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 STANDARD

1. Structured and ongoing efforts to obtain input from clients in the design and delivery of services

PERFORMANCE MEASURE/METHOD

1. Documentation of Consumer Advisory Board and public meetings – minutes, and/or
2. Documentation of existence and appropriateness of a suggestion box or other client input mechanism, and/or
3. Documentation of content, use, and confidentiality of a client satisfaction survey or focus groups conducted at least annually

SUB-RECIPIENT RESPONSIBILITY

1. Maintain file of materials documenting Consumer Advisory Board (CAB) membership and meetings, including minutes and/or;
2. Maintain visible suggestion box or other client input mechanism and/or;
3. Regularly implement client satisfaction survey tool, focus groups, and/or public meetings, with analysis and use of results documented.

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section A.1 [3]; Program National Monitoring Standards (NMS), Section H.1a and H.1b; FY 2017 Part B Funding Opportunity Announcement (FOA), pp. 10-11; Part B Manual revised in 2015, p. 77; DSHS POPS 13.2.
• Public Health Service (PHS) Act, 42 U.S.C. sections 2602(b)(6), 2605 (a)(7)(B), 2617 (b)(5), 2617 (b)(6), 2617(b)(7)(A), 2616(c)(4).
   

HRSA/DSHS STANDARD

2. Provision of services regardless of an individual’s ability to pay for the service

PERFORMANCE MEASURE/METHOD

Sub-recipients billing and collection policies and procedures do not:

• Deny services for non-payment
• Deny payment for inability to produce income documentation
• Require full payment prior to service
• Include any other procedure that denies services for non-payment

SUB-RECIPIENT RESPONSIBILITY

1. Have billing, collection, co-pay, and sliding fee policies that do not act as a barrier to providing services regardless of the client’s ability to pay
2. Maintain file of individuals refused services with reasons for refusal specified; include in file any complaints from clients, with documentation of complaint review and decision reached

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section A.2; Program Part B NMS, Section H.2b.
• PHS Act sections 2605(a)(7)(A)(i), and 2617(b)(7)(B)(i)
• DSHS Policy AA-5018 Section F.
   

HRSA/DSHS STANDARD

3. Provision of services regardless of the current or past health condition of the individual to be served

PERFORMANCE MEASURE/METHOD

Documentation of eligibility and clinical policies to ensure that they do not:

• Permit denial of services due to pre-existing conditions
• Permit denial of services due to non-HIV-related conditions (primary care)
• Provide any other barrier to care due to a person’s past or present health condition

SUB-RECIPIENT RESPONSIBILITY

1. Maintain files of eligibility and clinical policies
2. Maintain file of individuals refused services

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section A.3; Program Part B NMS, Section H.2b
• PHS Act sections 2605(a)(7)(A) and 2617(b)(7((B)(i)
• DSHS Policy AA-5018

HRSA/DSHS STANDARD

4. Language Assistance Services – Provision of services regardless of English proficiency or other barriers to communication

PERFORMANCE MEASURE/METHOD

Provide 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 RESPONSIBILITY

Provide culturally and linguistically appropriate goals and policies that ensure management accountability that language assistance is provided.

LIMITATIONS

N/A

SOURCE CITATION

What is CLAS? 

HRSA/DSHS STANDARD

5. Language Assistance Services – Provision of services regardless of English proficiency or other barriers to communication

PERFORMANCE MEASURE/METHOD

Provide 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 RESPONSIBILITY

Provide 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.

LIMITATIONS

N/A

SOURCE CITATION

• National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care

HRSA/DSHS STANDARD

6. Provision of services in a setting accessible to low-income individuals with HIV

PERFORMANCE MEASURE/METHOD

1. A facility that is handicapped accessible, accessible by public transportation
2. Policies and procedures that provide, by referral or vouchers, transportation if facility is not accessible to public transportation
3. No policies that may act as a barrier to care for low-income individuals

SUB-RECIPIENT RESPONSIBILITY

1. Comply with Americans with Disabilities Act (ADA) requirements
2. Ensure that the facility is accessible by public transportation or provide for transportation assistance

LIMITATIONS

NO direct cash payments to clients can be made for transportation needs.

SOURCE CITATION

• Universal National Monitoring Standards, Section A.4; Program Part B NMS, Section H.2c
• PHS Act sections 2605(a)(7)(B), 2617(b)(7)(B)(ii), 2616(c)(4)

HRSA/DSHS STANDARD

7. Efforts to inform low income individuals of the availability of HIV-related services and how to access them

PERFORMANCE MEASURE/METHOD

Availability of informational materials about sub-recipient's services and eligibility requirements such as:

• Newsletters
• Brochures
• Posters
• Community Bulletins
• Any other types of promotional materials

SUB-RECIPIENT RESPONSIBILITY

Maintain 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

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section A.5; Program Part B NMS, Section H.2d
• PHS Act sections 2605(a)(7)(C), 2617(b)(7)(B)(iii), 2616(c)(3)

