Universal Standards
Standards
DSHS is in the process of revising and reformatting the Ryan White Part B Universal Standards. For the monitoring indicators that will be used during the 2023-2024 monitoring cycle, please refer to the 2023 Universal Standards and the 2023 Monitoring Tool.
Universal Standards print version
The Universal Standards listed below are applicable to all service categories funded under the Ryan White Part B Program for direct care service providers. These Universal Standards are taken directly from the HRSA Standards listed in the Part B HIV/AIDS Bureau (HAB) Universal National Monitoring Standards and expanded to include DSHS program requirements for all Ryan White Part B and State Service sub-recipients. HRSA/HAB “expects recipients to monitor fiscal and programmatic compliance with all contracts and other agreements for HIV services in the State/Territory” and to report on “ongoing progress” of implementation of the National Monitoring Standards (NMS). [1]
Note: The Uniform Guidance, HHS Grants Policy Statement has not changed since January 1, 2007; Policy Clarification Notices, Program Letters, and the Notice of Grant Award are the Ryan White Part B grants management regulation and policy documents. [2]
Section A: Access to Care |
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NOTE: Recipients receiving Federal financial assistance take steps to ensure that people with limited English proficiency can meaningfully access health and social services. See EO 13166, August 11, 2000; FY 2017 NOA Standard Terms #9. Providers will ensure clients have access to the language line to ensure people can meaningfully understand their treatment plans and care goals. |
HRSA/DSHS STANDARD1. Structured and ongoing efforts to obtain input from clients in the design and delivery of services PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD2. Provision of services regardless of an individual’s ability to pay for the service PERFORMANCE MEASURE/METHODSub-recipients billing and collection policies and procedures do not:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD3. Provision of services regardless of the current or past health condition of the individual to be served PERFORMANCE MEASURE/METHODDocumentation of eligibility and clinical policies to ensure that they do not:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD4. Language Assistance Services – Provision of services regardless of English proficiency or other barriers to communication PERFORMANCE MEASURE/METHODProvide culturally and linguistically appropriate goals and policies that ensure management accountability that language assistance is provided to individuals who have limited English proficiency and/or other communication needs at no cost to them in order to facilitate timely access to all health care and services. SUB-RECIPIENT RESPONSIBILITYProvide culturally and linguistically appropriate goals and policies that ensure management accountability that language assistance is provided. LIMITATIONSN/A SOURCE CITATIONWhat is CLAS? |
HRSA/DSHS STANDARD5. Language Assistance Services – Provision of services regardless of English proficiency or other barriers to communication PERFORMANCE MEASURE/METHODProvide documentation of easy-to- understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services. SUB-RECIPIENT RESPONSIBILITYProvide documentation of print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services. LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARD6. Provision of services in a setting accessible to low-income individuals with HIV PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSNO direct cash payments to clients can be made for transportation needs. SOURCE CITATION
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HRSA/DSHS STANDARD7. Efforts to inform low income individuals of the availability of HIV-related services and how to access them PERFORMANCE MEASURE/METHODAvailability of informational materials about sub-recipient's services and eligibility requirements such as:
SUB-RECIPIENT RESPONSIBILITYMaintain file documenting sub-recipient's activities for the promotion of HIV services to low-income individuals, including copies of HIV program materials promoting services and explaining eligibility requirements LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD8. Use of Telehealth, Telemedicine, and Teledentistry PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYPolicies and procedures for Telehealth, Telemedicine, and Teledentistry, as applicable, must be in place for virtual platforms. Policies should align with all applicable State and Federal laws, as well as the DSHS Guidance for Telemedicine. LIMITATIONSN/A SOURCE CITATION |
Section B: Eligibility Determination |
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HRSA/DSHS STANDARD1. Eligibility determination and reassessment of clients to determine eligibility as specified by the jurisdiction (in this case State) or AIDS Drug Assistance Program (ADAP):
