3000, Administrative Policy

Body

Revision 23-2; Effective Sept. 8, 2023

This section assists the grantee in conducting administrative activities such as assuring client access to services and managing client records.

3100 Accessibility

Revision 25-3; Effective Sept. 1, 2025

Maintaining Clinic Information on 2-1-1

Grantees must maintain current and correct information on  211Texas.org for all clinic locations that provide TVFFS services. Grantees may use the Add or Edit Your 2-1-1 Listing link 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. Grantees must accurately maintain the following information in their 2-1-1 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.

Client Access

The grantee 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.
    • that delineates the timely provision of services, including:
      • applicants deemed eligible for TVFFS should be given an appointment as soon as possible and no later than 30 days from the initial request, and
      • clients who request a contraceptive method but cannot be given a clinical appointment immediately must be offered a non-prescription contraception method.
    • that requires qualified staff to assess and prioritize client needs.
  • provide referral resources for services outside of the scope of TVFFS.
  • manage funds to make sure established clients continue to receive services throughout the budget year, even after allocated funds are expended.
  • display appropriate exterior signage that identifies the entity as a health care facility.
  • comply with all applicable laws, regulations and contract terms in conditions as outlined in 3310, Civil Rights.

3200 Abuse and Neglect Reporting

Revision 25-4; Effective Dec. 15, 2025

Grantees must obey state laws that govern 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 911 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:

Grantees also must have written policies and procedures in place to identify and respond to:

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

Child Abuse and Neglect

Child abuse and neglect policies must include:

  • the requirement that medical professionals make a report no later the 24th hour after they first suspect a child has been abused or 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 people 17 years old and younger per Texas Family Code, Chapter 261.

More information on abuse reporting is at the Texas Department of Family and Protective Services website.

Human Trafficking

Grantees must comply with all state and federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000, 22 USC Section 7101, et seq., and Texas Occupations Code, Chapter 116 and 301, which require health practitioners to complete a Health and Human Services Commission (HHSC)-Approved Human Trafficking Course for every licensure renewal period.

Grantees must have a written policy on human trafficking that 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:

Domestic and Intimate Partner Violence (IPV)

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. 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 receipt of services.

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

3300 Confidentiality

Revision 25-3; Effective Sept. 1, 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 TVFFS provider must maintain all health care information as confidential to the extent required by law.

HIPAA requires grantees to develop and distribute a notice that provides a clear explanation of privacy rights and practices. Grantees must give this Notice of Privacy Practices to clients at the first appointment, upon request and every three years at minimum. Grantees also must post the notice in a clear and easy-to-find location for clients to view. The notice also must be on the organization’s website.

Grantees must make sure all employees and volunteers receive training about client confidentiality during orientation. Employees and volunteers must 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. The grantee must maintain a signed copy in client's record.

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

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

Minors and Confidentiality

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 cases of contagious disease or abuse. The definition of privacy is the person’s ability to maintain information in a protected way. Confidentiality in health care is the health care provider’s obligation not to disclose protected information. While confidentiality is generally understood to be part of 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 person with respect to uses and disclosures of the person’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. Review Code of Federal Regulations - 45 CFR Section 164.502(g).

Review Adolescent Health – A Guide for Providers (PDF) for more information.

3310 Civil Rights

Revision 25-3; Effective Sept. 1, 2025

Grantees must comply with state and federal anti-discrimination laws per grantee contracts with HHSC.

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

3320 Required Signage

Revision 25-3; Effective Sept. 1, 2025

Grantees that provide direct services to clients must display certain HHS posters related to civil rights. The posters must be displayed in areas 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 HHS services. The following posters are required:  

Grantees are encouraged to display signage about human trafficking and suicide prevention, including the 988 Suicide and Crisis Lifeline. If a grantee elects to display such signage, it must be displayed in areas where it is easily viewed by clients and the public, such as lobbies, waiting rooms, front reception desks, and locations where people apply for and receive services. Examples of a suitable flyers are available on the following Office of the Attorney General (OAG) and Substance Abuse and Mental Health Services Administration (SAMHSA) webpages: 

More mental health and suicide prevention resources are available here:  

3330 Complaints and Termination of Services

Revision 25-3; Effective Sept. 1, 2025

Termination of Services

A grantee 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, the safety of clinic staff or others.

A termination of services policy 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.

Resolution of Complaints

Grantees must make sure clients can express concerns about care received and further ensure those complaints 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 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 has requested more assistance 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.

