Quality Management Core Tool - Monitoring Instructions
- DSHS Monitoring reviews will reflect if the following Review Criteria have been Implemented (I), Partially Implemented (P), Not Implemented (N), Not Applicable (NA), Not Reviewed (NR).
- Before the review, DSHS Monitoring staff will ask about changes to agency policies/procedures and DSHS-approved Work Plan. This will include changes in response to DSHS guidance or policy changes or any other review criteria. If there are any changes, the agency will provide copies of related documents specific to grant-funded services and other program activities to the monitoring staff before the review.
- Refer to Program Operating Procedures and Standards Policy and Procedures Chapter 16 – Routine HIV Screening in Healthcare Settings for more information on 1) Screening recommendations/guidelines and Standing Delegation Orders, 2) Consent, 3) HIV testing technology, 4) Reporting new and acute HIV diagnosis, 5) Notification of positive HIV test results, 6) Referral and Confirmation to HIV-related medical care, 7) Confidentiality, and 8) Quality Assurance.
|I. Laws, Regulations and Policies|
1) Routine HIV screening follows CDC's Revised Recommendations for HIV Screening for Adults, Adolescents and Pregnant Women in Health Care Settings,
Include the following criteria specific to HIV screening in program policies/procedures. Attachment of the most recent DSHS-approved Work Plan is acceptable if you include all criteria below:
DSHS Monitoring staff will observe and document that:
|2) Contractor obtains consent for HIV screening under Texas law: Health and Safety Code 81.105—Informed Consent and 81.106—General Consent. Oral consent with documentation is allowed; a separate consent form is not required for HIV screening.||
Before the review, DSHS Monitoring staff will request current or updated policies related to general and informed consent, and the forms/documentation used for the consent for, or declination of, HIV screening.
Monitoring staff will review:
|3) Contractor ensures at least 90% of persons receive their HIV positive test results, including preliminary and confirmatory results, under Texas law: Health and Safety Code 81.109||
Before the review, DSHS Monitoring staff will request current/updated policies/procedures and ensure that:
Monitoring staff will review and confirm with the Contractor:
|4) Contractor reports positive HIV test results to appropriate local/regional health authority under Texas law: Health and Safety Code 81.043-44 and TAC Title 25, Part 1, Ch 97, Subchapter F, Rules 97.132-134.||
Before the review, DSHS Monitoring staff will request current/updated policies/procedures to ensure reporting of positive HIV test results to the appropriate local/regional health authority.
Monitoring staff will review the following processes with the contractor to ensure:
|5) Contractor complies with all applicable DSHS Security Policies and Procedures [refer to Section VI. Data, 18) Data Security]||
|6) Contractor reports to DSHS any changes or reassignment of staff funded through the HIV/ROUTN grant to prevent a potential decrease of grant funds.||Before the review, DSHS Monitoring staff will request the current/updated listing of HIV/ROUTN funded staff and verify all positions are filled, and/or vacant positions have been posted for employment through the Human Resources Department to ensure the best efforts to fill vacancies within 90 days.|
|7) Contractor maintains a contact list with appropriate back-up staff to ensure timely communication between Contractor and DSHS.||Before the review, monitoring staff will request the current/updated contact list including in-kind and DSHS-funded staff dedicated to HIV/ROUTN grant services and activities.|
|8) DSHS Required Training||Before review, DSHS Monitoring staff will request a listing of new staff and documented completion of DSHS training requirements.|
|a) Contractor ensures grant-supported staff complete DSHS Core Required Trainings during the first year of employment. This includes keeping Certificates of Completion on file.||
Training to be completed during the first year of employment include:
The contractor has documentation, including Certificates of Completions on file, of staff attendance at all DSHS-directed training, conferences, and meetings.
|b) Contractor authorizes and requires staff (including volunteers) to attend DSHS-identified training, conferences, and meetings as directed by DSHS.|
|9) Contractor has a written orientation plan for new staff.||
Before review, DSHS Monitoring staff will request a copy of the new staff orientation plan designed to ensure new staff are aware of the Routine Screening Program goals, policies, and clinical operations.
|10) Contractor ensures Routine HIV screening services are carried out by qualified clinical staff, which is ensured through appropriate and on-going trainings or continuing education opportunities. Note the orientation plan may include much of the required information. [Refer to No. 9 above, Orientation Plan]||
Before review, DSHS Monitoring staff will request documentation to determine the training is available to:
|11) Contractor provides or has made available appropriate training per the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care for grant supported staff to perform routine HIV screening and related services.||
The DSHS Monitoring staff will review with the contractor a sample of training offered to grant-funded routine HIV program staff. Training may include, but is not limited to:
|12) Contractor provides staff development based on grant-supported employee needs.||
DSHS Monitoring staff verifies that the staff development plan is based on an assessment of training needs, quality improvement indicators, and changing regulations or requirements.
Indicators for staff training needs assessments may include surveys, discussions at staff meetings, employee suggestions, and performance evaluations. Staff development is documented to include continuing education for grant-funded credentialed professional staff.
