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Universal Standards

HIV/STD Program

HIV/STD Program

HIV Medical and Support Service Categories

Universal Standards

Universal Standards print version

Texas Department of State Health Services, HIV Care Services Group – HIV/STD Program

The Universal Standards listed below apply to all service categories funded under the Ryan White Part B Program for direct care service providers. The HIV Care Services Group took these Universal Standards directly from the HRSA Ryan White HIV/AIDS Program (RWHAP) standards listed in the Part B RWHAP National Monitoring Standard (NMS) and expanded them to include DSHS program requirements for Ryan White Part B and State Service subrecipients.

HRSA AND DSHS STANDARD: Structured and ongoing efforts to obtain input from clients in the design and delivery of services   
1

The agency maintains documentation of at least one of the following efforts to obtain client input regarding the design and delivery of services:

  • Documentation of a Consumer Advisory Board (CAB) and public meetings minutes;
  • Documentation of the existence of the appropriate mechanism(s) for obtaining client input; or
  • Documentation of the content, use, and confidentiality of a client satisfaction survey or focus groups conducted at least annually.
2

The agency maintains documentation of an appeals and grievance process and a file of individuals to whom the provider refused services with the reasons for refusal specified, including: (Pilot Measure 2025-2026)

  • Client complaint; 
  • Documentation of the complaint review; and
  • Documentation of the decision reached or the response given, if any. 
HRSA AND DSHS STANDARD: Provision of services regardless of an individual’s ability to pay for the service
3

The agency’s sub-recipients billing and collection policies and procedures do not:

  • Deny services for non-payment;
  • Require full payment prior to service; or
  • Include other procedures that deny services for non-payment.
HRSA AND DSHS STANDARD: Provision of services regardless of the current or past health condition of the individual the agency will serve
4

The agency maintains eligibility and clinical policies that do not: 

  • Permit the denial of services due to pre-existing conditions; 
  • Permit the denial of services due to non-HIV-related conditions (primary care); or
  • Provide other barriers to care due to a person’s past or present health condition.
HRSA AND DSHS STANDARD: Provision of services regardless of English proficiency or other barriers to communication
5 The agency has culturally and linguistically appropriate policies, ensuring it provides language assistance to individuals who have limited English proficiency or other communication needs at no cost to them to facilitate timely access to all health care and services.
6 The agency provides documentation of print and multimedia materials and signage in the languages and personal health literacy commonly used by the populations in the service area to inform all individuals of the availability of language assistance services.
HRSA AND DSHS STANDARD: Provision of services in a setting accessible to individuals with HIV who are low-income and compliance with the Americans with Disabilities Act (ADA) Barrier-Free Health Care Initiative
7 The agency maintains policies and procedures for providing patients transportation for patients, using referrals or vouchers, if the facility is not accessible to public transportation, and has policies facilitating access to care for low-income individuals. (Pilot Measure 2025-2026)
8 The agency maintains an environment providing barrier-free access to healthcare, which includes provisions for mobility disabilities and communication disabilities. (Pilot Measure 2025-2026)
9 The agency’s policies do not dictate a dress code or conduct that may act as a barrier for low-income individuals. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: Dissemination of information to low-income individuals regarding the availability of HIV-related services and how to access them
10 The agency maintains a file documenting subrecipient activities for the promotion of HIV services to low-income individuals, including copies of HIV program materials promoting services and explaining eligibility requirements. 
HRSA AND DSHS STANDARD: The agency provides telehealth, telemedicine, and teledentistry in accordance with federal and state law and applicable guidelines
11 The agency maintains policies and procedures for telehealth, telemedicine, and teledentistry, as applicable. Policies must align with all applicable State and Federal laws and the DSHS Guidance for the Use of Telemedicine, Teledentistry, and Telehealth for HIV Core and Support Services.

IMPOSITION AND ASSESSMENT OF CLIENT CHARGES

Note: Universal Standards measures 12-17 apply to subrecipients providing any of the following clinical services: Home and Community Based Health Services, Home Health Care, Hospice Services, Medical Nutritional Therapy, Mental Health Services, Oral Health Services, Outpatient/Ambulatory Health Services, Substance Abuse Outpatient Care, Rehabilitation Services, and Substance Abuse Services (Residential).
HRSA AND DSHS STANDARD: Publicly available schedule of charges
12

The agency establishes, documents, and has available for review: (Pilot Measure 2024-2025)

  • A written imposition of charges policy including a current schedule of charges (agencies must determine client charges based on a client’s individual annual gross income, although agencies may base client eligibility for services on family income);
  • Fees charged by the provider and payments made to that provider by the clients; and
  • A process for obtaining and documenting client charges and payments through a manual or electronic accounting system. 
13 The agency maintains documentation that a schedule of charges is publicly available. (Pilot Measure 2024-2025)
14 The agency has policies and procedures to inform clients of their responsibility to track their expenditures to ensure the agency does not charge them beyond the annual cap on charges based on their federal poverty level (FPL). (Pilot Measure 2024-2025)
HRSA AND DSHS Standard: The agency imposes no charges on clients with individual incomes less than or equal to 100 percent of the FPL
15

The agency has policies and procedures documenting: (Pilot Measure 2024-2025)