HRSA/DSHS STANDARD

8. Use of Telehealth, Telemedicine, and Teledentistry

PERFORMANCE MEASURE/METHOD

1. Telehealth and Telemedicine is an alternative modality to provide most Ryan White Part B and State Services funded services.
2. Services are to be provided in real-time via audio and video communication technology, which can include videoconferencing software.
3. DSHS HIV Care Services requires that for Ryan White Part B or SS funded services providers must use features to protect ePHI transmission between client and providers. RW Providers must use a telehealth vendor that provides assurances to protect ePHI that includes the vendor signing a business associate agreement (BAA).
4. Ryan White Providers using telehealth must also follow DSHS HIV Care Services guidelines for telehealth and telemedicine outlined in DSHS Telemedicine Guidance.
5. Teledentistry services are defined as health care services delivered by a dentist or not more than five health professionals who are not dentists acting under the delegation and supervision of a dentist acting within the scope of the dentist’s or health professional’s license or certification to a patient at a different physical location than the dentist or health professional using telecommunications or information technology.

SUB-RECIPIENT RESPONSIBILITY

Policies 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.

LIMITATIONS

N/A

SOURCE CITATION

• Texas Occupations Code
• DSHS Telemedicine Guidance

HRSA/DSHS STANDARD

1. Eligibility determination and reassessment of clients to determine eligibility as specified by the jurisdiction (in this case State) or AIDS Drug Assistance Program (ADAP):

• Eligibility of determination of clients to determine eligibility for Ryan White services within a predetermined timeframe
• Reassessments of clients every 6 months to determine continued eligibility

PERFORMANCE MEASURE/METHOD

1. Documentation of eligibility required in client records, with copies of documents (e.g., proof of HIV status, proof of residence, proof of income eligibility based on the income limit established by the State, ADAP, or local area, proof of insurance, uninsured or underinsured), using approved documentation as required by the State
2. Eligibility and Determination Enrollment forms for other third party payors such as Medicaid and Medicare
3. Eligibility policy and procedures on file
4. Documentation that all staff involved in eligibility determination has participated in required training
5. Sub-recipient client data reports are consistent with eligibility requirements specified by funder
6. Documentation of reassessment of client’s eligibility status every six months
7. Training provided by the sub-recipient/ contractor to ensure understanding of the policy and procedures

SUB-RECIPIENT RESPONSIBILITY

1. Initial Eligibility Determination & once a year/12 month period recertification documentation requirements:
   • HIV diagnosis (at initial determination)
   • Proof of residence
   • Low income (Not more than 500% of FPL)
   • Uninsured or underinsured status (insurance verification as proof)
   • Determination of eligibility and enrollment in other third party insurance programs including Medicaid and Medicare
   • For underinsured, proof this service is not covered by other third party insurance programs including Medicaid and Medicare
   • Proof of compliance with eligibility determination as defined by the State or ADAP
2. Recertification (minimum of every six months) documentation requirements:
   • Proof of residence
   • Low income documentation (not more than 500% FPL)
   • Uninsured or underinsured status (insurance verification as proof)
   • Determination of eligibility and enrollment in other third party insurance programs including Medicaid and Medicare
   • Note: At six-month recertification one of the following is acceptable: full application and documentation, self-attestation of no change or self-attestation of change with documentation.
3. Proof of compliance with eligibility determination as defined by the State or ADAP
4. Document that the process and timelines for establishing initial client eligibility, assessment, and recertification takes place at a minimum of every six months
5. Document that all staff involved in eligibility determination have participated in required training
6. Sub-recipient client data reports are consistent with eligibility requirements specified by funder, which demonstrates eligible clients are receiving allowable services

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section B.1; FY 2017 FOA, pp. 15 & 43; Notice of Grant Award (NGA) dated 3/11/2016 for award #2 X07HA00054-26-00, Program Specific Terms (PST) #5; FY 2017 FOA Standard Terms #14 NMS: Frequently Asked Questions (FAQ), #35, 38-44.
• PHS Act sections 2616(b)(12), 2617(b)(7)(B)(iv)
• PCN #13-01 (rev 12/13/13), 13-02, 13-03 (rev 9/13/13), 16-02 (revised)
• DSHS Policy HIV/STD 220.001

HRSA/DSHS STANDARD

2. Ensure military veterans with Department of Veterans Affairs (VA) benefits are deemed eligible for Ryan White services

PERFORMANCE MEASURE/METHOD

Documentation 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 RESPONSIBILITY

Ensure that policies and procedures classify veterans receiving VA health benefits as uninsured, thus exempting these veterans from the “payor of last resort” requirement.

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section B.2; NMS FAQ #43; PCN 16-01
• DSHS HIV/STD Policy 220.001

HRSA/DSHS STANDARD

3. 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/METHOD

Ensure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients.

