3700, Clinic Operations

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Revision 24-2; Effective Oct. 15, 2024

3710 Personnel Policy and Procedures

Revision 25-3; Effective Oct. 29, 2025

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

  • job descriptions;
  • 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 members.

Job descriptions, including those for contracted personnel, must specify required qualifications and licensure.

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

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

Grantees must establish, annually review and train staff on FPP requirements, including any updates to this manual and required forms that 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 and 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, whether funded under this contract or not, to HHSC of:

  • Any grant-funded positions; and
  • chief executive officer (CEO), chief financial officer (CFO), program director or program manager;

Grantees must make sure at least one representative, the capabilities to disseminate information to program administrative and clinic staff:

  • attend a minimum of two priority technical assistance webinars offered by HHSC during the fiscal year. These specific webinars will be identified as mandatory or priority in HHSC’s electronic mail. To receive credit for participating, attendees must follow HHSC’s directions including completion of any sign-in sheet, registration, survey within the specified time frame or all three; and
  • has access to the HHSC’s web-based applications – SharePoint site. The grantee must sign and submit a Family Clinical Services Extranet and Data Upload Security Agreement form for each grantee staff person accessing HHSC’s web-based applications – SharePoint site. 

Grantees must make sure users of HHSC’s web-based applications have an Outlook or Microsoft Office 365 account.

3720 Facilities and Equipment

Revision 25-3; Effective Oct. 29, 2025

Grantees must maintain a safe environment. Grantee must provide clean and well-maintained facilities where services can be delivered with space for exam rooms, client intake, waiting areas and space for clinical and administrative staff. Grantees must have policies and procedures that address hazardous materials and waste, fire safety and medical equipment.

Hazardous Materials and Waste

Grantees must have written policies and procedures to 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

Grantees must have a written policy and keep documentation of the maintenance, testing and inspection of medical equipment, including automated external defibrillators (AEDs). 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 user 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 must:

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

Smoking and Vaping Ban

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

Disaster Response Plan

Grantees must have written plans that address how staff will respond to emergencies such as fires, flooding, power outages and bomb threats. The disaster plan must identify the procedures and processes to be initiated during a disaster and the staff position 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. For an employer with 10 or fewer employees, the plan may be communicated verbally.

For resources on facilities and equipment, review the Occupational Safety and Health Administration Compliance Assistance Guide.

Clinical Emergencies

Grantees must be adequately prepared to handle clinical emergencies as follows:

  • There must be a written plan for the management of on-site medical emergencies, emergencies that require ambulance services and hospital admission;
  • Each site must 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;
  • There must be written protocols to address vasovagal reactions, anaphylaxis, syncope, cardiac arrest, shock, hemorrhage and respiratory difficulties;
  • Each site must maintain emergency resuscitative drugs, supplies and equipment appropriate to the services provided at that site and appropriately trained staff when clients are present; and
  • Documentation must be maintained in personnel files that staff have been trained on these written plans or protocols.

Suicide Prevention Signage

Grantees are encouraged to display signage related to suicide prevention, including the 988 Suicide and Crisis Lifeline. If a grantee elects to display such signage, it must be displayed in areas where clients and the public can easily see it, such as lobbies, waiting rooms, front reception desks and locations where people apply for and receive services.

Examples of suitable flyers are available on the Substance Abuse and Mental Health Services Administration (SAMHSA) webpages:

More mental health and suicide prevention resources are at the: