Revision 19-0; Effective September 1, 2019


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


2100 Client Access

Revision 19-0; Effective September 1, 2019


The contractor must ensure that clients are provided services in a timely and nondiscriminatory manner. The contractor must:

  • Have a policy in place that delineates the timely provision of services;
  • Have policies in place to identify and eliminate possible barriers to client care;
  • Comply with all applicable civil rights laws and regulations, including Title VI of the Civil Rights Act of 1964, the Americans with Disabilities Act of 1990, the Age Discrimination Act of 1975, and Section 504 of the Rehabilitation Act of 1973, and ensure services are accessible to persons with Limited English Proficiency (LEP) and speech or sensory impairments;
  • Have a policy in place that requires qualified staff to assess and prioritize client needs;
  • Provide referral resources for clients that cannot be served or cannot receive a specific needed service;
  • Manage funds to ensure that established clients continue to receive services throughout the budget year;
  • Continue to provide services to established clients after allocated funds are expended;
  • Ensure family planning services are provided to clients within 30 days of the request for services (clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method), appointments for minors age 15 through 17 should be seen as soon as possible, with every effort made to provide an appointment within two weeks of the request; and
  • Ensure clinic/reception room wait times are reasonable so as not to represent a barrier to service.


2200 Abuse and Neglect Reporting

Revision 19-0; Effective September 1, 2019


HHSC requires contractors to be familiar with, and comply with, state laws governing the reporting of adult and child abuse and neglect. To report abuse or neglect, call the Texas Abuse Hotline 800-252-5400, use the secure website, or call any local or state law enforcement agency for cases that pose an imminent threat or danger to a person. Contractors must have an agency policy regarding abuse and neglect.


2210 Child Abuse Reporting

Revision 19-0; Effective September 1, 2019


Child Abuse Compliance and MonitoringTexas Family Code, Chapter 261 requires suspected abuse or neglect of a child to be reported. Contractors/providers are required to develop policies and procedures that comply with the child abuse reporting guidelines and requirements set forth in Chapter 261.

Policy – Contractors must develop an internal policy specific to how these reporting requirements will be implemented throughout their agency, how staff will be trained, and how internal monitoring will be done to ensure timely reporting.

Procedures – To verify compliance, Quality Assurance (QA) monitors will review that the contractor:

  • Has an internal policy which details how the contractor will determine, document, report and track instances of abuse, sexual or non-sexual, for all child/minor clients under the age of 18, in compliance with the Texas Family Code, Chapter 261;
    Note: Pursuant to TFC Sec. 101.003, "child" or "minor" means a person under 18 years of age who is not, and has not, been married or who has not had the disabilities of minority removed for general purposes.
  • Followed their internal policy; and
  • Documented staff training on child abuse reporting requirements and procedures.

References for Child Abuse Reporting Policy Development – Child abuse reporting requirements for DSHS contractors and providers includes links to policies, a child abuse reporting form and statutory references available at the Texas Department of Family and Protective Services (DFPS) website:

The contractor’s internal policy must clearly describe the reporting process for child abuse.


2220 Human Trafficking

Revision 19-0; Effective September 1, 2019


As part of the requirement that contractors comply with all applicable federal laws, HTW contractors must comply with the federal anti-trafficking laws, including the Trafficking Victims Protection Act of 2000 (22 USC § 7101, et seq.). Contractors must have a written policy on human trafficking which includes the provision of annual staff training. References for human trafficking policy development include:


2230 Domestic and Intimate Partner Violence

Revision 19-0; Effective September 1, 2019


Intimate partner violence (IPV) describes physical, sexual or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

Contractors must have a written policy related to assessment and prevention of domestic and IPV, including the provision of annual staff training.


2300 Client Rights

Revision 19-0; Effective September 1, 2019




2310 Confidentiality

Revision 19-0; Effective September 1, 2019


All contracting agencies must follow the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) established standards for protection of privacy. Contractors must ensure that all employees and volunteers receive training about client confidentiality during orientation and are made aware that violation of the law regarding confidentiality may result in civil damages and criminal penalties. All employees, volunteers, subcontractors, and board members and/or advisory board members must sign a confidentiality statement during orientation.