The contractor maintains monitoring and evaluation records of grant-supported program staff development.
|IV. Delivery of Services - Screening and Confirmation to HIV Medical Care|
|13) At least 90% of all eligible patients, as defined by the contractor, receive an HIV test, unless they decline.||
Before the review, DSHS Monitoring staff will request the current/updated definition of the population eligible for routine HIV screening. The will also request the total number of HIV tests to be performed during the contract period.
The monitoring staff will review with contractor staff to determine:
14) Grantee will ensure at least 75% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within one month and at least 90% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within three months.
Grantee will ensure that at least 75% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within one month and at least 90% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within three months.
In addition to HIV medical services, the grantee will ensure individuals are referred to other services, including housing, legal assistance and violence prevention as needed.
Before the review, DSHS Monitoring staff will request current/updated protocols regarding confirming persons who test positive for HIV to medical care and other services.
The monitoring staff will review the following:
|15) Delivery of services|
|a) Program delivers all services in a culturally responsive and sensitive manner, taking low health literacy into account, using the National CLAS in Health and Health Care.||
a) DSHS Monitoring staff will observe and review the following procedures to ensure services are delivered in a culturally responsive and sensitive manner, including low health literacy:
|b) Available resources ensure services are provided in a culturally and linguistically appropriate manner.||
b) DSHS Monitoring staff will review relevant resources available to ensure services are provided in a culturally and linguistically appropriate manner, which may include but are not limited to:
Patient/client information/education materials are available in appropriate language/s.
|V. Continuous Quality Improvement (CQI) and Monitoring Plan|
|16) Contractor has a written and implemented internal Continuous Quality Improvement (CQI) Plan to evaluate all services, processes and operations including routine HIV screening within the agency on an annual basis including a review of client grievance policy and procedures that includes:||
The CQI Plan describes the process for conducting quality assurance activities including:
|a) Establishment of CQI Committee||
The CQI plan describes the establishment of a multidisciplinary CQI Committee to include:
|b) Maintenance of CLIA certification and current screening/laboratory procedures||CQI Plan ensures maintenance of CLIA certification, and if applicable, CLIA Waivers to ensure screening is conducted in accordance with manufacturer’s instructions.|
|c) Monitoring DSHS Routine Screening Performance Measures (PM) to track progress to meet annual PMs by the end of contract term. (Refer to Appendix A for current DSHS Routine HIV Screening PMs)||This activity is part of the DSHS desk audit and is reviewed at least semi-annually as part of the Interim and Annual Progress reports and will be reviewed with the contractor as needed.|
|17) Contractor submits interim and annual progress reports to DSHS per contract requirements by required submission date.||This activity is part of the DSHS desk audit; DSHS will follow-up with the contractor as needed.|
|18) Data security
Contractor follows all applicable DSHS Security Policies and Procedures.
|DSHS Monitoring staff will review the following:|
|b) Data Release Agreement||
|c) Access to DSHS-designated reporting systems||
|d) Annual Security Trainings||
|19) Data collection and submission
Contractor submits required data set to the Texas Department of State Services via the reporting system/s designated by DSHS.
|Activities 19) a) and b) are part of the DSHS desk audit performed monthly; DSHS will follow-up with the Contractor as needed.|
|a) Data is submitted by the 20th of each month, or per DSHS instructions.||
|b) Data submission is accurate and complete.||
|20) Contractor submits financial reports to DSHS by required submission dates.||Activities 20) a), b) and c) are part of the DSHS desk audit performed monthly; DSHS will follow-up with the Contractor as needed.|
|a) Requests for reimbursement or payment are submitted by the last business day of the month following the month expenses were incurred or services provided.||Contractor submits monthly requests for payments using the State of Texas Purchase Voucher (Form B-13) and the Voucher Support Form (VSF) with acceptable supporting documentation for reimbursement of the required services/deliverables within allowable timeframes. Grantee is required to identify expenditures by budget category and funding code. Forms can be found on the Client Services Contracting Forms page.|
|b) Financial Status Reports (FSR) are submitted by required due dates documented in the current contract.|
|c) Expenditures are in accordance with the DSHS HIV Prevention approved line item categorical budget.|
|21) Contractor has implemented systems changes to work towards sustainability of routine HIV screening as a standard of care.||
Activities should include but are not limited to:
Performance Measures – Routine Screening Program Contractor Performance Measures to be met by the end of the 2021 contact term:
- Grantee will conduct at least 90% of the total projected number of HIV tests by the end of the contract term.
- Grantee will ensure that at least 95% of individuals with a positive HIV test receive their test results. *
- Grantee will ensure that at least 75% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 1 month.
- Grantee will ensure that at least 90% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 3 months.
- Grantee will ensure that at least 75% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 1 month.
- Grantee will ensure that at least 90% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 3 months.
- Grantee will achieve a minimum of 0.1% overall positivity rate.
- *While the goal is to link 100% of persons living with HIV to HIV-related medical care, this performance measure reflects DSHS minimum performance standards.
Guidance last revised April 2021