SUB-RECIPIENT RESPONSIBILITY

Agencies 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.

LIMITATIONS

N/A

SOURCE CITATION

• Part B Program National Monitoring Standards, Section H.4c; FY 2017 FOA, pp. 14, 15, 43; PCN 07-01; PCN 16-01; PCN 16-02; Part B Manual, p. 63
• PHS Act section 2617(b)(7)(F)
• DSHS Policy 590.001 and 220.001

HRSA/DSHS STANDARD

4. Vigorous Pursuit of Third-Party Payers.

PERFORMANCE MEASURE/METHOD

At 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 RESPONSIBILITY

Sub-recipients will have policies in place and maintain documentation that agency educated client on available health insurance options in area.

LIMITATIONS

N/A

SOURCE CITATION

• PCN 21-02 Access, Care and Engagement (ACE) TA Center. (2021, September 14). Basics of health coverage and resources for new staff.  

HRSA/DSHS STANDARD

5. Vigorous Pursuit of Third-Party Payers.

PERFORMANCE MEASURE/METHOD

All clients who are FPL-eligible to enroll in a marketplace plan were offered enrollment assistance or a referral for health insurance options.

SUB-RECIPIENT RESPONSIBILITY

Sub-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

LIMITATIONS

N/A

SOURCE CITATION

• PCN 21-02 Access, Care and Engagement (ACE) TA Center. (2021, September 14).

HRSA/DSHS STANDARD

1. Demonstrated structured and ongoing efforts to avoid fraud, waste and abuse (mismanagement) in any federally funded program

PERFORMANCE MEASURE/METHOD

1. Employee Code of Ethics including:
   • Conflict of Interest
   • Prohibition on use of property, information or position without approval or to advance personal interest
   • Fair dealing – engaged in fair and open competition
   • Confidentiality
   • Protection and use of company assets
   • Compliance with laws, rules, and regulations
   • Timely and truthful disclosure of significant accounting deficiencies
   • Timely and truthful disclosure of non-compliance

SUB-RECIPIENT RESPONSIBILITY

1. Maintain and review file documentation of:
   • Corporate Compliance Plan (required by CMS if providing Medicare-or Medicaid-reimbursable services)
   • Personnel Policies
   • Code of Ethics or Standards of Conduct
   • Bylaws and Board policies
   • File documentations of any employee or Board Member violation of the Code of Ethics or Standards of Conduct
   • Documentation of any complaint of violation of the Code of Ethics or Standards of Conduct and its resolution
2. For not-for-profit contractors/sub-recipient organizations, ensure documentation of sub-recipient Bylaws, Board Code of Ethics, and business conduct practices

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section C.1; NGA, Standard Terms (ST) #7
• PHS Act 42 U.S.C. 1320-7b(b)
• AA Core Competencies

HRSA/DSHS STANDARD

2. 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/METHOD

Any 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

1. Have adequate policies and procedures to discourage soliciting cash or in-kind payments for:
   • Awarding contracts
   • Referring clients
   • Purchasing goods or services, and/or
   • Submitting fraudulent billings
2. Have employee policies that discourage:
   • The hiring of persons who have a criminal record relating to or are currently being investigated for Medicaid/Medicare fraud
   • Large signing bonuses

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section C.2; NGA, ST #7
• PHS Act 42 U.S.C. 1320-7b(b)
• AA Core Competencies

HRSA/DSHS STANDARD

1. Proper stewardship of all grant funds including compliance with programmatic requirements

PERFORMANCE MEASURE/METHOD

Policies, procedures, and contracts that require:

• Timely submission of detailed fiscal reports by funding source, with expenses allocated by service category
• Timely submission of programmatic reports
• Documentation of method used to track unobligated balances and carryover funds
• A documented reallocation process
• Report of total number of funded sub-recipients/contractors
• A-133 or single audit
• Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Meet contracted programmatic and fiscal requirements, including:

• Provide financial reports that specify expenditures by service category and use of Ryan White funds as specified by Recipient
• Develop financial and sub-recipient Policies and Procedures Manual that meet federal and Ryan White program requirements
• Closely monitor any sub-recipients/contractor
• Commission an independent audit; for those meeting thresholds, an audit that meet A-133 requirements
• Respond to audit requests initiated by Recipient

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section D.1; NGA, PST #4; Part B Manual, p. 11; 45 CFR 75 - §75.300 (on compliance with regulations); 45 CFR 75 - §75.301 (Performance Measurement)
• AA Core Competencies

HRSA/DSHS STANDARD

2. Recipient accountability for the expenditure of funds it shares with lead agencies (usually health departments), sub-recipients