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARD2. Ensure military veterans with Department of Veterans Affairs (VA) benefits are deemed eligible for Ryan White services PERFORMANCE MEASURE/METHODDocumentation that eligibility determination policies and procedures do not consider VA health benefits as the veteran’s primary insurance and deny access to Ryan White services citing “payor of last resort.” SUB-RECIPIENT RESPONSIBILITYEnsure that policies and procedures classify veterans receiving VA health benefits as uninsured, thus exempting these veterans from the “payor of last resort” requirement. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD3. Payer of Last Resort: Ensure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients. PERFORMANCE MEASURE/METHODEnsure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients. SUB-RECIPIENT RESPONSIBILITYAgencies have written policies and/or protocols for ensuring RWHAP Part B and State Services funds are used as PoLR for eligible services and eligible clients. LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARD4. Vigorous Pursuit of Third-Party Payers. PERFORMANCE MEASURE/METHODAt initial RW enrollment and periodic re- assessments: Documentation that agency educated client on available health insurance options in area to include but not limited to: (1) Marketplace plans (2) Medicare Part A&B (3) Medicaid (4) Private health plans. SUB-RECIPIENT RESPONSIBILITYSub-recipients will have policies in place and maintain documentation that agency educated client on available health insurance options in area. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD5. Vigorous Pursuit of Third-Party Payers. PERFORMANCE MEASURE/METHODAll clients who are FPL-eligible to enroll in a marketplace plan were offered enrollment assistance or a referral for health insurance options. SUB-RECIPIENT RESPONSIBILITYSub-recipients will have policies in place and maintain documentation that all clients who are FPL-eligible to enroll in a marketplace plan were offered enrollment assistance or a referral for health insurance options LIMITATIONSN/A SOURCE CITATION |
Section C: Anti-Kickback Statute |
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HRSA/DSHS STANDARD1. Demonstrated structured and ongoing efforts to avoid fraud, waste and abuse (mismanagement) in any federally funded program PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARD2. Prohibition of employees (as individuals or entities), from soliciting or receiving payment in kind or cash for the purchase, lease, ordering, or recommending the purchase, lease, or ordering, of any goods, facility services, or items. PERFORMANCE MEASURE/METHODAny documentation required by the Compliance Plan or employee conduct standards that prohibits employees from receiving payments in kind or cash from suppliers and contractors of goods or services SUB-RECIPIENT RESPONSIBILITY
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Section D: Recipient Accountability |
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HRSA/DSHS STANDARD1. Proper stewardship of all grant funds including compliance with programmatic requirements PERFORMANCE MEASURE/METHODPolicies, procedures, and contracts that require:
SUB-RECIPIENT RESPONSIBILITY Meet contracted programmatic and fiscal requirements, including:
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HRSA/DSHS STANDARD2. Recipient accountability for the expenditure of funds it shares with lead agencies (usually health departments), sub-recipients PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYEstablish and implement:
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HRSA/DSHS STANDARD3. Business management systems that meet the requirements of the Office of Management and Budget code of federal regulations, programmatic expectations outlined in the Recipient assurances and the Notice of Grant Award PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYEnsure that the following are in place:
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HRSA/DSHS STANDARD4. Responsibility for activities that are supported under the Ryan White Program as outlined by Office of Management and Budget, Code of Federal Regulations, HHS Grant Policy Statement Program Assurances, and Notice of Grant Award (NOA) 45 CFR 75 - §75.300 (b) The non-Federal entity is responsible for complying with all requirements of the Federal award. For all Federal awards, this includes the provisions of FFATA (FFATA – NOT for Ryan White), which includes requirements on executive compensation, and also requirements implementing the Act for the non-Federal entity at 2 CRF part 25 and 2 CFR part 170. See also statutory requirements for whistleblower protections at 10 U.S.C. 2324 and 2409, and 41 U.S.C. 4304, 4310, and 4712. PERFORMANCE MEASURE/METHODDesk audits of budgets, applications, yearly expenses, programmatic reports; audit reports or on-site review when assessing compliance with fiscal and programmatic requirements SUB-RECIPIENT RESPONSIBILITYEnsure fiscal and programmatic policies and procedures are in place that comply with federal and Ryan White program requirements LIMITATIONSActivities do NOT support Trafficking Victims SOURCE CITATION
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Section E: Reporting |
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HRSA/DSHS STANDARD1. Submission of standard reports as required in circulars as well as program-specific reports as outlined in the Notice of Grant Award PERFORMANCE MEASURE/METHODRecords that contain and adequately identify the source of information pertaining to:
SUB-RECIPIENT RESPONSIBILITYEnsure:
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Section F Monitoring |