  • The schedule of charges does not allow the agency to charge clients with an individual annual gross income less than or equal to 100 percent of FPL for RWHAP services; and 
  • The agency does not charge RWHAP clients with individual annual gross incomes less than or equal to 100 percent FPL for RWHAP services.
HRSA AND DSHS Standard: The agency uses a schedule of charges to determine charges for RWHAP services for clients with individual annual gross incomes greater than 100 percent of the FPL
16

The agency has policies and procedures limiting the annual aggregate charges in a calendar year for RWHAP services based on the percent of the client’s annual individual gross income, as follows: (Pilot Measure 2024-2025)

  • Five percent for patients with individual annual gross incomes between 101 percent and 200 percent of the FPL; 
  • Seven percent for patients with individual annual gross incomes between 201 percent and 300 percent of the FPL; and
  • Ten percent for patients with individual annual gross incomes greater than 300 percent of the FPL.
17

The agency’s imposition of charges policy includes: (Pilot Measure 2024-2025)

  • A process for alerting the billing system if the client has reached the cap and the agency should not further charge the client for the remainder of the year;  
  • A client eligibility determination process to establish individual fees and limitations on annual aggregate charges for RWHAP services; and
  • A process for tracking RWHAP charges or medical expenses, inclusive of enrollment fees, deductibles, copayments, etc., if applicable.
ELIGIBILITY DETERMINATION
HRSA AND DSHS STANDARD: Eligibility determination and reassessment of clients to determine eligibility as specified by the State within a predetermined timeframe
18 The agency documents that the process and timelines for establishing initial client eligibility, assessment, and recertification occur at least every six months.
19 The agency documents that all staff involved in eligibility determination have participated in eligibility training.
HRSA AND DSHS STANDARD: Ensure the agency deems military veterans with Department of Veterans Affairs (VA) benefits eligible for Ryan White services
20 The agency maintains documentation that eligibility determination policies and procedures do not classify VA health benefits as an insurance program or deny access to RWHAP services citing “payor of last resort.”
HRSA AND DSHS STANDARD: Maintain policies and document efforts to ensure RWHAP recipients and subrecipients assist clients to vigorously pursue enrollment in health care coverage and clients have accessed all other available public and private funding sources for which they may be eligible
21 The agency has written policies or protocols for ensuring it uses RWHAP Part B and State Services funds as the payor of last resort (PoLR) for eligible services and clients.
22 Subrecipients have policies in place and maintain documentation that agency staff provide clients with education on available health insurance options in their area.
23 Subrecipients have policies in place and maintain documentation that the agency offers clients who are eligible to enroll in a marketplace plan enrollment assistance or a referral for health insurance options.
HRSA AND DSHS STANDARD: Ensure agencies provide American Indians (AI) and Alaska Natives (AN) access to Ryan White services
24 The agency maintains documentation that eligibility determination policies and procedures do not consider Indian Health Service benefits as primary insurance (as they are exempt) and deny access to RWHAP services citing “payor of last resort.” (Pilot Measure 2025-2026)
ANTI-KICKBACK STATUTE
HRSA AND DSHS STANDARD: Demonstrated structured and ongoing efforts to avoid fraud, waste, and abuse (mismanagement) in any federally funded program
25 The agency has policies and procedures to ensure compliance with the Anti-Kickback Statute (AKS) and a code of ethics or standards of conduct, including conflict of interest, prohibition on the use of agency property without approval, fair and open competition, confidentiality, use of company assets, timely and truthful disclosure of accounting deficiencies and non-compliance, and penalties and disclosure procedures for conduct deemed to be felonies. (Pilot Measure 2025-2026)
26 The agency has an anti-kickback policy prohibiting the solicitation of cash or in-kind payments for awarding contracts, referring clients, purchasing goods or services, and submitting fraudulent billings. It must also include the uses and applications of safe harbor laws. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: Salary Rate Limitation—Subrecipients may not use HRSA funds to pay the salary of an individual at a rate in excess of an Executive Level II employee. This amount reflects an individual’s base salary exclusive of fringe and income an individual earns outside of the duties to the applicant organization. This salary rate limitation also applies to subawards and subcontracts for substantive work under a HRSA grant or cooperative agreement.
27 The agency provides identification and description of individual employee salary expenditures, ensuring salaries are within the HRSA Salary Rate Limitation. (Pilot Measure 2025-2026)
28 The agency determines whether individual staff receives additional HRSA income through other subawards or subcontracts. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: Salary Rate Limitation Fringe Benefits—If an individual is under the salary rate limitation, the agency applies fringe as usual. If an individual is over the salary rate limitation, the agency calculates fringe on the adjusted base salary
29 The agency provides identification of individual employee fringe benefit allocation. (Pilot Measure 2025-2026)
QUALITY MANAGEMENT
HRSA AND DSHS STANDARD: Implementation of a Clinical Quality Management (CQM) Program 
30

The agency provides documentation that the subrecipient is actively participating in the regional Clinical Quality Management (CQM) Program, including an agency-level CQM plan or inclusion in a regional CQM plan with the following elements: (Pilot Measure 2024-2025)

  • Performance measurement per HRSA Policy Clarification Notice (PCN) 15-02; and
  • Focus on improvement to one or more of the following Ryan White Part B CQM domains: improving access to care and support services, improving health outcomes, improving the client or patient experience, or reducing health disparities.
PROHIBITION ON CERTAIN ACTIVITIES
HRSA AND DSHS STANDARD: Recipients cannot use RWHAP funds to support HIV programs or materials designed to promote or directly encourage intravenous drug use or sexual activity, whether homosexual or heterosexual
31 The agency has a policy prohibiting the use of RWHAP funds to support HIV programs or materials designed to promote or directly encourage intravenous drug use or sexual activity, whether homosexual or heterosexual. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: No use of Ryan White funds by recipients or subrecipients for the purchase of vehicles without the written approval of the HRSA Grants Management Officer (GMO)
32 The agency has a policy prohibiting the use of Ryan White funds for the purchase of vehicles without the written approval of the HRSA Grants Management Officer (GMO).
33 The agency has written permission from the GMO for any vehicles purchased using Ryan White funds. 
HRSA AND DSHS STANDARD: No use of RWHAP funds for broad-scope awareness activities about HIV services targeting the general public, including outreach programs that have HIV prevention education as their exclusive purpose
34 The agency has a policy prohibiting the use of RWHAP funds for broad-scope awareness activities about HIV services targeting the general public, including outreach programs that have HIV prevention education as their exclusive purpose. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: Lobbying Activities—Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel
35 The agency has a policy prohibiting the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel.
36 The agency’s personnel manual and employee orientation include information on regulations forbidding lobbying with federal funds. 
HRSA AND DSHS STANDARD: Direct Cash Payments—Subrecipients may not use Ryan White funds to make cash payments to intended service recipients of Ryan White-funded services
37 The agency has policies and procedures for service categories involving payments made on behalf of individuals ensuring agencies do not make direct payments to individuals (e.g., emergency financial assistance, transportation, health insurance premiums, medical or medication copays and deductibles, food, and nutrition).
HRSA AND DSHS STANDARD: Prohibition on the use of Ryan White program funds to support employment, vocational, or employment-readiness services
38 The agency has a policy prohibiting the use of Ryan White program funds to support employment, vocational, or employment-readiness services.
HRSA AND DSHS STANDARD: No use of Ryan White funds for direct maintenance expenses (tires, repairs, etc.) of a privately owned vehicle or other costs associated with a vehicle, such as lease or loan payments, insurance, or license and registration fees 
39 The agency maintains documentation that it does not use Ryan White for direct maintenance expenses or other costs associated with privately owned vehicles, such as lease or loan payments, insurance, or license and registration fees—except for vehicles operated by organizations for program purposes.
HRSA AND DSHS STANDARD: No use of Ryan White funds to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drugs
40 The agency maintains documentation that it does not use Ryan White funds for programs related to sterile needles or syringe exchange for injection drug use.
HRSA AND DSHS STANDARD: Additional prohibitions
41

The agency maintains documentation that it does not use Ryan White funds for the following activities or to purchase these items: (Pilot Measure 2025-2026)

  • Clothing;
  • Funeral, burial, cremation, or related expenses;
  • Local or state personal property taxes (for residential property, private automobiles, or other personal property against which taxes may be levied);
  • Household appliances;
  • Pet foods or other non-essential products;
  • Off-premises social or recreational activities or payments for a client’s gym membership;
  • Purchase or improve land, or purchase, construct, or permanently improve (other than minor remodeling) any building or other facility;
  • Pre-exposure prophylaxis (PrEP);
  • Post-exposure prophylaxis (PEP); or
  • International travel.
HRSA AND DSHS STANDARD: Maintenance of appropriate referral relationships with entities considered key points of access to the healthcare system for the purpose of facilitating Early Intervention Services (EIS) for individuals who have a diagnosed HIV infection
42 The agency has written referral and linkage agreements with key points of entry and makes these agreements available for review by the grantee upon request. 
43 The agency has a policy or procedure with a mechanism to track referrals from these key points of entry and linkages to care. (Pilot Measure 2025-2026)
44 The agency maintains documentation that funded awareness activities target specific groups of low-income people with HIV to inform them of such services. (Pilot Measure 2025-2026)
HRSA AND DSHS STANDARD: Recipients and subrecipients who provide Medicaid-reimbursable services must vigorously pursue Medicaid enrollment for individuals likely to be Medicaid eligible and seek payment from Medicaid when the agency provides a covered service to a Medicaid beneficiary. Recipients must also back bill Medicaid for RWHAP-funded services provided to Medicaid eligible clients when Medicaid determines eligibility.
45 The agency maintains documentation of Medicaid status on file and that the provider can receive Medicaid payments. (Pilot Measure 2025-2026)
46 The agency documents efforts and timeline for certification if the provider is in the process of obtaining Medicaid certification. (Pilot Measure 2025-2026)
SECTION 2: STATEWIDE PROGRAMMATIC STANDARDS
GENERAL HIV POLICIES AND PROCEDURES
Grievance Policies: DSHS requires contractors to have a written client complaint procedure in place to meet the minimum requirements for client complaints  
47 The agency has a policy or procedure for handling client grievances.
Delivery of Client Services: Maintain client relations of the highest possible quality 
48 The agency has written procedures to address disruptive or uncooperative behaviors from clients.
49 The agency has written procedures to address violent or threatening behavior from clients. 
Non-Discrimination Policy: Written non-discrimination policies and procedures are in place addressing protected classes and persons with disabilities, including prohibiting discrimination against sexual orientation and gender identity
50 The agency has comprehensive non-discrimination policies, which prohibit discrimination on the basis of race, color, national origin, religion, sex, and any other non-discrimination provision in specific statutes under which the client makes the application for federal or state assistance. (Pilot Measure 2025-2026)
Confidentiality of Client Information: The agency will protect and maintain information collected to prevent, treat, and control the spread of tuberculosis, HIV, sexually transmitted diseases (STDs) and viral hepatitis to ensure client confidentiality 
51 Staff, management, and volunteers have completed a signed confidentiality agreement annually affirming the individual's responsibility for keeping client information and data confidential.
52 Staff, management, and volunteers have successfully completed confidentiality and security training.
Breach of Confidentiality: All subcontractors and sub-recipient agencies must have policies outlining how to address negligent or purposeful release of confidential client information 
53 The agency has detailed policies outlining how to address negligent or purposeful release of confidential client information in accordance with the Texas Health and Safety Code and Health Insurance Portability and Accountability Act (HIPAA) regulations.
Child Abuse Reporting: HIV and STD contractors must monitor for compliance with Texas child abuse reporting laws and for compliance with DSHS policy relating to the reporting of child abuse
54 The agency has detailed policies outlining how to address suspected child abuse in accordance with Texas law and DSHS policy.
55 The agency has documented evidence of training provided to staff on reporting child abuse.
Incarcerated Persons in Community Facilities: Agencies may not use Ryan White and State Services funds to pay for medical care or medications for people incarcerated in a state or federal prison, or a local jail.
56 The agency has policies in place to ensure it does not utilize RWHAP and State Services to pay for medical care or medications when incarcerated persons in community facilities receive services in local service provider locations.
Conflict of Interest: Agency provides services without interference by conflict of interest
57 The agency has a written conflict of interest policies and procedures.
58 Employees and board members of the agency have completed and signed an annual Conflict of Interest Disclosure Form, which contains, at a minimum, the content in the sample provided.
Personnel Policies and Procedures
59 Personnel and human resources policies address new staff orientation, an ongoing training and development plan, employee performance evaluations, and employee grievances.
Required Training: Personnel and human resource departments maintain required trainings, conferences, and meetings attended as indicated in the staff development plan, or in accordance with licensure requirements for direct care service providers
60 The agency maintains documentation of staff trainings, conferences, and meetings to ensure program compliance.
61 Providers shall complete a cultural competency training to include cultural awareness of relevant local priority populations based on epidemiological data and service priorities.
Take Charge Texas (TCT)
TCT Security Policy: Agency maintains policies ensuring employees protect and maintain TCT and the information collected in TCT to ensure client confidentiality
62 Funded agency locations maintain policies that ensure employees protect and maintain TCT information to ensure client confidentiality.
Policy for timely and routine entry of service delivery information
63 The agency has local policies and procedures in place relating to TCT and the timely and routine entry of service delivery information into TCT.
CORE SERVICES ADDITIONAL POLICIES AND PROCEDURES
Outpatient/Ambulatory Health Services
64 The agency maintains documentation of the certification, licenses, or FDA approval of the laboratory or laboratories from which providers order tests. (Pilot Measure 2025-2026)
65 Client medical records document the services provided, the dates and frequency of the services provided, and that the services are for the treatment of HIV.
66 The agency includes clinician notes in client records with the signature of the licensed provider of services. 
67 The agency maintains professional certifications and licensure documents and makes them available to the recipient on request.
68 The medical provider reviews, dates, and signs standing delegation orders annually and makes them available to staff.
69 The agency follows Texas Medical Board guidelines for client notification and the posting of guidance on filing complaints for in-person care and telemedicine (English and Spanish).                                                               
70 When the subrecipient utilizes OAHS funding to pay for specialty visits or preventive care and screening that the client’s primary clinic does not cover: (1) the agency documents the limitations of the use of funds in the contract between the subrecipient and the Administrative Agency (AA); and (2) the agency writes established guidelines into agency policies regarding the use of OAHS funds. 
Local AIDS Pharmaceutical Assistance Program (LPAP)
71

The agency has an LPAP policy that meets HRSA and HIV/AIDS Bureau requirements and documents the following: (Pilot Measure 2025-2026)

  • Uniform benefits for all enrolled clients;
  • Compliance with RWHAP payor of last resort requirements;
  • A record-keeping system for distributed medications, if applicable; and
  • A drug distribution system including a drug formulary approved by the local LPAP Advisory Board.
72

The agency maintains documentation that the LPAP is not dispensing medications: (Pilot Measure 2025-2026)

  • As a one-time component of a primary medical visit;
  • As a single occurrence of short duration (an emergency);
  • While awaiting ADAP eligibility determination; or
  • By vouchers to clients on a single occurrence.
73 The agency has a policy for timeliness of services. Per the LPAP service standard, the agency must approve prescriptions for LPAP assistance within two business days.
74 The agency has policies and memoranda of understanding (MOUs) ensuring the agency has cost-efficient methods in place and implements the LPAP in accordance with requirements of the 340B Drug Pricing Program, Prime Vendor Program, Alternative Methods Project, or any combination thereof. (Pilot Measure 2025-2026)
75 The agency has MOUs establishing dispensing fees and their implementation.
76 If the agency has a pharmacy, it maintains an active pharmacy license on-site and renews it every two years.
Oral Health Care
77 General dental practitioners, dental specialists, dental hygienists, and auxiliaries provide oral health care services, and services meet current dental care guidelines.
78 Oral health professionals providing the services have appropriate and valid licensure and certification, based on State and local laws.
79 The agency has a policy requiring that services fall within specified service caps, expressed by dollar amount, type of procedure, limitations on the procedures, or a combination thereof, according to State and AA requirements.
Early Intervention Services
80 The agency maintains documentation that it uses Part B funds for HIV testing only where existing federal, state, and local funds are not adequate, and Ryan White (RW) funds will supplement, and not supplant, existing funds for testing.
81 The agency establishes MOUs with key points of entry into care to facilitate access to care for those who test positive. (Pilot Measure 2025-2026)
82

The agency documents the provision of all four required EIS components with Part B or other funding: (Pilot Measure 2025-2026)

  • Targeted HIV testing
  • Referral services
  • Access and linkage to HIV care and treatment services, and 
  • Services for outreach and health education and risk reduction. 
83 The agency documents and makes available to DSHS the numbers of HIV tests and positives, as well as where and when Part B-funded HIV testing occurs. (Pilot Measure 2025-2026)
84 The agency has a policy to obtain general consent for medical tests and procedures or informed consent specific to HIV testing prior to conducting testing for HIV. (Pilot Measure 2025-2026)
85 The agency has a policy concerning counseling provided for positive test results. (Pilot Measure 2025-2026)
86 The agency maintains documentation that testing processes follow Centers for Disease Control recommendations for HIV testing in clinical or nonclinical settings. (Pilot Measure 2025-2026)
87 The agency maintains documentation that it refers and links individuals who test positive to health care and supportive services.
88 The agency maintains documentation that staff provide health education and literacy training that enables clients to navigate the HIV system.
89 The agency maintains documentation that it provides EIS at or in coordination with documented key points of entry.
90 The agency maintains documentation that it coordinates EIS services with HIV prevention efforts and programs.
Health Insurance Premium and Cost-sharing Assistance
91 The agency has a policy outlining caps on assistance and payment limits and adheres to the HIV/STD Section Policy 270.001, Calculation of Estimated Expenditures on Covered Clinical Services.
92 The agency has a policy detailing the expectation for client contributions and tracks these contributions under client charges.
93

The agency maintains a list of all medical insurance and dental insurance plans for which the agency provides premium assistance, and maintains documentation that the policies meet minimum HRSA standards: (Pilot Measure 2025-2026)

  • Medical insurance provides comprehensive primary care and has a formulary with the full range of HIV medications; and
  • Dental insurance provides comprehensive oral healthcare services.
94 The agency provides documentation demonstrating that the agency does not use funds to cover costs associated with the creation, capitalization, or administration of liability risk pools or Social Security costs. (Pilot Measure 2025-2026)
95 The agency has a policy requiring referral relationships with organizations or individuals who can provide expert assistance to clients on their health insurance coverage options and available cost reductions.
96 The agency has policies and procedures detailing the process to make premium and out-of-pocket payments or IRS payments.
97 The agency maintains documentation that it does not use Ryan White funds to pay for services that the client receives from a provider that does not belong to the client’s health plan network unless the client is receiving services that the client could not have reasonably obtained from an in-network provider. (Pilot Measure 2025-2026)
98 The agency has a process to track true-out-of-pocket (TrOOP) costs for clients when the agency is providing assistance with Medicare Part D payments. (Pilot Measure 2025-2026)
Home Health Care
99 The agency maintains on file and provides to the recipient, upon request, copies of the licenses of home health care workers.
100 The agency has a current policy with procedures for clients to contact the agency after hours for urgent or emergency care.
Home and Community-based Health Services
101 The agency provides services only in the home of a client living with HIV or in an integrated setting appropriate to the client’s health, such as a day treatment or other partial hospitalization services program.
102 The agency maintains and makes available copies of appropriate licenses and certifications for professionals providing services to the recipient.
103 The agency has a policy or procedures for clients to contact the agency after hours for urgent or emergency care.
104 The agency establishes and maintains a program and client record keeping system to document the types of home services provided, dates provided, the location of the service, and the signature of the professional who provided the service at each visit. (Pilot Measure 2025-2026)
Hospice Services
105 The agency obtains and has available for inspection appropriate and valid licensure to provide hospice care.
106 The agency maintains and provides the Recipient access to program files and client records.
107 The agency maintains documentation that staff attended continuing education on HIV/AIDS and end-of-life issues.
108 The agency maintains documentation that the supervisory provider or registered nurse provided supervision to staff.
109 The agency has a policy regarding reasons for refusal of referral.
110 The agency has a policy for client discharge.
Mental Health Services
111 The agency obtains and has on file and available for Recipient review the appropriate and valid licensure and certification of mental health professionals, including supervision of licensed staff.
112 The agency has MOUs available for referral needs.
113 The agency has policies and procedures in place for emergency and a crisis intervention plan. 
114 The agency or provider has a policy or procedure documenting how staff introduce clients to program services in writing or orally. (Pilot Measure 2025-2026)
115 The agency or provider has a discharge policy and procedure.
Medical Nutrition Therapy
116 The agency maintains and makes available copies of the dietitian’s license and registration.
117 The agency has a policy and procedure for determining the frequency of licensed Registered Dietitian contact based on the level of care needed.
118 The agency has a policy and procedure on obtaining, tracking inventory, storing, and administering supplemental nutrition products, if applicable.
119 The agency has a policy and procedure on discharging a patient from medical nutrition therapy and the process for discharge.
Medical Case Management, including Treatment Adherence
120 The agency maintains documentation showing that staff providing Medical Case Management (MCM) services are trained professionals who are either medically credentialed or trained healthcare staff who operate as part of the clinical care team.
121 The agency maintains documentation that MCM supervisors hold minimum qualifications: degreed or licensed in the fields of health, social services, mental health, or a related area (preferably Masters’ level). Additionally, MCM supervisors must have three years’ experience providing case management services, or other similar experience in a health or social services-related field (preferably with one year of supervisory or clinical experience).
122 The agency documents required MCM trainings in personnel files. 
123 The agency has policies or procedures for the initial comprehensive assessment.
124 The agency has policies or procedures for MCM acuity level and client contact.
125 The agency has policies or procedures for care planning.
126 The agency has policies or procedures for viral suppression and treatment adherence. 
127 The agency has policies or procedures for referral and follow-up.
128 The agency has policies or procedures for case closure and graduation.
129 The agency has policies or procedures for case conferencing. 
130 The agency has policies or procedures for caseload management.
131 The agency has policies or procedures for case transfer (internal and external).
132 The agency has policies or procedures for probationary period (new hire).
133 The agency has policies or procedures for staff supervision.
134 The agency has policies or procedures for staff training, including agency-specific training.
Substance Abuse Outpatient Care
135 The agency maintains and provides provider licensure or certifications as required by the State of Texas.
136 The agency maintains documentation of a staffing structure showing supervision by a physician or other qualified personnel. (Pilot Measure 2025-2026)
137 The agency provides assurance that they provide all services on an outpatient basis. (Pilot Measure 2025-2026)
138 If applicable, facilities providing substance use treatment services maintain a license from the Texas Department of State Health Services (DSHS) or register as a faith-based exempt program.
139 If applicable, the agency has documentation on site that the license is current for the treatment facility’s physical location.
140 The agency maintains documentation of appropriate clinical supervision for counselor interns.
141 The agency maintains documentation of professional liability for the agency and all staff.
142

The agency develops and implements policies and procedures for handling crisis situations and psychiatric emergencies, which include, but are not limited to, the following:

  • Verbal intervention;
  • Non-violent physical intervention;
  • Emergency medical contact information;
  • Incident reporting;
  • Voluntary and involuntary patient admission;
  • Follow-up contacts; and
  • Continuity of services in the event of a facility emergency.
143 The agency has a policy and procedure for clients needing after-hours assistance.
144 The agency has policies and procedures for staff to follow in psychiatric or medical emergencies.
145 The agency has policies and procedures defining emergency situations and identifying the responsibilities of key staff.
SUPPORT SERVICES POLICIES AND PROCEDURES
Non-Medical Case Management
146

The agency maintains client records with the required elements as detailed by the Recipient, including: (Pilot Measure 2025-2026)

  • The date of the encounter;
  • The type of encounter;
  • The duration of the encounter; and
  • The key activities, including benefits and entitlement counseling and referral services.
147 The agency provides assurances that transitional case management for incarcerated persons meets contract requirements. The agency must provide services only as part of discharge planning or for individuals who are in the correctional system for a brief period.
148 The agency maintains documentation that non-medical case managers have completed annual trainings per DSHS.
Child Care Services
149 The agency maintains documentation of childcare services provided.
150 The agency maintains valid licensure and registration of childcare providers.
151

Where the provider manages informal childcare arrangements, the agency maintains and has available for recipient review: (Pilot Measure 2025-2026)  

  • Documentation of compliance with a recipient-required mechanism for handling payments for informal childcare arrangements; 
  • Appropriate liability release forms obtained protecting the client, provider, and the RWHAP;
  • Documentation that the agency does not make cash payments to clients or primary caregivers; and 
  • Documentation that the payment is for the actual costs of the service.
152 The agency has a policy and procedure to address liability issues through liability release forms designed to protect the client, provider, and the RW program.
Emergency Financial Assistance
153 The agency has a policy for documenting client eligibility, types of EFA provided, dates of EFA, and the methods of providing EFA.
154

The agency maintains and makes available to the recipient program documentation of assistance provided, including: (Pilot Measure 2025-2026)

  • The number of clients and the amount expended for each type of EFA;
  • A summary of the number of EFA services received by the client; and
  • The methods used to provide EFA (e.g., payments to agencies, vouchers).
155 The agency has policies that include medication purchase limitations.
156 Agencies providing EFA medications must have policies and procedures to pursue all feasible alternative revenue systems (e.g., pharmaceutical company patient assistance programs) before requesting reimbursement through EFA.
157 The agency has a process to track annual expenditures on a per-client basis to ensure adherence to the $800 per client per calendar year cap. (Pilot Measure 2025-2026)
Food Bank/Home-Delivered Meals
158

The agency maintains documentation of: (Pilot Measure 2025-2026)

  • The services provided by type, number of clients served, and levels of services;
  • The amount and use of funds for the purchase of non-food items; and
  • Assurance that the agency used RW only for allowable purposes and that RW was the payor of last resort.
159 The agency maintains documentation that the food pantry program meets regulations on food service sanitation as set forth by the Texas Department of State Health Services, Regulatory Licensing Unit, and local city or county health regulatory agencies.
160 The agency displays current license(s) on site.
161 The agency maintains records of local health department food handling and food safety inspections.
162 The agency has a license for non-profit salvage from the Texas Department of State Health Services Regulatory Licensing Unit and local city or county health regulating agencies, as applicable.
163 The agency’s Food Pantry must display "And Justice for All" posters informing people how to report discrimination.
164 The agency must document a method to regularly obtain client input about food preference and satisfaction. The agency shall use such input to make program changes.
165 The agency director of the meal program must complete and pass the Service Safety certification every three (3) years.
166 Each staff and volunteer position applicant must complete an application form, which includes a written job description.
167 The agency maintains personnel files reflecting the completion of applicable trainings and orientation for all staff and volunteers.
Health Education/Risk Reduction (HE/RR)
168 The agency maintains records of services provided.
169 The agency maintains documentation that supervisors reviewed 10 percent of each HE/RR staff’s client records each month.
Housing Services
170 The agency maintains documentation of services provided, including the number of clients served, duration of housing services, types of housing provided, and housing referral services. (Pilot Measure 2025-2026)
171 The agency ensures that staff providing housing services are case managers or other professionals who possess knowledge of local, state, and federal housing programs and how to access them.
172 The agency has policies and procedures ensuring individualized written housing plans are consistent with local, state, and federal housing policy.
173 The agency has an established payment methodology for issuing direct payments to housing vendors or a voucher system, with no direct payments to clients. The payment process must include documentation of a lease or mortgage, utility bill, fees (late fees, legal, etc.), and IRS Form W-9.
174

The agency maintains documentation in personnel files of required initial training by Housing Services staff. All professional housing providers must complete training within three (3) months of hire that includes, but is not limited to, the following topics: 

  • Effective communication;
  • The Texas HIV Medication Program; 
  • HIV case management; 
  • HIV and behavioral risk; 
  • Substance use and HIV; 
  • Mental health and HIV; 
  • Local, state, and federal housing program rules and regulations; and 
  • How to access housing programs.
Linguistic Services
175

The agency has a policy outlining documentation procedures for the provision of linguistic services, including: (Pilot Measure 2025-2026)

  • The number and types of providers requesting and receiving services;
  • The number of assignments; 
  • The languages involved; and
  • The types of services provided – oral interpretation or written translation, and whether the interpretation is for an individual client or a group.
176 The agency maintains documentation showing that interpreters and translators employed with RW funds have appropriate training and hold relevant State and local certification.
177 The agency maintains documentation showing that services provided comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS). (Pilot Measure 2025-2026)
Other Professional Services
178 The agency documents services provided, including specific types of services.
179 The agency provides assurance that the agency is using funds only for services directly necessitated by an individual’s HIV status.
180 All licensed agency professional staff, contractors, and consultants who provide legal services hold current licensure from the State Bar of Texas.
181 The agency provides documentation that a qualified licensed attorney supervises law students, law school graduates, and other legal professionals.
182 Agency-paid legal staff and contractors must complete two (2) hours of HIV-specific training annually.
183 The agency maintains systems for the dissemination of HIV/AIDS information relevant to the legal assistance needs of people living with HIV to staff and volunteers.
Medical Transportation Services
184

The agency maintains program files documenting: (Pilot Measure 2025-2026)

  • The level of services and number of trips provided; 
  • The reason for each trip and its relation to accessing health and support services; 
  • The trip origin and destination; 
  • Client eligibility;
  • The cost per trip; and
  • The method used to meet the transportation need.
185

The agency maintains documentation that the provider is meeting stated contract requirements regarding methods of providing transportation: (Pilot Measure 2025-2026)

  • Reimbursement methods that do not involve cash payments to service recipients; 
  • Mileage reimbursement that does not exceed the federal reimbursement rate; and
  • The use of volunteer drivers that appropriately addresses insurance and other liability issues.
186 The agency collects and maintains data documenting that it uses funds only for transportation designed to help eligible individuals remain in medical care by enabling them to access medical and support services.
187 The agency obtains HRSA and State approval prior to purchasing or leasing a vehicle(s).
Outreach Services
188 The agency documents the design, implementation, priority areas and populations, and outcomes of outreach activities, including the number of individuals reached, referred for testing, found to be positive, referred to care, and entering care. (Pilot Measure 2025-2026)
189 The agency documents and provides data showing that it is meeting request for proposal (RFP) and contract requirements regarding program design, targeting, activities, and use of funds.
190

The agency maintains documentation of staff and volunteer training. Within the first (3) months of hire, new staff and volunteers must complete 16 hours of training, which includes, but is not limited to:

  • Specific HIV-related issues;
  • Substance abuse and treatment;
  • Mental health issues;
  • Domestic violence;
  • Sexually transmitted diseases;
  • Partner notification;
  • Housing services;
  • Adolescent health issues;
  • People who engage in sex work;
  • Incarcerated individuals and individuals recently released from incarceration; and
  • Concerns affecting people who belong to gender and sexual minorities
Psychosocial Support Services
191 The agency maintains documentation of training to perform nutritional assessment for all program staff conducting nutritional counseling.
192 The agency documents a supervision structure for non-professional staff. Licensed professionals must supervise all non-professional staff delivering support group facilitation.
193

The agency documents the provision of psychosocial support services, including: (Pilot Measure 2025-2026)

  • The types and level of activities provided; and 
  • The client eligibility determination.
194

The agency maintains documentation demonstrating: (Pilot Measure 2025-2026)

  • The agency uses funds only for allowable services; 
  • The agency does not use funds for the provision of nutritional supplements; and
  • Any pastoral care or counseling services are available to all clients regardless of their religious denominational affiliation.
Referral for Health Care/Supportive Services
195

The agency maintains program files documenting: (Pilot Measure 2025-2026)

  • The number and types of referrals provided; 
  • Benefits counseling and referral activities;
  • The number of clients served; and
  • Follow-up provided.
196 The agency maintains documentation demonstrating services and circumstances of referral services meet contract requirements.
Rehabilitation Services
197

The agency maintains client records including the required elements as detailed by the State, including: (Pilot Measure 2025-2026)

  • An individualized plan of care; 
  • The types of rehabilitation services provided; and
  • The dates, duration, and location of services.
198

The agency maintains and shares with the recipient, upon request, program and financial records documenting: (Pilot Measure 2025-2026)

  • The types of services provided;
  • The type of facility;
  • The provider licensing; and
  • That the agency uses funds only for allowable services by appropriately licensed and authorized professionals.
199 The subrecipient assures that it provides rehabilitative services only in an outpatient setting, which may include ambulatory outpatient or home settings. 
200 The agency documents direct supervision by a licensed or certified professional during client interaction if assistants or students provide care.
201 Staff participating in the direct provision of services to clients must satisfactorily complete all appropriate continuing education units (CEUs) based on license requirements for each licensed and certified therapist. Courses in HIV disease and transmission should be part of continuing education. 
Respite Care
202

The agency maintains in each client file documentation of: (Pilot Measure 2025-2026)

  • The client and primary caretaker eligibility;
  • The services provided, including dates and duration; and 
  • The setting and method of services.
203 The agency maintains personnel files documenting that staff have the skills, experience, and qualifications appropriate to providing respite care services. 
204 The agency documents supervision of non-professional staff. A licensed or degreed individual (preferably master’s level) in the fields of health, social services, mental health, or a related area, or with equivalent experience, must supervise all non-professional staff.
205 The agency has a policy on supervisor review. Supervisors must review a 10 percent sample of each employee's records each month for completeness, compliance with these standards, and quality and timeliness of service delivery.
Substance Abuse Services (residential)
206 The agency maintains documentation of provider licensure or certifications as the State requires. This includes licensures and certifications for acupuncture service providers.
207 The agency maintains documentation of a staffing structure, which shows supervision by a physician or other qualified personnel.
208 The agency provides assurance that it provides all services in a short-term residential setting.
209 The agency maintains program files documenting allowable services provided, and the quantity, frequency, and modality of treatment services.
210

The agency maintains client records documenting: (Pilot Measure 2025-2026)

  • The date treatment begins and ends;
  • An individual treatment plan; and
  • Evidence of regular monitoring and assessment of client progress.
211 The agency will have documentation on site that the license is current for the treatment facility’s physical location.
212 The agency maintains documentation of appropriate clinical supervision for counseling interns.
213

Each staff member will have documentation of minimum experience to include:

  • Continuing education in HIV;
  • Non-violent crisis intervention training; and 
  • Training in mental health issues and knowledge of when to refer a patient to a mental health program or counselor.

214

 All direct care staff shall maintain current cardiopulmonary resuscitation (CPR) and first aid certification. Licensed health professionals and personnel in licensed medical facilities are exempt if emergency resuscitation equipment and trained response teams are available 24 hours a day.
215 The agency maintains documentation of professional liability for all staff and agency.
216 The agency has a policy and procedure to conduct interdisciplinary case conferences for each active client at least once every six (6) months.
217

The agency has policies and procedures for handling crisis situations and psychiatric emergencies, which include, but are not limited to, the following:

  • Verbal intervention;
  • Non-violent physical intervention;
  • Emergency medical contact information;
  • Incident reporting;
  • Voluntary and involuntary patient admission;
  • Follow-up contacts; and
  • The continuity of services in the event of a facility emergency.
218 The agency has policies and procedures for staff to follow for psychiatric or medical emergencies.
219 The agency has policies and procedures defining emergency situations and identifying the responsibilities of key staff.