PERFORMANCE MEASURE/METHOD

1. A copy of each contract
2. Fiscal, program site visit reports and action plans
3. Audit reports
4. Documented reports that track funds by formula, supplemental, service categories
5. Documented reports that track unobligated balance and carryover funds
6. Documented reallocation process
7. Report of total number of funded sub-recipients/contractors
8. Sub-recipient A-133 or single audit conducted annually and made available to the State every year an audit is conducted. (Note: State requires submission to the System Agency and Office of Inspector General within 30 calendar days of receipt of the audit reports every year an audit is conducted)*
9. Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Establish and implement:

1. Fiscal and general policies and procedures that include compliance with federal and Ryan White programmatic requirements
2. Flexible fiscal reporting systems that allow the tracking of unobligated balances and carryover funds and detail service reporting of funding sources
3. Timely submission of independent audits (A-133 audits if required) to the State
4. Policies in place the ensure program income is documented per the Notice of Award using the “additive” method.
5. Program income must be used for the purposes for which the award was made, and may only be used for allowable costs under the award.

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section D.2; FY 2017 FOA, pp. 22-23; Part B Manual, p. 47.
• *Submission of audit to State: HHSC Uniform Terms and Conditions Section 4.03
• PCN 15-03
• Texas Health and Human Services Commission, HHSC Uniform Terms and Conditions-Grant, Version 2.13, Section 2.08 Program Income.

HRSA/DSHS STANDARD

3. 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

1. Review of sub-recipient contracts
2. Fiscal and program site visit reports and action plans
3. Policies and Procedures that outline compliance with federal and Ryan White programmatic requirements
4. Independent audits
5. Auditor management letter

SUB-RECIPIENT RESPONSIBILITY

Ensure that the following are in place:

1. Documented policies and procedures and fiscal /programmatic reports that provide effective control over and accountability for all funds in accordance with federal and Ryan White programmatic requirements

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section D.3; National Part B Fiscal Monitoring Standards, Sections E & K
• 45 CFR 75
• 45 CFR 75 - §75.302 (Financial management and standards for financial management systems)

HRSA/DSHS STANDARD

4. 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/METHOD

Desk audits of budgets, applications, yearly expenses, programmatic reports; audit reports or on-site review when assessing compliance with fiscal and programmatic requirements

SUB-RECIPIENT RESPONSIBILITY

Ensure fiscal and programmatic policies and procedures are in place that comply with federal and Ryan White program requirements

LIMITATIONS

Activities do NOT support Trafficking Victims

SOURCE CITATION

• RW Part B Universal National Monitoring Standards, Section D.4; FY 2017 NOA ST #10; Part B Manual, p. 11; DSHS Statement of Work
• 45 CFR 75
• 45 CFR 75 - §75.300 (on compliance with regulations)

HRSA/DSHS STANDARD

1. Submission of standard reports as required in circulars as well as program-specific reports as outlined in the Notice of Grant Award

PERFORMANCE MEASURE/METHOD

Records that contain and adequately identify the source of information pertaining to:

• Federal award revenue, expenses, obligations, unobligated balances, assets, outlays, program income, interest
• Client level data
• Aggregate data on services provided; clients served, client demographics and selected financial information

SUB-RECIPIENT RESPONSIBILITY

Ensure:

1. Submission of timely sub-recipient reports
2. File documentation or data containing analysis of required reports to determine accuracy and any reconciliation with existing financial or programmatic data. Example: Test program income final FFR with calendar year RDR.
3. Submission of periodic financial reports that document the expenditure of Ryan White funds, positive and negative spending variances, and how funds have been reallocated to other line-items or service categories

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section E.1, NGA, PST #16 & #17, and Reporting Requirements; National Part B Program Monitoring Standards, Sections I & J; National Fiscal Monitoring Standards, Section K.10; Part B Manual, Section IV
• 45 CFR 75

HRSA/DSHS STANDARD

1. 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/METHOD

Development and consistent implementation of policies and procedures that establish uniform administrative requirements governing the monitoring of awards

SUB-RECIPIENT RESPONSIBILITY

1. Participate in and provide all material necessary to carry out monitoring activities at least annually
2. Monitor any service contractors for compliance with federal and programmatic requirements at least annually

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.1; FY 2017 FOA p. 23; NGA, PST #6 and PST #22; Part B Manual, Section IV; PCN 16-02
• 45 CRF 75
• 45 CFR 75 - §75.351 and 75.352 (Sub-recipient Monitoring and Management)
• DSHS Statement of Work

HRSA/DSHS STANDARD

2. 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/METHOD

Review of the following program monitoring documents and actions:

1. Policies and procedures
2. Tools, protocols, or methodologies
3. Reports
4. Corrective action plans
5. Progress on meeting goals of corrective action plans

SUB-RECIPIENT RESPONSIBILITY

1. Establish policies and procedures to ensure compliance with federal and programmatic requirements
2. Submit auditable reports
3. Provide the recipient access to financial documentation

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.2; FY 2017 FOA, p. 22; NMS FAQ #25
• 45 CFR 75
• 45 CFR 75 - §75.301 (Performance Measurement)

HRSA/DSHS STANDARD

3. Performance of fiscal monitoring activities to ensure that Ryan White funding is being used for approved purposes

PERFORMANCE MEASURE/METHOD

Review of the following fiscal monitoring documents and actions:

• Fiscal monitoring policy and procedures
• Fiscal monitoring tool or protocol
• Fiscal monitoring reports
• Fiscal monitoring corrective action plans
• Compliance with goals of corrective action plans

SUB-RECIPIENT RESPONSIBILITY

Have documented evidence that federal funds have been used for allowable services and comply with Federal and Ryan White requirements

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.3; FY 2017 FOA, p. 22; NMS FAQ #25; Part B Manual, Section V
• Inspector General 2004 OEI-02-01-00641
• DSHS Statement of Work I. M.