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HRSA/DSHS STANDARD1. Any recipient or sub-recipient or individual receiving federal funding is required to monitor for compliance with federal requirements and programmatic expectations at least annually PERFORMANCE MEASURE/METHODDevelopment and consistent implementation of policies and procedures that establish uniform administrative requirements governing the monitoring of awards SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARD2. Monitoring activities expected to include annual site visits of all Provider/Sub-recipients. Note: 45 CFR 75 - §75.301 “Performance reporting frequency and content should be established to not only allow the HHS awarding agency to understand the recipient progress but also to facilitate identification of promising practices among recipients and build the evidence upon which the HHS awarding agency’s program and performance decisions are made.” PERFORMANCE MEASURE/METHODReview of the following program monitoring documents and actions:
SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARD3. Performance of fiscal monitoring activities to ensure that Ryan White funding is being used for approved purposes PERFORMANCE MEASURE/METHODReview of the following fiscal monitoring documents and actions:
SUB-RECIPIENT RESPONSIBILITYHave documented evidence that federal funds have been used for allowable services and comply with Federal and Ryan White requirements LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD4. Salary Limit: HRSA funds may not be used to pay the salary of an individual at a rate in excess of the most current HRSA Executive Salary Level II. This amount reflects an individual’s base salary exclusive of fringe and any income that an individual may be permitted to earn outside of the duties to the applicant organization. This salary limitation also applies to sub-awards/subcontracts for substantive work under a HRSA grant or cooperative agreement. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARD5. Salary Limit Fringe Benefits: If an individual is under the salary cap limitation, fringe is applied as usual. If an individual is over the salary cap limitation, fringe is calculated on the adjusted base salary. PERFORMANCE MEASURE/METHODIdentification of individual employee fringe benefit allocation. SUB-RECIPIENT RESPONSIBILITYMonitor to ensure that when an employee salary exceeds the salary limit, the fringe benefit contribution is limited to the percentage of the maximum allowable salary. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD6. Corrective actions taken when sub-recipient outcomes do not meet program objectives and recipient expectations, which may include:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYPrepare and submit:
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Section G Quality Management |
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HRSA/DSHS STANDARD1. Implementation of a Clinical Quality Management (CQM) Program to:
CQM program to include:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYParticipate in quality management activities as contractually required; at a minimum:
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Section H: Other Service Requirements |
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HRSA/DSHS STANDARD1. WICY – Women, Infants, Children, and Youth: Amounts set aside for women, infants, children, and youth to be determined based on each of these population’s relative percentage of the total number of persons living with HIV in the State Note: Waiver available if recipient can document that funds sufficient to meet the needs of these population groups are being provided through other federal or state programs PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYNot Applicable: DSHS will conduct all necessary documentation requirements to fulfill the State WICY report. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD2. Referral relationships with key points of entry: Requirement that Part B service providers maintain appropriate referral relationships with entities that constitute key points of entry. Key points of entry defined in legislation:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
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Section I: Prohibition on Certain Activities |
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HRSA/DSHS STANDARD1. Purchase of Vehicles without Approval: No use of Ryan White funds by recipients or sub-recipients for the purchase of vehicles without written approval of HRSA Grants Management Officer (GMO) PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD2. Broad Scope Awareness Activities: No use of Ryan White funds for broad scope awareness activities about HIV services that target the general public PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD3. Lobbying Activities: Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD4. Direct Cash Payments: No use of Ryan White program funds to make direct payments of cash to clients PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSNO direct cash payments to service recipients (clients/consumers) SOURCE CITATION
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HRSA/DSHS STANDARD5. Employment and Employment-Readiness Services: Prohibition on the use of Ryan White program funds to support employment, vocational, or employment- readiness services PERFORMANCE MEASURE/METHODImplementation of actions specified in I.1 above SUB-RECIPIENT RESPONSIBILITYCarry out sub-recipient actions specified in I.1 above LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD6. Maintenance of Privately Owned Vehicle: No use of Ryan White funds for direct maintenance expenses (tires, repairs, etc.) of a privately owned vehicle or any other costs associated with a vehicle, such as lease or loan payments, insurance, or license and registration fees Note: This restriction does not apply to vehicles operated by organizations for program purposes PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYCarry out sub-recipient actions specified in I.1 above LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD7. Syringe Services: No use of Ryan White funds shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drugs. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYCarry out sub-recipient actions specified in I.1 above LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD8. No use of Part B funds for construction (other than minor remodeling) or to make cash payments to clients PERFORMANCE MEASURE/METHODDocumentation that no Part B funds are used for construction or to make cash payments to recipients of services SUB-RECIPIENT RESPONSIBILITYNot Applicable: DSHS will conduct all necessary documentation requirements. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD9. Additional Prohibitions: No use of Ryan White Funds for the following activities or to purchase these items:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYCarry out sub-recipient actions specified in I.1 above LIMITATIONSN/A SOURCE CITATION
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Section J: Minority AIDS Initiative |
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HRSA/DSHS STANDARD1. Reporting Submission of an Annual Plan 60 days after the budget start date or as specified on the Notice of Award that details:
PERFORMANCE MEASURE/METHODDocumentation that the recipient has submitted a MAI Annual Plan 60 days after the budget start date that contains required elements and meets HRSA/HAB reporting requirements SUB-RECIPIENT RESPONSIBILITYEstablish and maintain a system that tracks and reports the following for MAI services:
Not Applicable for Part B sub-recipients: DSHS will maintain tracking and reporting for MAI services and expenditures. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD2. Submission of an Annual Report following completion of the MAI fiscal year PERFORMANCE MEASURE/METHODDocumentation that the recipient has submitted an Annual Report on MAI services that includes:
SUB-RECIPIENT RESPONSIBILITY
Not Applicable for Part B sub-recipients: DSHS will maintain tracking and reporting for MAI services and expenditures. LIMITATIONSN/A SOURCE CITATION
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Section K: Data Reporting Requirements |
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HRSA/DSHS STANDARD1. Submission of the online service providers report of the Ryan White HIV/AIDS Program Services Report (RSR). PERFORMANCE MEASURE/METHODDocumentation that all service providers have submitted their sections of the online service providers report. SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARD2. Submission of the online client report PERFORMANCE MEASURE/METHODDocumentation that all service providers have submitted their sections of the online client report SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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STATEWIDE PROGRAMMATIC STANDARDS
The following programmatic standards are identified for ease in determining program compliance specific to services provided in the Ryan White Part B Program for the State of Texas.
Section L: General HIV Policies & Procedures |
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HRSA/DSHS STANDARDGrievance Policies: All contractors are required to have a written client complaint procedure in place to meet the minimum requirements for client complaints. PERFORMANCE MEASURE/METHODAgencies have a policy and/or procedure for handling client grievances. SUB-RECIPIENT RESPONSIBILITYAAs will ensure all subcontractors and vendors will have a policy and/or procedure for handling client grievances. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDDelivery of Client Services: Maintain client relations of the highest possible quality. PERFORMANCE MEASURE/METHODAgencies must have written procedures to deal with clients who may be disruptive or uncooperative. Agencies must have written procedures to deal with clients who are violent or exhibit threatening behavior. SUB-RECIPIENT RESPONSIBILITYAAs will ensure all subcontractors and vendors have written procedures to deal with clients who may be disruptive or uncooperative. AAs will ensure all subcontractors and vendors have written procedures to deal with clients who are violent or exhibit threatening behavior. LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARDNon-Discrimination Policy: Written non-discrimination policies and procedures are in place that addresses protected classes and persons with disabilities, including prohibiting discrimination against sexual orientation and gender identity. PERFORMANCE MEASURE/METHODAgencies shall have comprehensive non-discrimination policies, which prohibits discrimination on the basis of race, color, national origin, religion, sex, sexual orientation, age, or disability, gender identity, and any other non-discrimination provision in specific statures under which application for federal or state assistance is being made. SUB-RECIPIENT RESPONSIBILITYAAs will ensure all subcontractors have comprehensive non-discrimination policies and procedures in place. To report complaints of discrimination for Texas Health and Human Services funded services:
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HRSA/DSHS STANDARDConfidentiality regarding Client Information: It is the policy of the DSHS THS Section that information collected to prevent, treat, and control the spread of TB, HIV, STIs and Viral Hepatitis will be protected and maintained to ensure client confidentiality. PERFORMANCE MEASURE/METHODAll staff, management, and volunteers must complete a signed confidentiality agreement annually affirming the individuals’ responsibility for keeping client information and data confidential. All staff, management, and volunteers must successfully complete confidentiality and security training. SUB-RECIPIENT RESPONSIBILITYAAs are to ensure that all vendors, subcontractors, and sub-recipient staff, management and volunteers have completed signed confidentiality agreements annually. AAs are to ensure that all vendors, subcontractors, and sub-recipient staff, management and volunteers have completed confidentiality and security training. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDBreach of Confidentiality: All subcontractors and sub-recipient agencies must have policies that outline how to address negligent or purposeful release of confidential client information. PERFORMANCE MEASURE/METHODAgencies will have detailed policies outlining how to address negligent or purposeful release of confidential client information in accordance with the Texas Health and Safety Code and HIPAA regulations SUB-RECIPIENT RESPONSIBILITYAAs are to ensure that all subcontractors, vendors, and sub-recipient agencies have detailed policies outlining how to address negligent or purposeful release of confidential information in accordance with the Texas Health and Safety Code and HIPAA regulations LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARDChild Abuse Reporting: HIV and STI contractors who provide clinical and/or case management services or are required to review these services if provided by subcontractors are required to monitor for compliance with Texas child abuse reporting laws and for compliance with DSHS policy referenced relating to the reporting of child abuse and the use of the DSHS “Checklist for DSHS Monitoring.” PERFORMANCE MEASURE/METHODAgencies will have detailed policies outlining how to address suspected child abuse in accordance with Texas law and the DSHS policy, including the use of the DSHS “Checklist for DSHS Monitoring.” Agencies have documented evidence of training provided to all staff on reporting child abuse. SUB-RECIPIENT RESPONSIBILITYAll contracting agencies are required to ensure their staff is trained on Texas child abuse reporting laws and that suspected cases of child abuse are being reported as prescribed by Texas law. Call the Texas Department of Family & Protective Service’s Abuse Hotline at 1-800-252-5400 when the situation is urgent. Report situations that do not need to be investigated right away at txabusehotline.org. LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARDIncarcerated Persons in Community Facilities: Ryan White and State Services funds may not be used to pay for medical care or medications for any person incarcerated in a state or federal prison, or a local jail. PERFORMANCE MEASURE/METHODAgencies will have policies ensuring RWHAP and State Services funds are not utilized to pay for medical care or medications when incarcerated persons in community facilities are receiving services in local service provider locations. SUB-RECIPIENT RESPONSIBILITYAll contracting agencies have policies in place ensuring RWHAP and State Services funding is not utilized in paying for medical care or medications when incarcerated persons in community facilities are receiving services in local service provider locations. LIMITATIONSRWHAP and State Services funds are NOT utilized to pay for services rendered to incarcerated individuals SOURCE CITATION
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HRSA/DSHS STANDARDConflict of Interest: Services will be provided without interference by any conflict of interest. PERFORMANCE MEASURE/METHODAgencies will have policies ensuring services will be provided without interference by any conflict of interest. SUB-RECIPIENT RESPONSIBILITYAll contracting agencies have written conflict of interest policies and procedures. All employees and board members of any agency are required to complete and sign a Conflict of Interest Disclosure Form annually, which contains, at a minimum, the content in the sample provided by DSHS. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDPersonnel Policies and Procedures: Personnel and human resources policies are available that address new staff orientation, ongoing training plan and development, employee performance evaluations, and employee/staff grievances. PERFORMANCE MEASURE/METHODAgencies have personnel policies and procedures in place that address all items as indicated. SUB-RECIPIENT RESPONSIBILITYAgencies have personnel policies and procedures that are in compliance with local, state, and federal program requirements. LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDRequired Training: Personnel and human resource departments required trainings, conferences, and meetings are documented and attended as indicated in the staff development plan, and/or in accordance with licensure requirements for direct care service providers. PERFORMANCE MEASURE/METHODStaff will attend required trainings, conferences, and meetings as indicated in the staff development plan and/or as directed by DSHS Program Staff. SUB-RECIPIENT RESPONSIBILITYAgencies will maintain documented evidence of staff trainings, conferences, and meetings to ensure program compliance. Providers shall complete cultural competency training to include cultural awareness of youth and the aging population and/or relevant local priority populations based on epidemiological data and service priorities. LIMITATIONSN/A SOURCE CITATION
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Section M: ARIES |
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HRSA/DSHS STANDARDARIES Security Policy: Policies are in place to ensure that ARIES and the information collected in ARIES is protected and maintained to ensure client confidentiality. PERFORMANCE MEASURE/METHODPolicies are in place at all agency locations that are funded in the state of Texas with RWHAP Part B and State Services funds that ensure ARIES information is protected and maintained to ensure client confidentiality. SUB-RECIPIENT RESPONSIBILITYAgencies will maintain policies and procedures to ensure ARIES information is protected and maintained to ensure client confidentiality. LIMITATIONSN/A SOURCE CITATION |
HRSA/DSHS STANDARDARIES Data Managers Core Competencies: Data managers are required to perform certain activities and possess certain knowledge, skills, and abilities, which includes but is not limited to managing and overseeing data collecting, reporting, and the Uniform Reporting System ARIES. PERFORMANCE MEASURE/METHODData managers develop and implement local policy and procedures relating to ARIES and the data collected through ARIES. SUB-RECIPIENT RESPONSIBILITYAgencies have local policies and procedures in place relating to ARIES and the data collected through ARIES. LIMITATIONSN/A SOURCE CITATION |
Section N: Core Services Additional Policies and Procedures |
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HRSA/DSHS STANDARDOutpatient/Ambulatory Health Services: OAHS are diagnostic and therapeutic services provided directly to a client by a licensed healthcare provider in an outpatient medical setting. PERFORMANCE MEASURE/METHODDocumentation of the following:
Please refer to the Outpatient Ambulatory Medical Care Standards of Care for additional information on Peer Review SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSService is NOT being provided in an emergency room, urgent care, hospital or any other type of inpatient treatment center SOURCE CITATION
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HRSA/DSHS STANDARDLocal AIDS Pharmaceutical Assistance Program (LPAP): RWHAP Part B recipients using the LPAP service category must establish the following:
PERFORMANCE MEASURE/METHODDocumentation that the LPAP program’s drug distribution system has:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSOnly Part B Base award funds may be used to support an LPAP. LPAP are not to be used for EFA. Medications are NOT dispensed with LPAP funds as:
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HRSA/DSHS STANDARDOral Health Care: Oral Health Care services provide outpatient diagnostic, preventive, and therapeutic services by dental health care professionals, including general dental practitioners, dental specialists, dental hygienists, and licensed dental assistants. PERFORMANCE MEASURE/METHODDocumentation that:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDEarly Intervention Services: includes identification of individuals at points of entry and access to services and provisions of:
NOTE: All 4 components MUST be present, but Part B funds to be used for HIV testing only as necessary to supplement, not supplant, existing funding PERFORMANCE MEASURE/METHODDocumentation that:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDHealth Insurance Premium and Cost-sharing Assistance: Provides financial assistance for eligible clients living with HIV to maintain continuity of health insurance or to receive medical and pharmacy benefits under a health care coverage program. To use RWHAP funds for health insurance premium and cost-sharing assistance, a RHWAP Part recipient must implement a methodology that incorporates the following requirements:
PERFORMANCE MEASURE/METHODDocumentation that:
SUB-RECIPIENT RESPONSIBILITY
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HRSA/DSHS STANDARDHome Health Care: Provision of services in the home that are appropriate to a client’s needs and are performed by licensed professionals. Services must relate to the client’s HIV and may include:
The provision of Home Health Care is limited to clients that are homebound. PERFORMANCE MEASURE/METHODAssurance that:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSHome settings do NOT include nursing facilities or inpatient mental health/substance abuse treatment facilities SOURCE CITATION
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HRSA/DSHS STANDARDHome and Community-based Health Services: Provided to a client living with HIV in an integrated setting appropriate to a client’s needs, based on a written plan of care established by a medical care team under the direction of a licensed clinical provider. Services include:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYAssurance of:
LIMITATIONSInpatient hospitals, nursing homes, and other long-term care facilities are not considered an integrated setting for the purposes of providing home and community-based health services. SOURCE CITATION
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HRSA/DSHS STANDARDHospice Services: End of life care services provided to clients in the terminal stage of an HIV-related illness. Allowable services are:
Services may be provided in a home or other residential setting, including a non-acute care section of a hospital that is designated and staffed to provide hospice care. Physician must certify that a client is terminally ill and has a defined life expectancy as established by recipient. PERFORMANCE MEASURE/METHODDocumentation including:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSDoes NOT extend to skilled nursing facilities or nursing homes. SOURCE CITATION
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HRSA/DSHS STANDARDMental Health Services: Provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment, and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSOnly for HIV clients. SOURCE CITATION
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HRSA/DSHS STANDARDMedical Nutrition Therapy (MNT): MNT includes nutrition assessment and screening, dietary/nutritional evaluation, food and/or nutritional supplements per medical provider’s recommendation, and nutrition education and/or counseling. These services can be provided in individual and/or group settings and outside of HIV OAHS. All services performed must be pursuant to a medical provider’s referral and based on nutritional plan developed by the registered dietitian or other licensed nutrition professional. PERFORMANCE MEASURE/METHODDocumentation of:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDMedical Case Management (MCM), including Treatment Adherence: Provision of a range of client-centered activities focused on improving health outcomes in support of the HIV care continuum. Activities may be prescribed by an interdisciplinary team that includes other specialty care providers. Please reference DSHS MCM service standard for full complement of key activities. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDSubstance Abuse Outpatient Care: Provision of outpatient services for the treatment of alcohol or other drug use disorders. Services include:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITYMaintain and provide:
LIMITATIONSSyringe access services are allowable, to the extent that they comport with appropriate law and applicable HHS guidance, including HRSA- or HAB-specific guidance. SOURCE CITATION
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Section O:Support Services Policies and Procedures |
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NOTE: Use of Part B funds only to support “Support Services that are needed by individuals with HIV/AIDS to achieve medical outcomes related to their HIV/AIDS-related clinical status” and Support Services approved by the Secretary of Health and Human Services; see Part B Program National Monitoring Standards, Section A.1 bullet #2 and Section C.1; FY 2017 FOA, p. 2 |
HRSA/DSHS STANDARDNon-Medical Case Management (NMCM): Provides guidance and assistance in accessing medical, social, community, legal, financial, and other needed services. NMCM services may also include assisting eligible clients to obtain access to other public and private programs for which they may be eligible. Please reference DSHS NMCM service standard for full complement of key activities. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDChild Care Services: RWHAP supports intermittent childcare services for the children living in the household of HIV clients for the purpose of enabling clients to attend medical visits, related appointments, and/or RWHAP-related meetings, groups, or training sessions. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSNo cash to clients or primary caregivers to pay for these services. SOURCE CITATION
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HRSA/DSHS STANDARDEmergency Financial Assistance: Provides limited one-time or short-term payments to assist the RWHAP client with an emergent need for paying for essential utilities, housing, food (including groceries and food vouchers), transportation, and medication. Services must be for limited amounts, uses, and periods of time. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONS
SOURCE CITATION
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HRSA/DSHS STANDARDFood Bank/Home-Delivered Meals: Provision of actual food items, hot meals, or a voucher program to purchase food. This also includes the provision of essential non-food items that are limited to:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSUnallowable costs include household appliances, pet foods, and other non-essential products. SOURCE CITATION
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HRSA/DSHS STANDARDHealth Education/Risk Reduction: Provision of education to clients living with HIV about HIV transmission and how to reduce the risk of HIV transmission. It includes sharing information about medical and psychosocial support services and counseling with clients to improve their health status. PERFORMANCE MEASURE/METHODDocumentation that:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSHE/RR services cannot be delivered anonymously. SOURCE CITATION
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HRSA/DSHS STANDARDHousing Services: Provide transitional, short-term, or emergency housing assistance to enable a client or family to gain or maintain OAHS services and treatment. Housing services include housing referral services and transitional, short-term, or emergency housing assistance. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSHousing services cannot be in the form of direct cash payments to clients and cannot be used for mortgage payments. SOURCE CITATION
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HRSA/DSHS STANDARDLinguistic Services: Provide interpretation and translation services, both oral and written, to eligible clients. These services must be provided by qualified linguistic service providers as a component of HIV service delivery between the healthcare provider and the client. These services are to be provided when such services are necessary to facilitate communication between the provider and client and/or support delivery of RWHAP-eligible services. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSServices provided must comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS). SOURCE CITATION
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HRSA/DSHS STANDARDOther Professional Services: Provision of professional and consultant services rendered by members of particular professions licensed and/or qualified to offer such services by local governing authorities. Such services may include:
Income tax preparation services to assist clients in filing Federal tax returns that are required by the Affordable Care Act for all individuals receiving premium tax credits. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSExclude criminal defense and class-action suits unless related to access to services eligible for funding under the RWHAP. SOURCE CITATION
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HRSA/DSHS STANDARDMedical Transportation Services: Provision of nonemergency transportation services that enable an eligible client to access or be retained in core medical and support services. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSNo direct cash payments or reimbursements to clients. No direct maintenance expenses of a privately-owned vehicle. No costs associated with a privately-owned vehicle such as lease, loan payments, insurance, license, or registration fees. SOURCE CITATION
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HRSA/DSHS STANDARDOutreach Services: Provision of the following three activities:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONS
SOURCE CITATION
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HRSA/DSHS STANDARDPsychosocial Support Services: Provide group or individual support and counseling services to assist eligible PLWH to address behavioral and physical health concerns. Services include:
PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONS
SOURCE CITATION
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HRSA/DSHS STANDARDReferral for Health Care/Supportive Services: Directs a client to needed core medical or support services in person or through telephone, written, or other type of communication. This service may include referrals to assist eligible clients to obtain access to other public and private programs for which they may be eligible. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDRehabilitation Services: Provided by a licensed or authorized professional in accordance with an individualized plan of care intended to improve or maintain a client’s quality of life and optimal capacity for self-care. PERFORMANCE MEASURE/METHODDocumentation that services:
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSN/A SOURCE CITATION
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HRSA/DSHS STANDARDRespite Care: Provision of periodic respite care in community or home-based settings that includes non-medical assistance designed to provide care for an HIV client to relieve the primary caregiver responsible for the day-to-day care of an adult or minor living with HIV. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSFunds may not be used for off premise social/recreational activities or to pay for a client’s gym membership. SOURCE CITATION
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HRSA/DSHS STANDARDSubstance Abuse Services (residential): Provision of services for the treatment of alcohol or other drug use disorders in a residential setting to include screening, assessment, diagnosis, and treatment of substance use disorder. This service includes: pretreatment/recovery readiness programs; harm reduction; behavioral health counseling associated with substance use disorder; medication assisted therapy; neuro-psychiatric pharmaceuticals; relapse prevention; and detoxification if offered in a separate licensed residential setting. PERFORMANCE MEASURE/METHOD
SUB-RECIPIENT RESPONSIBILITY
LIMITATIONSFunds may not be used for inpatient detoxification in a hospital setting, unless the detoxification facility has a separate license. SOURCE CITATION
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1. FY 2017 Part B Funding Opportunity Announcement, pp. 22-23.
2. Ryan White Part B Manual, 2015; pp. 56-57.
3. HIV/AIDS Bureau, Division of Metropolitan HIV/AIDS Programs & Division of State HIV/AIDS Programs National Monitoring Standards for Ryan White Part A and Part B Grantees: Universal – Part A and B (Covers Both Fiscal and Program Requirements). Accessed October 2020 on hab.hrsa.gov/program-grants-management/ryan-white-hivaids-program-recipient-resources. Universal Monitoring Standards will be utilized throughout Source Citation in this document and reflects this footnoted resource.