The person’s preferred method of follow-up to clinic services (cell phone, email, work phone and/or text) and preferred language must be documented in the client’s record (See Section 3312, Client Health Record and Documentation of Patient Encounters). Everyone must receive verbal assurance of confidentiality, an explanation of what confidentiality means (kept private and not shared without permission) and any applicable exceptions such as abuse reporting (See Section 2200, Abuse and Neglect Reporting).


2320 Minors and Confidentiality

Revision 19-0; Effective September 1, 2019


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 the cases of contagious disease or abuse. Privacy is defined as the ability of a person to maintain information in a protected way. Confidentiality in health care is the obligation of the health care provider to not disclose protected information. While confidentiality is implicit in maintaining a person’s privacy, confidentiality between provider and a person 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. (See Title 45 of the Code of Federal Regulations, Part 164).


2330 Nondiscrimination

Revision 19-0; Effective September 1, 2019


HHSC contractors must comply with state and federal anti-discrimination laws, including and without limitation:

It is highly recommended that contractors comply with Texas Government Code, §2054.457, Access to Electronic and Information Resources. More information about nondiscrimination laws and regulations can be found on the HHSC Civil Rights website and at the HHSC Civil Right Office, Requirements for Contractors website.


Contract Terms and Conditions

To ensure compliance with nondiscrimination laws, regulations and policies, contractors must:

  • Have a written policy that states the agency does not discriminate based on race, color, national origin, including limited English proficiency (LEP), sex, age, religion, disability or sexual orientation;
  • Have a policy that addresses individual rights and responsibilities that is applicable to all people requesting health care services;
  • Sign a written assurance to comply with applicable federal and state nondiscrimination laws and regulations;
  • Notify all people who are applying for services of the contractor’s nondiscrimination policies, including LEP policies, and HHSC complaint procedures;
  • Ensure all contractor staff are trained in the contractor’s nondiscrimination policy, including policies for serving people with LEP and people with disabilities, and HHSC complaint procedures; and
  • Notify the HHSC Civil Rights Office of any discrimination allegation or complaint related to its programs and services no more than 10 calendar days after receipt of the allegation or complaint.

Send notices to:

HHSC Civil Rights Office
701 W. 51st Street, Mail Code W-206
Austin, Texas 78751

Phone Toll Free: 888-388-6332 or 512-438-4313

Fax: 512-438-5885


Limited English Proficiency

To ensure compliance with civil rights requirements related to LEP, contractors must:

  • Take reasonable steps to ensure that people with LEP have meaningful access to its programs and services and not require a person with LEP to use friends or family members as interpreters. However, a family member or friend may serve as a person’s interpreter, if requested, and the family member or friend does not compromise the effectiveness of the service nor violate client confidentiality; and
  • Make people with language service needs, including persons with LEP and disabilities, aware that the contractor will provide an interpreter free of charge.


Civil Rights Posters

Contractors must prominently display civil rights posters in common areas, including lobbies and waiting rooms, front reception desk and locations where clients apply for services. The following posters can be found on the Civil Rights Office website:

  • “Know Your Rights” [English] [Spanish]
    Size: 8.5” x 11” (standard size sheet of paper)
    Posting Instructions: Post the English and Spanish versions next to each other.
  • “Need an Interpreter” [Language Translation] [American Sign Language]
    Size: 8.5” x 11” (standard size sheet of paper)
    Posting Instructions: Post the “Language Translation” and “American Sign Language” versions next to each other.
  • ”Americans with Disabilities Act” [English] [Spanish]
    Size: 8.5” x 11” (standard size sheet of paper)
    Posting instructions: Post the English and Spanish versions next to each other.

Questions concerning this section and civil rights matters can be directed to the HHSC Civil Rights Office.


2340 Important Information for Former Military Service Members

Revision 19-0; Effective September 1, 2019


Women who served in any branch of the U.S. Armed Forces, including Army, Navy, Marines, Air Force, Coast Guard, Reserves or National Guard, may be eligible for additional benefits and services beyond the HTW Program. For more information, visit the Texas Veterans Portal at


2350 Termination of Services

Revision 19-0; Effective September 1, 2019


Contractors have the right to terminate services to a person if the person is disruptive, unruly, threatening or uncooperative to the extent that the person seriously impairs the contractor’s ability to provide services, or if the person’s behavior jeopardizes her own safety, clinic staff or others. Any policy related to termination of services must be included in the contractor’s Policy and Procedures Manual.