HRSA/DSHS STANDARD

4. 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

1. Identification and description of individual employee salary expenditures to ensure that salaries are within the HRSA Executive Salary Limit.
2. Determine whether individual staff receive additional HRSA income through other sub-awards or subcontracts.

SUB-RECIPIENT RESPONSIBILITY

1. Monitor staff salaries to determine whether the salary limit is being exceeded.
2. Monitor prorated salaries to ensure that the salary, when calculated at 100%, does not exceed the HRSA Executive Salary Limit
3. Monitor staff salaries to determine that the salary limit is not exceeded when the aggregate salary funding from other federal sources including all parts of Ryan White do not exceed the limitation.
4. Review payroll reports, payroll allocation journals, and employee contracts.

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.4; NGA, ST #11
• Consolidated Appropriations Act, 2020, Division H, §202 (Limit set at $197,300 effective January 5, 2020)

HRSA/DSHS STANDARD

5. 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/METHOD

Identification of individual employee fringe benefit allocation.

SUB-RECIPIENT RESPONSIBILITY

Monitor 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.

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.4; NGA, ST #11
• Consolidated Appropriations Act, 2020, Division H, §202 (Limit set at $197,300 effective January 5, 2020)

HRSA/DSHS STANDARD

6. Corrective actions taken when sub-recipient outcomes do not meet program objectives and recipient expectations, which may include:

• Improved oversight
• Redistribution of funds
• A “corrective action” letter
• Sponsored technical assistance

PERFORMANCE MEASURE/METHOD

1. Review corrective action plans
2. Review resolution of issues identified in corrective action plan
3. Policies that describe actions to be taken when issues are not resolved in a timely manner

SUB-RECIPIENT RESPONSIBILITY

Prepare and submit:

• Timely and detailed response to monitoring findings
• Timely progress reports on implementation of corrective action plan

LIMITATIONS

N/A

SOURCE CITATION

• Universal National Monitoring Standards, Section F.6; FY 2017 FOA, p. 23; NMS FAQ #25; Part B Manual, Section V
• DSHS Program Policy 540.001

HRSA/DSHS STANDARD

1. Implementation of a Clinical Quality Management (CQM) Program to:

• Assess the extent to which HIV health services provided to clients under the grant are consistent with the most recent HHS guidelines for the treatment of HIV and related opportunistic infections
• Develop strategies for ensuring that services are consistent with the guidelines for improvement in the access to and quality of HIV health services

CQM program to include:

• A Quality Management Plan
• Quality expectations for providers and services
• A method to report and track expected outcomes
• Monitoring of provider compliance with HHS treatment guidelines and the Part B Program’s approved Service Standards

PERFORMANCE MEASURE/METHOD

1. Documentation that the Part B Program has in place a Clinical Quality Management Program that includes, at a minimum:
   • A Quality Management Plan
   • Quality expectations for providers and services
   • A method to report and track expected outcomes
   • Monitoring of provider compliance with HHS treatment guidelines and the Part B Program’s approved service category definition for each funded service
2. Review of CQM program to ensure that both the recipient and providers are carrying out necessary CQM activities and reporting CQM performance data
3. Develop and monitor own Service Standards as part of CQM Program

SUB-RECIPIENT RESPONSIBILITY

Participate in quality management activities as contractually required; at a minimum:

• Compliance with relevant service category definitions
• Collection and reporting of data for use in measuring performance

LIMITATIONS

N/A

SOURCE CITATION

• Ryan White Part B Program National Monitoring Standards, Section D.1; FY 2017 FOA pp. 2, 3, 20; NGA, PST #18; PCN 15-02, including FAQ; Part B Manual, p. 60 only.
• PHS Act 204(h)(5), 2618(b)(3)(E), 2664(g)(5), and 2671(f)(2)
• DSHS Statement of Work
• AA Core Competencies

HRSA/DSHS STANDARD

1. 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

1. Documentation that the amount of Part B funding spent on services for women, infants, children, and youth is at least equal to the proportion each of these populations represents of the entire population of persons living with HIV in the State
2. If a waiver is requested, documentation that the service needs of one or more of these populations are already met through funding from another federal or state program

SUB-RECIPIENT RESPONSIBILITY

Not Applicable: DSHS will conduct all necessary documentation requirements to fulfill the State WICY report.

