Revision 25-3; Effective Nov. 14, 2025

Maintaining Clinic Information on 2-1-1  

Grantees must maintain current and correct information on 211Texas.org for all clinic locations providing PHC services. Grantees may use the Add or Edit Your 2-1-1 Listing link found at the top of the webpage or contact their local 2-1-1 resource manager to make any changes to their clinic location information listings or add a new listing.

At a minimum, grantees must maintain up-to-date information on each clinic’s:

• phone number;
• physical location;
• hours of operation; and
• services provided.

3110 Client Access

Revision 23-2; Effective Sept. 15, 2023

Grantees 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. The grantee must ensure that clients are provided services in a timely and non-discriminatory 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, Title IX of the Education Amendments of 1972, and ensure services are accessible to persons 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 individuals who cannot be served or cannot receive a specific needed service;
• manage funds to ensure that established clients continue to receive services throughout the budget year, even after allocated funds are expended;
• ensure that services are provided to clients in a timely manner, preferably within 30 days of the request for services. Clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method;
• ensure clinic or reception room wait times are reasonable and do not present a barrier to care; and
• display appropriate exterior signage that identifies the entity as a healthcare facility.

Revision 25-3; Effective Nov. 14, 2025

Grantees must obey state laws governing the reporting of suspected abuse and neglect.

Call the Texas Abuse Hotline at 800-252-5400 or use the secure Texas Abuse Hotline website to report abuse or neglect. For cases that pose an imminent threat or danger to a person, call 9-1-1 or the appropriate local law enforcement agency.

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);
• child abuse and neglect (Texas Family Code, Chapter 261);

In addition, grantees must have written policies and procedures in place for identifying and responding to:

• human trafficking; and
• domestic and intimate partner violence (Texas Family Code, Chapter 91).

Grantees must provide annual staff training on each separate policy and procedure listed in this section.

3210 Child Abuse Reporting, Compliance and Monitoring

Revision 25-3; Effective Nov. 14, 2025

Child abuse and neglect policies must include:

• The requirement that medical professionals must make a report no later than the 48^th hour after first suspecting a child was abused or neglected or is a victim of an offense.  
• How to determine, document, report, and track instances of abuse, either sexual or non-sexual, or neglect for all people 17 and younger, per Texas Family Code, Chapter 261.

Refer to the Texas Department of Family and Protective Services website for more information on abuse reporting.

3220 Human Trafficking

Revision 25-3; Effective Nov. 14, 2025

Grantees must comply with all state and federal anti-trafficking laws. This includes the Trafficking Victims Protection Act of 2000 (22 USC Ch 78) and Texas Occupations Code, Chapter 116, which requires health practitioners complete an HHSC-Approved Human Trafficking Course for every licensure renewal period.

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

• the definition of human trafficking;
• how to identify possible situations of human trafficking;
• the screening tool used 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; and
• victim support resources.

References for human trafficking policy development:

• Texas Health and Human Services Human Trafficking Resource Center
• Texas Health and Human Services Health Care Practitioner Training Page
• Governor’s Child Sex Trafficking Team
• HHS National Human Trafficking Hotline website or dial 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 for identifying and aiding trafficking victims. Includes slide presentations for training purposes.

3230 Domestic and Intimate Partner Violence

Revision 25-3; Effective Nov. 14, 2025

Intimate partner violence (IPV) describes 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 does not require sexual intimacy.

Grantees must comply with all requirements listed in Texas Family Code, Chapter 91 and have a written policy about assessment and prevention of domestic violence and IPV.

Find more information on IPV on the Centers for Disease Control and Prevention website. The National Domestic Violence Hotline operates 24/7 and provides interpretation services in over 200 languages at 800-799-7233.

Revision 25-3; Effective Nov. 14, 2025

All grantees must comply with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA)  established 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 HIPAA 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, and at a minimum, every three years. The notice must also be posted in a clear and easy-to-find location for clients to review. It must be included on the organization’s website.