2360 Resolutions of Complaints

Revision 19-0; Effective September 1, 2019


Contractors must ensure clients can express concerns about care received and to further ensure that those complaints are handled in a consistent manner. Contractors’ Policy and Procedure Manuals must explain the process clients will follow if they are not satisfied with the care received. If an aggrieved person requests a hearing, a contractor shall not terminate services to the person until a final decision is rendered. Contractors should also reference the appeal procedures for denial, suspension or termination of services under the Texas Administrative Code §357, Subchapter A. Any complaint must be documented in the client’s record.


2370 Prompt Services

Revision 19-0; Effective September 1, 2019


Contractors are responsible for ensuring that HTW services are provided to clients within 30 days of the request for services. Clients who request contraception but cannot be immediately provided a clinical appointment must be offered a nonprescription method. HTW minors ages 15 through 17 must be provided family planning counseling and medical services as soon as possible after the request, with every effort made to provide an appointment within two weeks of the request. Clinic/reception room wait times should be reasonable so as not to represent a barrier to service.


2380 Freedom of Choice

Revision 19-0; Effective September 1, 2019


HTW clients are guaranteed the right to choose HTW providers and family planning methods without coercion or intimidation. Acceptance of family planning services must not be a prerequisite to eligibility for, or receipt of, any other service or assistance.


2390 Research (Human Subject Clearance)

Revision 19-0; Effective September 1, 2019


HTW contractors that wish to participate in any proposed research that would involve the use of HHSC HTW clients as subjects, the use of HHSC HTW clients’ records or any data collection from HHSC HTW clients, must obtain prior approval from HHSC and be approved by the Institutional Review Board #1 (IRB #1).

Contractors should first contact the HHSC HTW program ( to initiate a research request. Next, program staff will assist contractors to find the most current version of the IRB application to complete and submit. The IRB will review the materials and approve or deny the application.

The contractor must have a policy in place that indicates that prior approval will be obtained from the HHSC HTW Program, as well as the IRB, prior to instituting any research activities. The contractor must also ensure that all staff is made aware of this policy through staff training. Documentation of training on this topic must also be maintained.


2400 Client Record Management

Revision 19-0; Effective September 1, 2019


HHSC contractors must have an organized and secure client record system. The contractor must ensure that records are organized, readily accessible and available to clients upon request with a signed release of information. Records must be kept confidential and secure, as follows:

  • Safeguarded against loss and use by unauthorized persons;
  • Secured 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, except as may be necessary to provide services to the client or as required by law, with appropriate safeguards for confidentiality. If the client is 15 through 17 years of age, the client’s parent, managing conservator or guardian, as authorized by the Texas Family Code Chapter 151 or by federal law or regulations, must authorize the release. HIV information should be handled according to law.

When information is requested, contractors should release only the specific information requested. Information collected for reporting purposes may be disclosed only in summary, statistically, or in a form that does not identify a client. Upon request, clients transferring to other providers must be provided with a copy or summary of their records to expedite continuity of care. Electronic records are acceptable as medical records.

Contractors, providers, subrecipients and subcontractors must maintain all records pertaining to services, contracts and payments for the time specified by HHSC. Additionally, contractors 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 relating to services must be accessible for examination at any reasonable time to representatives of HHSC and as required by law.  

2500 Personnel

Revision 19-0; Effective September 1, 2019


Contractors must develop and maintain personnel policies and procedures to ensure clinical staff are hired, trained and evaluated appropriately to their job position. Contracted staff must also be trained and evaluated according to their responsibilities. Job descriptions, including those for contracted personnel, must specify required qualifications and licensure. All staff must be appropriately identified with a name badge. Personnel policies and procedures must include:

  • Job descriptions;
  • A written orientation plan for new staff to include skills evaluation and/or competencies appropriate for the position; and
  • Performance evaluation process for all staff.  

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

Contractors shall 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 contactor’s HTW Program medical director must be a licensed Texas physician.

Contractors must have a documented plan for organized staff development. There must be an assessment of:

  • training needs;
  • quality assurance indicators; and
  • changing regulations/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 advisory committees. Employee orientation and continuing education must be documented in agency personnel files.