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Sections F.1 and H.3d; FY 2017 FOA, p. 16; NGA, PST #7
• PHS Act Section 2612(e)

HRSA/DSHS STANDARD

2. 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:

• Emergency rooms
• Substance use and mental health treatment programs
• Detoxification centers,
• Detention facilities
• Clinics regarding sexually transmitted infections (STIs)
• Homeless shelters
• HIV sites
• Health care points of entry specified by eligible areas
• Federally Qualified Health Centers
• Entities such as Ryan White Part A, C and D and F recipients

PERFORMANCE MEASURE/METHOD

1. Documentation that written referral relationships exist between Part B service providers and key points of entry

SUB-RECIPIENT RESPONSIBILITY

1. Establish written referral relationships with specified points of entry
2. Document referrals from these points of entry

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Sections F.2 and H.2a; Part B Manual, pp. 15, 22
• PHS Act 2617(b)(7)(G)

HRSA/DSHS STANDARD

1. 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

1. Implementation of measure/method, recipient responsibility and provider/sub-recipient responsibility actions specified in I.1 above
2. Where vehicles were purchased, review of files for written permission from GMO

SUB-RECIPIENT RESPONSIBILITY

1. Carry out sub-recipient actions specified in I.1 above
2. If vehicle purchase is needed, seek recipient assistance in obtaining written GMO approval and maintain document in file

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.2; Part B Fiscal NMS, Section B.5; NGA, PST #11
• HAB Policy Notice 16-02

HRSA/DSHS STANDARD

2. 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

1. Implementation of actions specified in I.1 above
2. Review of program plans, budgets, and budget narratives for marketing, promotions and advertising efforts, to determine whether they are appropriately focused on geographic areas and/or disproportionately affected populations rather than targeting the general public

SUB-RECIPIENT RESPONSIBILITY

1. Carry out sub-recipient actions specified in I.1 above
2. Prepare a detailed program plan and budget narrative that describe planned use of any advertising or marketing activities

LIMITATIONS

N/A

SOURCE CITATION 

• RW Part B Program National Monitoring Standards, Section G.3; Part B Fiscal NMS, Section B.6; FY 2017 FOA, p. 47; PCN 12-01

HRSA/DSHS STANDARD

3. 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

1. Implementation of actions specified in I.1 above
2. Review of lobbying certification and disclosure forms for both the recipient and sub-recipients

SUB-RECIPIENT RESPONSIBILITY

1. Carry out sub-recipient actions specified in I.1 above
2. Include in personnel manual and employee orientation information on regulations that forbid lobbying with federal funds

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.4; Part B Fiscal NMS, Section B.8; FY 2017 FOA, p. 49
• 45 CFR 93 or 31. U.S.C. 1352 
• 45 CFR 75.450
• Consolidated Appropriations Act, 2016, Division H, §503

HRSA/DSHS STANDARD

4. Direct Cash Payments: No use of Ryan White program funds to make direct payments of cash to clients

PERFORMANCE MEASURE/METHOD

1. Implementation of actions specified in I.1 above
2. Review of Service Standards and other policies and procedures for service categories involving payments made on behalf of individuals to ensure that no direct payments are made to individuals (e.g., emergency financial assistance, transportation, health insurance premiums, medical or medication co- pays and deductibles, food and nutrition)
3. Review of expenditures by sub-recipients to ensure that no cash payments were made to individuals

SUB-RECIPIENT RESPONSIBILITY

1. Carry out sub-recipient’s actions specified in I.1 above
2. Maintain documentation of policies that forbid use of Ryan White funds for cash payments to service recipients

LIMITATIONS

NO direct cash payments to service recipients (clients/consumers)

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section g.5 and unnumbered section immediately after Section H.4b; Part B Fiscal NMS, Section B.3; NGA, PST #12; FY 2017 FOA, p. 47; PCN 16-02
• PHS Act 2618(b)(6)
• TDSHS AA Contract SOW II. F.

HRSA/DSHS STANDARD

5. Employment and Employment-Readiness Services: Prohibition on the use of Ryan White program funds to support employment, vocational, or employment- readiness services

PERFORMANCE MEASURE/METHOD

Implementation of actions specified in I.1 above

SUB-RECIPIENT RESPONSIBILITY

Carry out sub-recipient actions specified in I.1 above

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.6; PCN 16-02

HRSA/DSHS STANDARD

6. 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

1. Implementation of actions specified in I.1 above
2. Documentation that Ryan White funds are not being used for direct maintenance expenses or any 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

SUB-RECIPIENT RESPONSIBILITY

Carry out sub-recipient actions specified in I.1 above

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.7

HRSA/DSHS STANDARD

7. 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

1. Implementation of actions specified in I.1 above
2. Documentation that Ryan White funds are not being used for programs related to sterile needles or syringe exchange for injection drug use.

