely reporting.
The requirement that medical professionals must make a report no later than 24 hours after first suspecting a child has been abused, neglected, or is a victim of an offense.
How to determine, document, report and track instances of sexual or non-sexual abuse or neglect for all children 17 years old and younger.

For more information on abuse and neglect reporting, refer to the Texas Department of Family and Protective Services website.

3220 Human Trafficking

Revision 26-2; Effective Sept. 1, 2026

Grantees must comply with all state and federal anti-trafficking laws. This includes the Trafficking Victims Protection Act of 2000 and Texas Occupations Code, Chapter 116 and 301. These regulations require health practitioners to complete an HHSC-Approved Human Trafficking Course for every licensure renewal period.

Grantees must display signs about human trafficking in areas where clients and the public can easily see them. This includes lobbies, waiting rooms, front reception desks and locations where people apply for and receive services.

Grantees must have a written policy on human trafficking which includes:

the definition of human trafficking
how 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
victim support resources
annual staff training

References for human trafficking policy development:

HHS Texas Human Trafficking Resource Center
HHS Health Care Practitioner Training Page
Governor’s Child Sex Trafficking Team
HHS National Human Trafficking Hotline webpage or call 888-373-7888
Rescue and Restore Campaign by the U.S. Department of Health and Human Services. Contains multiple resources for health care providers, social service personnel and law enforcement identify and aid trafficking victims. Includes slide presentations for training purposes.

3230 Domestic and Intimate Partner Violence

Revision 26-2; Effective Sept. 1, 2026

Intimate partner violence (IPV) includes 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 threat of harm. This type of violence can exist regardless of the presence of sexual intimacy.

Grantees must comply with all requirements in Texas Family Code, Chapter 91 and have a written policy about the assessment and prevention of domestic violence and IPV. Clients who experience IPV are not required to submit information to verify income eligibility if doing so jeopardizes the client's safety or imposes a barrier to receiving services.

Any medical professional who treats a person for injuries they have reason to believe were caused by IPV is required to provide the person with the Notice to Victims on the HHSC Family Violence Program webpage.

More information and resources on IPV are on the Centers for Disease Control and Prevention website. Grantees can also contact the National Domestic Violence Hotline at 800-799-7233. The hotline operates 24 hours a day, seven days a week and provides interpretation services in over 200 languages.

3300, Confidentiality

Revision 26-2; Effective Sept. 1, 2026

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

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

Grantees are required by HIPPA 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,
at least every three years.

Grantees must post this notice in a clear and easy to find location for clients to review. It must be included on the organization’s website.

Grantees must make sure all employees and volunteers receive training on client confidentiality during orientation. Grantees also must make all employees and volunteers aware that violation of the law about 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.

Grantees must monitor client records to make sure only appropriate staff and HHSC may access the records.

Grantees must document the client’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, an explanation of what confidentiality means, and any applicable exceptions, such as abuse reporting. Grantees must also provide clients with a copy of their confidentiality policy or agreement. Clients must sign this policy or agreement, and the grantee must maintain a signed copy in the client's record.

More information on confidentiality and required postings is available on these HHSC and U.S. Department of Health and Human Services (HHS) webpages:

HIPAA and Privacy Laws – HHSC
Notice of Privacy Practices for Protected Health Information – HHS.gov
Your Rights Under HIPAA – HHS.gov for information for individuals
HIPAA Guidance Materials – HHS.gov for information for providers

3310 Minors and Confidentiality

Revision 26-2; Effective Sept. 1, 2026

Except as permitted by law, providers are legally required to maintain the confidentiality of care provided to minors. 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 cases of contagious disease or abuse. Privacy refers to a person’s ability to control access to their personal information. Confidentiality in health care is the obligation of the health care provider to refrain from disclosing protected health information. While confidentiality is inherent in maintaining a patient's privacy, it is not an absolute right.

The HIPAA Privacy Rule requires covered entities to treat a personal representative the same as the person about the use and disclosure of that person’s protected health information. In most cases, parents serve as the personal representatives of their minor children. Parents may exercise personal rights, such as access to medical records, on behalf of their minor children. Review 45 Code of Federal Regulations Section 164.502(g).

For more information, review the Adolescent Health – A Guide for Providers webpage.

3320 Civil Rights

Revision 26-2; Effective Sept. 1, 2026

HHSC contracts require grantees to comply with state and federal antidiscrimination laws. This includes state rules in Texas Administrative Code (TAC) Title 1, Part 15, Chapter 395, Subchapter B, Rule 395.11.

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

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 including limited English proficiency (LEP)
- sex
- age
- religion
- disability
have a policy that addresses client rights and responsibilities that is applicable to all people who request 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 grantee's nondiscrimination policies;
notify everyone who applies for services of the grantee's nondiscrimination policies and complaint procedures; and
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.

