Revision 20-1; Effective May 8, 2020

 

3100 Client Records Management

Revision 20-0; Effective November 2019

 

HHSC contractors must have an organized and secure client record system. The contractor must ensure that the record is organized, readily accessible and available to the client upon request with a signed release of information. The 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.

The written consent of the client 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 17 years of age 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. 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 individuals. Upon request, clients transferring to other providers must be provided with a copy or summary of their record to expedite continuity of care. Electronic records are acceptable as medical records.

Contractors, providers, subrecipients and subcontractors must maintain for the time specified by HHSC all records pertaining to client services, contracts and payments. 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.

 

3200 Personnel Policy and Procedures

Revision 20-0; Effective November 2019

 

Contractors must develop and maintain personnel policies and procedures to ensure that 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, including those for contracted personnel;
  • A written orientation plan for new staff to include skills evaluation and/or competencies appropriate for the position, and
  • A 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. All dental services must be provided under the supervision, direction and responsibility of a qualified licensed dentist.

The PHC medical director for the clinic must be a licensed Texas physician and the PHC dental director for the clinic must be a U.S. licensed dentist.

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 their advisory committees. Employee orientation and continuing education must be documented in agency personnel files.

 

3300 Facilities and Equipment

Revision 20-0; Effective November 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.

 

3310 Hazardous Materials

Revision 20-0; Effective November 2019

 

Contractors must have written policies and procedures that address:

  • The handling, storage and disposing of hazardous materials and waste, according to applicable laws and regulations;
  • The handling, storage 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.

 

3320 Fire Safety

Revision 20-0; Effective November 2019

 

Contractors 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.

 

3330 Medical Equipment

Revision 20-0; Effective November 2019

 

Contractors must have a written policy and maintain documentation of the maintenance, testing and inspection of medical equipment, including an Automated External Defibrillator (AED). 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 the care and use of medical equipment.

 

3340 Radiology Equipment and Standards

Revision 20-0; Effective November 2019

 

All facilities providing radiology services, including dental x-rays, must:

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

 

3350 Smoking Ban

Revision 20-0; Effective November 2019

 

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.

 

3360 Disaster Response Plan

Revision 20-0; Effective November 2019

 

Written and oral plans address how staff must respond to emergency situations (i.e., fires, flooding, power outage, bomb threats, etc.). The disaster plan must identify the procedures and processes 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. 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.

 

3400 Emergency Responsiveness

Revision 20-1; Effective May 8, 2020

 

HHSC contractors are required to have an emergency preparedness plan. Contractors must have written policies and procedures that address emergency situations.

 

3410 Clinical Emergencies

Revision 20-1; Effective May 8, 2020

 

Contractors must be adequately prepared to handle clinical emergency situations, as follows:

  • There must be a written plan for the management of on-site medical emergencies, emergencies requiring 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 vaso-vagal 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.
  • Documentation must be maintained in personnel files that staff have been trained regarding these written plans or protocols.

 

3420 Emergency Preparedness

Revision 20-1; Effective May 8, 2020

 

There must be a written safety plan that includes maintenance of fire safety equipment, an emergency evacuation plan and a disaster response plan.

 

3500 Quality Management

Revision 20-1; Effective May 8, 2020

 

Contractors must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC services. Contractors must have a Quality Management (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, quality and continuity of care.

Contractors should integrate QM concepts and methodologies into the structure of the organization and day-to-day operations.

Contractors 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 such a way that provides 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 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/CEO, medical director, 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, at a minimum, must:

  • Include clinical and administrative standards by which services will be monitored;
  • Include a process for credentialing and peer review of clinicians;
  • Identify individuals responsible for implementing monitoring, evaluating and reporting;
  • Establish timelines for quality monitoring activities;
  • Identify tools/forms to be used; 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 assure compliance with program requirements and clinical standards of care;
  • 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 prescriptive authority agreements (PSAs), policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and
  • Performance evaluations to include primary license verification, drug enforcement administration (DEA) and immunization status to ensure they are current.

HHSC 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;
  • Eligibility and billing review;
  • On-site facility review;
  • Annual client satisfaction evaluation process; and
  • Child abuse training and reporting for subcontractor staff.

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.