3340 Research, Human Subjects Clearance

Revision 25-3; Effective Sept. 1, 2025

Grantees considering clinical or sociological research using TVFFS-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 that indicates prior approval will be obtained from the HHSC TVFFS program, as well as the IRB, before beginning 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 Records Management

Revision 25-3; Effective Sept. 1, 2025

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 persons,
  • protected 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 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 17 years or younger, the client’s parent, managing conservator or guardian, as authorized by Chapter 32 of the Texas Family Code or by federal law or regulations, must authorize the release of information. 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 be only disclosed in summary, statistically or in a format that does not identify anyone. Upon request, clients transferring to other providers must be given a copy or summary of their record to facilitate continuity of care.

Grantees, providers and subrecipients must maintain all records that pertain to client services, contracts and payments for the time specified by HHSC. 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 related to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law. 

3500 Personnel Policies and Procedures

Revision 25-3; Effective Sept. 1, 2025

Grantees must develop and maintain personnel policies and procedures to make sure 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 the responsibility of the grantee to verify that all staff who provide services to TVFFS 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. Grantees must offer appropriate immunizations to health care staff, following Advisory Committee on Immunization Practices (ACIP) 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, which includes skills evaluation or competencies appropriate for the position; and
  • a performance evaluation process for all staff.

Grantees must show evidence that employees meet all required qualifications and receive annual training. All staff must have appropriate clinical and administrative background to serve TVFFS populations. Job evaluations should include observation of staff and client interactions during clinical, counseling and educational services. Grantees must have at least one provider in network who has an active medical or dental license in Texas with a minimum of five years of medical or dental practice experience, respective to the program services they intend to provide.

Grantees must establish safeguards to prohibit employees from using their positions in ways 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 TVFFS medical director for the clinic must be a licensed Texas physician. The TVFFS 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 or 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 establish, annually review and train staff on TVFFS 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 participate in all HHSC-scheduled meetings. Additionally, one representative who is responsible for training staff must participate in two TVFFS mandatory training sessions per state fiscal year, at the discretion of HHSC.

Grantees must make sure at least one representative from their organization has access to the SharePoint site to view and upload program and contract information. Each staff person who has access to this site must sign and submit an extranet and data security agreement form to HHSC. This form must be signed by the user and their supervisor. If only one representative has access to the SharePoint site, that person must be responsible for disseminating necessary information to administrative and clinic staff. All users 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 name, email address and phone number.

3600 Facilities and Equipment

Revision 25-3; Effective Sept. 1, 2025

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 intends to serve.

Hazardous Materials

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.

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

Medications and medical supplies must be kept in locked storage. Grantees must have a written policy and maintain documents of the maintenance, testing and inspection of medical equipment, including an automated external defibrillator (AED). Documentation must include:

  • equipment 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 care and use of medical equipment.

Radiology Equipment and Standards

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

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

Laboratory Standards 

All facilities that provide 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.  

Smoking Ban

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 subcontractor must also comply with this policy. 

3700 Emergency Responsiveness

Revision 25-3; Effective Sept. 1, 2025

Clinical Emergencies

Grantees must adequately prepare 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 or hospital admission.
  • 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.
  • maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site. Have appropriately trained staff when clients are present.
  • maintain documentation that staff are trained in the clinical emergencies plans or protocols.

Dental Emergencies

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.

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 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 25-3; Effective Sept. 1, 2025

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor TVFFS 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 management program should ensure availability and accessibility of services; and 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 in a way that provides 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 will be assessed with the subcontracting entities.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, the medical director and dental director, and other appropriate staff where applicable, annually reviews and approves the 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 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 must, at minimum:

  • be reviewed annually,
  • include clinical and administrative standards by which services will be monitored,
  • include a process for credentialing and peer review of clinicians,
  • identify people responsible for implementing monitoring, evaluation and reporting,
  • establish timelines for quality monitoring activities,
  • identify tools and forms to be used, and
  • outline reporting to the QM Committee.

Although each organization’s QA program is unique, the following activities are required by all agencies that provide client services:

  • ongoing eligibility, billing and clinical record reviews to assure compliance with program requirements and clinical standards of care,
  • utilization review,
  • client satisfaction surveys,
  • defining, reporting, tracking and follow-up of adverse outcomes,
  • annual performance evaluations to include primary license verification, verification of Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications,
  • 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 delegation orders (SDOs) and clinical protocols, 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. 

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 subcontracting entities, including:

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

3900 Fiscal Policies and Requirements

Revision 25-3; Effective Sept. 1, 2025

Grantee must have written policies and procedures in compliance with state and federal guidelines to address financial management systems and secure data storage.