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

Limited English Proficiency – LEP

To comply with civil rights requirements related to LEP, grantees must:

take reasonable steps to make sure people with LEP have meaningful access to its programs and services;
not require a person with LEP to use friends or family members as interpreters:
- a family member or friend may serve as a person’s interpreter if the person requests it; and
- the family member or friend does not compromise the effectiveness of the service or violate client confidentiality; and
make sure people with language service needs, including people with LEP and disabilities, are aware that the grantee will provide an interpreter free of charge.

3330 Required Signage

Revision 26-2; Effective Sept. 1, 2026

Grantees that provide direct services to clients must display certain HHS posters about civil rights. The posters must be displayed 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:

Grantees must display signs about human trafficking and suicide prevention, including the 988 Suicide and Crisis Lifeline. Signs must be displayed 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 services.

Examples of suitable flyers are available here:

More mental health and suicide prevention resources are available at:

3340 Termination of Services

Revision 26-2; Effective Sept. 1, 2026

Grantees must never deny services to an eligible client because of 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 must be included in the grantee’s policy.

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.

3350 Resolution of Complaints

Revision 26-2; Effective Sept. 1, 2026

Grantees must make sure clients can express concerns about the care they’ve received. Grantees must also make sure any complaints or concerns are handled in a consistent and timely manner. A grantee’s policy and procedure manuals must explain the process clients may follow if they are not satisfied with the care received. This process includes:

Grantees must investigate and resolve a complaint or concern within 30 business days, beginning on the day they are notified by the aggrieved client.
Clients may contact the grantee during and after the resolution of an investigation to receive more information on the grantee's decision or to help correct the issue.
Grantees must provide the client with contact information to the HHS Office of the Ombudsman. If a client has requested 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.
All complaints and concerns must be documented in the client's record.

3360 Research, Human Subject Clearance

Revision 26-2; Effective Sept. 1, 2026

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

The grantee must have a policy in place that shows approval will be obtained from the HHSC PHC program, as well as the IRB, before instituting any research activities. The grantee must also make sure 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 26-2; Effective Sept. 1, 2026

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

safeguarded against loss and 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, home and office visits.

Written consent is required for the release of personally identifiable information. Written consent is not required when personally identifiable information is necessary to provide services to the client or as required by law with appropriate safeguards for confidentiality. If the client 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 federal and state law.

If the client 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.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may only be disclosed in summary, statistical or other format that does not identify clients. Upon request, clients 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.

Grantees, providers and subrecipients must maintain all records that pertain to client services, contracts and payments for the period specified by HHSC. Requirements about time limits for submitted claims are in TAC Title 1, Part 15, Chapter 354, Rule 354.1003. Requirements for medical record maintenance are in TAC Title 22, Part 9, Chapter 163. Grantees must follow contract provisions, maintain medical records for at least seven years after the contract closes, and follow the retention standards of the appropriate licensing entity. All records of services must be accessible to HHSC representatives to examine at any reasonable time as required by law.

3500, Personnel Policy and Procedures

Revision 26-2; Effective Sept. 1, 2026

Grantees must develop and maintain personnel policies and procedures to make sure all staff are hired, trained and evaluated appropriately for their job position. This includes contracted personnel.

Grantees also must verify that all staff who provide services to PHC clients have the appropriate licenses and certifications required by applicable law. All licenses and certifications must be current, valid and in good standing, and must remain so for the term of the grant. All staff must be appropriately identified with a name badge.

Personnel policies and procedures, including those for contracted personnel, must include:

job descriptions that specify any required qualifications and licensure;
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.

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

All medical care for PHC clients must be provided under the supervision, direction and responsibility of a qualified medical director. The designated medical director must be a licensed Texas physician. All dental care for PHC clients must be provided under the supervision, direction and responsibility of a qualified licensed dentist. The designated dental director must be a licensed Texas dentist.

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.

Grantees must establish, annually review and train staff on PHC program requirements and policies. This includes reviewing and updating staff on any updates to the program’s policy manual and required forms that may 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. 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 to HHSC of:

chief executive officer (CEO), signature authority
chief financial officer (CFO), fiscal contact
program director or program manager, program contact

Grantees must make sure at least one representative:

Communicates program information. Responsible for disseminating information to PHC program administrative and clinic staff.
Has HHSC SharePoint access. Can view and upload program and grant information via HHSC’s web-based applications on the SharePoint site.
- Must have an Outlook or Microsoft Office 365 account.
- Must sign and submit a Family Clinical Services Extranet and Data Upload Security Agreement form for each staff person accessing the site.
Attends relevant HHSC webinars during the fiscal year.
- Grantees should aim for representation at one or more relevant technical assistance, training or evaluation webinars.
- HHSC may designate certain webinars as mandatory, such as for a priority policy or procedure change, and will notify grantees accordingly.
- To receive participation credit, attendees must complete any required sign-in sheet, registration or survey within the specified time frame.

3600, Facilities and Equipment

Revision 26-2; Effective Sept. 1, 2026

Grantees must always maintain a safe environment and provide clean and well-maintained facilities where services are delivered. Appropriate space must be provided for exam rooms, client intake, waiting areas and clinical and administrative staff attendance and functions.

Clinic sites must be geographically close to the target population(s) the grantee plans to serve.

3610 Hazardous Materials and Waste

Revision 26-2; Effective Sept. 1, 2026

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.

3620 Fire Safety

Revision 26-2; Effective Sept. 1, 2026

Grantees must have a written fire safety policy that includes a schedule for testing and the maintenance of fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

3630 Medical Equipment

Revision 26-2; Effective Sept. 1, 2026

Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an automated external defibrillator (AED). Documents 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 the care and use of medical equipment.

Medications and medical supplies must be kept in locked storage.

3640 Radiology Equipment and Standards

Revision 26-2; Effective Sept. 1, 2026

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

have 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 (PDF).

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

3645 Laboratory Standards

Revision 26-2; Effective Sept. 1, 2026

All facilities providing laboratory services must have a current Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver. CLIA requires that any facility examining human specimens for the diagnosis, prevention, treatment of a disease or for an assessment of health must register with the federal Centers for Medicare & Medicaid Services (CMS) and obtain CLIA certification.

3650 Smoking and Vaping Ban

Revision 26-2; Effective Sept. 1, 2026

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

3700, Emergency Responsiveness

Revision 26-2; Effective Sept. 1, 2026

Medical Emergencies

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

have a written plan for the management of on-site medical emergencies and emergencies that require ambulance services.
have staff trained in basic CPR and emergency medical action, who 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 appropriately trained staff when clients are present.
maintain documents in personnel files that confirm staff are trained in the medical emergencies plans or protocols.

Dental Emergencies

The dental office or clinic must have a written emergency plan that includes criteria to manage 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 Administrative Code, Title 22, Part 5, Chapter 108, Rule 108.7, Minimum Standard of Care, General.

3710 Emergency Preparedness

Revision 26-2; Effective Sept. 1, 2026

Grantees must have a written safety plan that includes an emergency evacuation plan and a disaster response plan.

Disaster Response Plan

Grantees must have a written disaster response plan that addresses how staff must respond to emergency situations such as:

fires
flooding
power outage
bomb threats

The disaster plan must identify the procedures and processes that will be initiated during a disaster. The staff position(s) responsible for each activity must also be identified. A disaster response plan must be in writing, formally communicated to staff and be available to employees in the workplace for review. An employer with 10 or fewer employees may communicate the plan verbally.

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

3720 Emergency Preparedness

Revision 25-3; Effective Nov. 14, 2025

Grantees must have 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 a written disaster response plan that addresses 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 26-2; Effective Sept. 1, 2026

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 PHC services. Grantees must have a Quality Management (QM) program tailored to their organizational structure and the services they provide. The goals of the quality management program should ensure availability and accessibility of services, quality and continuity of care. Grantees should integrate QM concepts and methodologies 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
teamwork

The QM program must be developed and implemented in a way that provides for the ongoing evaluation of services. Grantees should have:

a comprehensive quality work 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 to provide PHC services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with subrecipients.

3810 QM Committee

Revision 26-2; Effective Sept. 1, 2026

The committee is an important part of the QM program. The committee’s membership consists of the organization’s key leadership, including the:

executive director or CEO
medical director
dental director
other appropriate staff where applicable

The committee must review and approve a quality work plan for the organization annually.

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
reassess outcomes and goal achievement

Meeting dates, a list of the attendees and minutes of the discussion and actions taken by the committee must be maintained.

3820 Comprehensive Quality Work Plan

Revision 26-2; Effective Sept. 1, 2026

The comprehensive quality work plan must:

be reviewed annually
include clinical and administrative standards to monitor services
include a process for credentialing and peer review of clinicians
identify personnel responsible for implementing, monitoring, evaluating and reporting
establish timelines for quality management activities
identify tools and forms to be used
outline reporting to the QM Committee

3830 Quality Assurance Activities

Revision 26-2; Effective Sept. 1, 2026

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 client record reviews to ensure compliance with program requirements and clinical standards of care;
utilization review;
defining, reporting, tracking and following up on adverse outcomes;
client satisfaction surveys and reporting of 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), including protocols, for mid-level providers;
annual review of all standing orders (SOs) and clinical protocols;
up-to-date performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications; 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.

3840 Subrecipient Quality and Compliance

Revision 26-2; Effective Sept. 1, 2026

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 subrecipient. This includes:

annual license verification or the primary source verification
clinical record review
eligibility and billing review
utilization review
on-site facility review
annual client satisfaction evaluation process
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.