Grantees must ensure that all employees and volunteers receive training about client confidentiality during orientation and be made aware that violation of privacy laws may result in civil damages and criminal penalties. A health care provider’s staff, both paid and unpaid, must be informed during orientation of the importance of keeping client information confidential. Grantees must maintain a written confidentiality policy that requires staff to be informed during orientation of the importance of keeping client information confidential. 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. A grantee must document a client’s preferred language and method of communication, including phone, email, or text, 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 are required to 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 client's record.

A health care provider may not require consent for services from the spouse of a married client.

Additional information on confidentiality and required postings are available here:

• HIPAA and Privacy Laws | Texas Health and Human Services
• Notice of Privacy Practices for Protected Health Information | HHS.gov
• Your Rights Under HIPAA | HHS.gov for information for individuals
• Guidance Materials | HHS.gov for information for providers 

3310 Minors and Confidentiality

Revision 23-2; Effective Sept. 15, 2023

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 individual 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 use and disclosure 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 (45 Code of Federal Regulations Section 164.502(g)).

For more information, see Adolescent Health – A Guide for Providers.

3320 Civil Rights

Revision 25-1; Effective Jan. 28, 2025

Per grantee contracts with HHSC, grantees must comply with state and federal anti-discrimination laws.

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

3330 Required Signage

Revision 25-3; Effective Nov. 14, 2025

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:

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

Grantees must display signage about human trafficking and suicide prevention, including the 988 Suicide and Crisis Lifeline. Signage 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:

• Signs for Commercial Establishments | Office of the Attorney General
• 988 Suicide & Crisis Lifeline Poster (English) | SAMHSA
• 988 Suicide & Crisis Lifeline Poster (Spanish) | SAMHSA
• Suicide Warning Signs for Youth Poster | SAMHSA
• Texting 988 Poster 1 (Spanish) | SAMHSA
• Texting 988 Poster 2 (English) | SAMHSA

Additional mental health and suicide prevention resources are available here:

• Behavioral Health Provider Resources
• Suicide Prevention
• 988 Partner Toolkit | SAMHSA
• Find Resources or a Provider | You're Not Alone | Mental Health Texas

3340 Termination of Services

Revision 25-3; Effective Nov. 14, 2025

A grantee must never deny services to an eligible client 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 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 manual.

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. More information is available in the PHC rules under Section 364.17, Appeals.

3350 Resolution of Complaints

Revision 25-3; Effective Nov. 14, 2025

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

1. Grantees must investigate and resolve a complaint or concern within 30 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 to help correct the issue.

3. 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.

4. All complaints and concerns must be documented in the client's record.

3360 Research (Human Subject Clearance)

Revision 25-3; Effective Nov. 14, 2025

Grantees considering clinical or sociological research using PHC Program funded clients as subjects must get prior approval from their own internal Institutional Review Board (IRB) and HHSC.

The grantee must have a policy in place showing that prior approval will be obtained from the HHSC PHC program, as well as the IRB, before 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.

Revision 25-3; Effective Nov. 14, 2025

HHSC grantees must have an organized and secure client record system. The grantee must ensure that records are organized, readily accessible, and available to clients once a signed release of information is received. 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 to release 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 or younger, the client’s parent, managing conservator or guardian, authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release. HIV information should be handled per federal and state law.

When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may only be disclosed in summary, statistically, or in a format that does not identify people. 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, and subrecipients must maintain for the time specified by HHSC all records about 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 about services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.

Revision 25-3; Effective Nov. 14, 2025

Grantees must develop and maintain personnel policies and procedures to ensure clinical staff are hired, trained and evaluated appropriately for their position. Contracted staff must also be trained and evaluated per their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. It is recommended that grantees follow the Advisory Committee on Immunization Practices (ACIP) for immunization of health care 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 competencies appropriate for the position; and
• a performance evaluation process for all staff.

Grantees must show evidence that employees meet all required qualifications and have 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 in a way 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 PHC medical director for the clinic must be a licensed Texas physician and the PHC dental director for the clinic must be a licensed Texas 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 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 establish, annually review, and train staff on PHC program requirements and policies. This includes any updates to the Program Policy Manual and required forms that occur during the Grant Term.

Grantees must have at least one representative:

• responsible for training staff, participate in two PHC mandatory training sessions per state fiscal year, at the discretion of HHSC;
• participate in all HHSC-scheduled meetings;
• responsible for disseminating information to PHC program administrative and clinic staff; and
• sign and submit an extranet and data security agreement form for each staff person accessing HHSC’s web-based applications (SharePoint site) to access program or Contract information. All users of system administrator’s web-based applications must have an Outlook or Microsoft 365 account.

Designated representatives may be the same person or different people. Grantees must notify their contract manager when a designated representative changes and provide updated contact information including but not limited to name, email address and phone number.

Revision 25-3; Effective Nov. 14, 2025

HHSC grantees must always maintain a safe environment and provide clean and well-maintained facilities where services are delivered. There must be appropriate space 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. Grantees must have written policies and procedures that address these requirements, as well as hazardous materials, fire safety and medical equipment.

3610 Hazardous Materials

Revision 23-2; Effective Sept. 15, 2023

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.

3620 Fire Safety

Revision 23-2; Effective Sept. 15, 2023

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.

3630 Medical Equipment

Revision 25-3; Effective Nov. 14, 2025

Medications and medical supplies must be kept in locked storage. Grantees must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an 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 the care and use of medical equipment.

3640 Radiology Equipment and Standards

Revision 25-3; Effective Nov. 14, 2025

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

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

Refer to the DSHS Radiation Control Program for information on X-ray machine registration.
 

3645 Laboratory Standards

Revision 23-2; Effective Sept. 15, 2023

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.

3650 Smoking Ban

Revision 24-2; Effective Sept. 16, 2024

Grantees must have written policies that prohibit smoking in any portion of their indoor facilities. If a grantee subcontracts with another entity for the provision of health services, the subrecipient also comply with this policy.

Revision 23-2; Effective Sept. 15, 2023

3710 Clinical Emergencies

Revision 25-3; Effective Nov. 14, 2025

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, emergencies requiring ambulance services, and hospital admission;
• have staff trained in basic cardiopulmonary resuscitation (CPR) who must be present during all hours of clinic operations
• have staff trained in emergency medical action;
• maintain emergency resuscitative drugs, supplies, and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present; and
• maintain documentation in personnel files that confirm staff are trained in the written plans or protocols.

Dental Emergency Responsiveness

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 are at the Texas State Board of Dental Examiners website and in the Texas Administrative Code, Title 22, Part 5, Chapter 108, under Section 108.7, Minimum Standard of Care, General.
 

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.  

Revision 25-3; Effective Nov. 14, 2025

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC 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 to provide 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 are assessed with subrecipients.

The QM Committee’s membership consists of key leadership of the organization, including the executive director or CEO, medical director, dental director and other appropriate staff. They annually review and approve the quality work plan for the organization, where applicable.

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 to monitor services;
• include a process for credentialing and peer review of clinicians;
• identify people responsible for implementing, monitoring, evaluation and reporting;
• establish timelines for QM activities;
• identify tools and forms to use; and
• outline reporting to the QM Committee.

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

• ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• client satisfaction surveys, including providing survey data to HHSC in the frequency, manner, and format determined 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 (SDOs) and clinical protocols;
• annual review of all policies and forms;
• defining, reporting, tracking and follow-up of adverse outcomes; and
• annual performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications.

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

HHSC grantees who subcontract for the provision of services must address how quality will be evaluated. They also address how compliance with policies and basic standards are assessed with the subcontracting entities, including:

• annual license verification or the primary source verification;
• clinical record review;
• eligibility and billing review;
• on-site facility review;
• annual client satisfaction evaluation process; and
• compliance with all Abuse and Neglect and Civil Rights requirements.

Present the data from these activities to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the committee and should be documented.