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.