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Revision 25-3; Effective Sept. 1, 2025
Grantees must have an organized and secure client record system. The grantee must make sure the record is organized, readily accessible and available to the client upon request with a signed release of information. Records must be kept confidential, secure and:
- safeguarded against loss or use by unauthorized people;
- secured by lock when not in use and inaccessible to unauthorized people; and
- maintained in a secure environment in the facility, as well as during transfer between clinics and between home and office visits.
The client’s 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. HIV information must be handled per law. Refer to the DSHS HIV/STD Program Laws, Rules, and Authorization webpage for more information.
When information is requested, grantees should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistical or other form that does not identify clients. Providers must give clients transferring to other providers, upon request, a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.
Grantees, providers and subrecipients must maintain all records that pertain to client services, contracts and payments for the period specified by HHSC. Requirements about time limits for submitted claims are in TAC Title 1, Part 15, Chapter 354, Section 354.1003. Requirements for medical record maintenance are in TAC Title 22, Part 9, Chapter 163. Grantees must follow contract provisions, maintain medical records for at least seven years after the contract closes, and follow the retention standards of the appropriate licensing entity. All records about services must be accessible for examination at any reasonable time to HHSC representatives and as required by law.
2510 Personnel Policy and Procedures
Revision 25-3; Effective Sept. 1, 2025
Grantees must develop and maintain personnel policies and procedures to ensure 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 to include skills evaluation and competencies appropriate for the position; and
- a performance evaluation process for all staff.
Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge.
Grantees must designate:
- one (1) Medicaid for Breast and Cervical Cancer (MBCC) point-of-contact with responsibilities to provide training and technical help to staff helping with and submitting MBCC applications; and
- one (1) Evidence-Based Intervention (EBI) point-of-contact with responsibilities to oversee and support HHSC BCCS-sponsored and clinic-level EBI projects. The EBI contact is responsible for providing training and technical assistance to staff implementing EBI projects. The EBI contact, or a designee, is required to attend EBI-specific meetings and webinars.
Grantees must show evidence employees meet all required qualifications and receive required annual training. Job evaluations should include observation of staff and 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 medical director must be a licensed Texas physician.
Grantees must establish, annually review, and train staff on BCCS program requirements and policies, including any updates to the Program Policy Manual and required forms that occur during the Grant Term.
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.
Whether positions are funded under this grant or not, grantees must notify HHSC in writing, within 30 calendar days of any change in:
- any grant-funded positions;
- Chief Executive Officer (CEO), Chief Financial Officer (CFO), program director or program manager;
- MBCC point-of-contact; and
- EBI point-of-contact.
Grantees must ensure that at least one representative with capabilities and responsibility to disseminate information to program administrative and clinic staff:
- attends a minimum of two priority technical assistance webinars offered by HHSC during the fiscal year. These specific webinars are 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, or survey within the specified time frame; and
- has access to the HHSC’s web-based applications on the 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 SharePoint site. Grantees must ensure users of HHSC’s SharePoint site have an Outlook or Microsoft Office 365 account.