SUB-RECIPIENT RESPONSIBILITY

Carry out sub-recipient actions specified in I.1 above

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.8; FY 2017 FOA, p. 47; NGA, PST #10
• Consolidated Appropriations Act 2016, Division H, §520

HRSA/DSHS STANDARD

8. No use of Part B funds for construction (other than minor remodeling) or to make cash payments to clients

PERFORMANCE MEASURE/METHOD

Documentation that no Part B funds are used for construction or to make cash payments to recipients of services

SUB-RECIPIENT RESPONSIBILITY

Not Applicable: DSHS will conduct all necessary documentation requirements.

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section H.4b bullet 2; FY 2017 NOA PST #12
• PHS Act 2618(b)

HRSA/DSHS STANDARD

9. Additional Prohibitions: No use of Ryan White Funds for the following activities or to purchase these items:

• Clothing
• Funeral, burial, cremation or related expenses
• Local or State personal property taxes (for residential property, private automobiles, or any other personal property against which taxes may be levied)
• Household appliances
• Pet foods or other non- essential products
• Off-premise social/recreational activities or payments for a client¡¦s gym membership
• Purchase or improve land, or to purchase, construct, or permanently improve (other than minor remodeling) any building or other facility
• Pre-exposure prophylaxis

PERFORMANCE MEASURE/METHOD

1. Implementation of actions specified in I.1 above
2. Review and monitoring of recipient and sub-recipient activities and expenditures to ensure that Ryan White funds are not being used for any of the prohibited activities

SUB-RECIPIENT RESPONSIBILITY

Carry out sub-recipient actions specified in I.1 above

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section G.9 for all; Part B Fiscal NMS, Section B.2 for purchasing/improvements of land/buildings/facilities and PrEP; PCN 16-02 for clothing, funeral, burial and property taxes
• PHS Act 2618(b)(6)
• Dr. Parham-Hopson Letter 12/2/2010 on PrEP

HRSA/DSHS STANDARD

1. Reporting Submission of an Annual Plan 60 days after the budget start date or as specified on the Notice of Award that details:

• The actual award amount
• Anticipated number of unduplicated clients who will receive each service
• Anticipated units of service
• Planned client-level outcomes for each minority population served under the Minority AIDS Initiative (MAI)

PERFORMANCE MEASURE/METHOD

Documentation 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 RESPONSIBILITY

Establish and maintain a system that tracks and reports the following for MAI services:

• Dollars expended
• Number of clients served
• Units of service overall and by race and ethnicity, women, infants, children, youth
• Client-level outcomes

Not Applicable for Part B sub-recipients: DSHS will maintain tracking and reporting for MAI services and expenditures.

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section I; FY 2017 FOA, p. 17; NGA Reporting Requirements

HRSA/DSHS STANDARD

2. Submission of an Annual Report following completion of the MAI fiscal year

PERFORMANCE MEASURE/METHOD

Documentation that the recipient has submitted an Annual Report on MAI services that includes:

• Expenditures
• Number and demographics of clients served
• Outcomes achieved

SUB-RECIPIENT RESPONSIBILITY

1. Maintain a system to track and report MAI expenditures, the number and demographics of clients served, and the outcomes achieved
2. Provide timely data to the Recipient for use in preparing the Annual Report

Not Applicable for Part B sub-recipients: DSHS will maintain tracking and reporting for MAI services and expenditures.

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section I; FY 2017 FOA, p. 17; NGA, Reporting Requirements

HRSA/DSHS STANDARD

1. Submission of the online service providers report of the Ryan White HIV/AIDS Program Services Report (RSR).

PERFORMANCE MEASURE/METHOD

Documentation that all service providers have submitted their sections of the online service providers report.

SUB-RECIPIENT RESPONSIBILITY

1. Report all the Ryan White Services the provider offers to clients during the funding year.
2. Submit both interim and final reports by the specified deadlines.

LIMITATIONS

N/A

SOURCE CITATION

1. RW Part B Program National Monitoring Standards, Section J; NGA, PST #17 and Reporting Requirements
2. 2016 Annual Ryan White HIV/AIDS Program Services Report (RSR) Instruction Manual
3. DSHS Statement of Work

HRSA/DSHS STANDARD

2. Submission of the online client report

PERFORMANCE MEASURE/METHOD

Documentation that all service providers have submitted their sections of the online client report

SUB-RECIPIENT RESPONSIBILITY

1. Maintain client-level data on each client served, including in each client record demographic status, HIV clinical information, HIV-care medical and support services received, and the client’s Unique Client Identifier
2. Submit this report online as an electronic file upload using the standard format
3. Submit both interim and final reports by the specified deadlines

LIMITATIONS

N/A

SOURCE CITATION

• RW Part B Program National Monitoring Standards, Section J; NGA, PST #17 and Reporting Requirements
• 2016 Annual Ryan White HIV/AIDS Program Services Report (RSR) Instruction Manual
• DSHS Statement of Work

HRSA/DSHS STANDARD

Grievance Policies: All contractors are required to have a written client complaint procedure in place to meet the minimum requirements for client complaints.

