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Revision 26-3; Effective Sept. 1, 2026
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 on 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 to prevent access by unauthorized people; and
- maintained in a secure environment in the facility and during transfer between clinics and 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
- with appropriate safeguards for confidentiality as required by law.
HIV information should be handled per federal and state law.
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. Upon request, clients transferring to other providers must be given 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 regarding 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, Subchapter A. 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 26-3; Effective Sept. 1, 2026
Grantees must develop and maintain personnel policies and procedures to make sure all staff are hired, trained and evaluated appropriately for their job position, including contracted personnel. The grantee must verify that all staff who provide services to BCCS clients have the appropriate licenses and certifications required by applicable law. All licenses and certifications must be current, valid, in good standing and remain so for the term of the grant. All staff must be appropriately identified with a name badge.
Personnel policies and procedures, including those for contracted personnel, must include:
- job descriptions that specify any required qualifications and licensure;
- a written orientation plan for new staff that includes a statement of skills, competencies or both as appropriate for the position; and
- a performance evaluation process for all staff.
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.
All medical care for BCCS clients 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 designate:
- one Medicaid for Breast and Cervical Cancer (MBCC) point-of-contact with responsibilities to provide training and technical help to staff who help with and submit MBCC applications; and
- one 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 who implement EBI projects. The EBI contact, or a designee, is required to attend EBI-specific meetings and webinars.
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.
Grantees must establish BCCS program requirements and policies, review them annually, and train staff accordingly. This includes reviewing and updating staff on any updates to the program’s policy manual and required forms that may 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. Government entities must provide orientation for their advisory committees. All 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 to HHSC of:
- chief executive officer (CEO) – signature authority;
- chief financial officer (CFO) – fiscal contact;
- program director or program manager – program contact;
- patient navigator(s) funded by this program;
- EBI Champion; and
- MBCC contact.
Grantees must make sure at least one representative:
- Communicates program information. Person is responsible for disseminating information to BCCS program administrative and clinic staff.
- Has HHSC SharePoint access. Person can view and upload program and grant information via HHSC web-based applications on the SharePoint site.
- Must have an Outlook or Microsoft Office 365 account.
- Must sign and submit a Family Clinical Services Extranet and Data Upload Security Agreement form for each staff person who accesses the site.
- Attends relevant HHSC webinars during the fiscal year.
- Grantees should aim for representation at one or more relevant technical assistance, training or evaluation webinars.
- HHSC may designate certain webinars as mandatory, such as for a priority policy or procedure change, and will notify grantees accordingly.
- To receive participation credit, attendees must complete any required sign-in sheet, registration or survey within the specified time frame.