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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.