2600 Facilities and Equipment

Revision 19-0; Effective September 1, 2019


HHSC contractors are required to always maintain a safe environment. Contractors must have written policies and procedures that address hazardous waste, fire safety and medical equipment.

Hazardous Materials – Contractors must have written policies and procedures that address:

  • Handling, storing and disposing of hazardous materials and waste, according to applicable laws and regulations;
  • Handling, storing and disposing 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 – Contractors must have a written fire safety policy that includes a schedule for testing and maintaining fire safety equipment. Evacuation plans for the premises must be clearly posted and visible to all staff and clients.

Medical Equipment – Contractors must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an automated external defibrillator. 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 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 providing radiology services must:

For information on x-ray machine registration, see the Texas Department of State Health Services, Radiation Control Program.

Smoking Ban – Contractors must have written policies that prohibit smoking in any portion of their indoor facilities. If a contractor subcontracts with another entity for the provision of health services, the subcontractor must also comply with this policy.

Disaster Response Plan – Contractors must have written and oral plans that address how staff is to respond to emergency situations (i.e., fires, flooding, power outage, bomb threats, etc.). 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 orally to employees. For additional resources on facilities and equipment, see the Occupational Safety and Health Administration website.


2700 Quality Management

Revision 19-0; Effective September 1, 2019


Organizations shall comply with quality management (QM) concepts and methodologies and integrate them into the structure of the organization and day-to-day operations. QM programs can vary in structure and organization and will be most effective if they are individualized to meet the needs of a specific agency, services and the populations served.

Contractors are expected to develop quality processes based on the four core QM principles that focus on:

  • The client;
  • Systems and processes;
  • Measurements; and
  • Teamwork.

Contractors must have a QM program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, and quality and continuity of care.

A QM program must be developed and implemented to provide for ongoing evaluation of services. Contractors 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.  

Contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHS 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/CEO and the medical 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;
  • Reassess outcomes and goal achievement; and
  • Ensure minutes of the discussion, actions taken by the Committee, and a list of the attendees are maintained and made available during quality assurance/quality improvement reviews.

The comprehensive quality work plan at a minimum must:

  • Include clinical and administrative standards by which services will be monitored;
  • Include the process for credentialing and peer review of clinicians;
  • Identify those responsible for implementing, monitoring, evaluating and reporting;
  • Establish timelines for quality monitoring activities;
  • Identify tools/forms to be utilized; and
  • Outline reporting to the QM Committee.

Although each organization’s quality assurance program is unique, the following activities must be undertaken by all agencies providing client services:

  • Ongoing eligibility, billing, and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
  • Utilization review;
  • Tracking and reporting of adverse outcomes;
  • Client satisfaction surveys;
  • Annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • Annual review of policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and
  • Performance evaluations to include primary license verification, Drug Enforcement Administration and immunization status to ensure they are current.

Contractors 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;
  • Billing and eligibility review;
  • Utilization review;
  • Facility on-site review; and
  • Annual client satisfaction evaluation process.

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 Committee and should be documented.


2800 Pharmacy

Revision 19-0; Effective September 1, 2019




2810 Vendor Drug Program

Revision 19-0; Effective September 1, 2019


HTW uses the Vendor Drug Program (VDP), which provides statewide access to covered outpatient drugs in an efficient and cost-effective manner. HTW clients may receive approved medications from an associated pharmacy at no cost to the client by providing an HTW benefits card. For further information on the VDP, what drug benefits are covered by HTW, and to locate local pharmacies, visit:


2820 Class D Pharmacy

Revision 19-0; Effective September 1, 2019


To facilitate client access to, and compliance with, contraceptive methods and related medications, it is highly recommended but not required, that all contractors have at least a Class D pharmacy at each HTW clinic site.

If a contractor chooses to have a Class D pharmacy, the pharmacy must be operated in accordance with federal and state laws relating to security and record keeping for drugs and devices. The inventory, supply, and provision of pharmaceuticals must be conducted in accordance with state pharmacy laws and professional practice regulations. It is essential that each facility maintain an adequate supply and variety of contraceptive methods and other medications on-site to effectively manage clients’ contraceptive needs.