PERFORMANCE MEASURE/METHOD

Agencies have a policy and/or procedure for handling client grievances.

SUB-RECIPIENT RESPONSIBILITY

AAs will ensure all subcontractors and vendors will have a policy and/or procedure for handling client grievances.

LIMITATIONS

N/A

SOURCE CITATION

• PHS Act Section 2602(b)
• DSHS Policy 530.002 section 5.5

HRSA/DSHS STANDARD

Delivery of Client Services: Maintain client relations of the highest possible quality.

PERFORMANCE MEASURE/METHOD

Agencies 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 RESPONSIBILITY

AAs 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.

LIMITATIONS

N/A

SOURCE CITATION

• DSHS Policy 530.002 section 6.0
• DSHS Policy 530.003

HRSA/DSHS STANDARD

Non-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/METHOD

Agencies 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 RESPONSIBILITY

AAs 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:

• 888-388-6332 or
• Email: HHSCivilRightsOffice@hhsc.state.tx.us
   

LIMITATIONS

N/A

SOURCE CITATION

• NGA, PST #12
• Title VI of Civil Rights Act of 1964, P.L. 88-352 as amended
• 45 CFR 75.300
• Texas Health and Human Services Non-Discrimination Statement

HRSA/DSHS STANDARD

Confidentiality 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/METHOD

All 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 RESPONSIBILITY

AAs 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.

LIMITATIONS

N/A

SOURCE CITATION

• NGA, PST #21
• DSHS Policy 2011.01

HRSA/DSHS STANDARD

Breach 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/METHOD

Agencies 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 RESPONSIBILITY

AAs 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

LIMITATIONS

N/A

SOURCE CITATION

• DSHS Policy 2011.04
• hhs.gov/hipaa/for-professionals/

HRSA/DSHS STANDARD

Child 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/METHOD

Agencies 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 RESPONSIBILITY

All 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.

LIMITATIONS

N/A

SOURCE CITATION

• 2020-2021 General Appropriations Act, House Bill 1, 86th Legislature, Regular Session, 2019 (Article II, Section 31). Subtitle E, Chapter 261

HRSA/DSHS STANDARD

Incarcerated 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/METHOD

Agencies 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 RESPONSIBILITY

All 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.

LIMITATIONS

RWHAP and State Services funds are NOT utilized to pay for services rendered to incarcerated individuals

SOURCE CITATION

• PCN 18-02
• DSHS Policy 591.000

HRSA/DSHS STANDARD

Conflict of Interest: Services will be provided without interference by any conflict of interest.

PERFORMANCE MEASURE/METHOD

Agencies will have policies ensuring services will be provided without interference by any conflict of interest.

SUB-RECIPIENT RESPONSIBILITY

All 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.

LIMITATIONS

N/A

SOURCE CITATION

• DSHS Policy 241.005
• DSHS Conflict of Interest Statement Form
• AA Core Competencies

HRSA/DSHS STANDARD

Personnel 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/METHOD

Agencies have personnel policies and procedures in place that address all items as indicated.

SUB-RECIPIENT RESPONSIBILITY

Agencies have personnel policies and procedures that are in compliance with local, state, and federal program requirements.

LIMITATIONS

N/A

SOURCE CITATION

• DSHS POPS 13.2
• Ryan White Service Delivery Statement of Work

HRSA/DSHS STANDARD

Required 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/METHOD

Staff will attend required trainings, conferences, and meetings as indicated in the staff development plan and/or as directed by DSHS Program Staff.

SUB-RECIPIENT RESPONSIBILITY

Agencies 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.

LIMITATIONS

N/A

SOURCE CITATION

• PCN 15-02
• Ryan White Service Delivery Statement of Work

HRSA/DSHS STANDARD

ARIES 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/METHOD

Policies 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 RESPONSIBILITY

Agencies will maintain policies and procedures to ensure ARIES information is protected and maintained to ensure client confidentiality.

LIMITATIONS

N/A

SOURCE CITATION

• DSHS Policy 231.001

HRSA/DSHS STANDARD

ARIES 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/METHOD

Data managers develop and implement local policy and procedures relating to ARIES and the data collected through ARIES.

SUB-RECIPIENT RESPONSIBILITY

Agencies have local policies and procedures in place relating to ARIES and the data collected through ARIES.

LIMITATIONS

N/A

SOURCE CITATION

• DSHS Policy 231.002

HRSA/DSHS STANDARD

Outpatient/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/METHOD

Documentation of the following:

• Care is provided by health care professionals certified in their jurisdictions to prescribe medications in an outpatient setting
• Only allowable services are provided
• Services are provided as part of the treatment of HIV
• Specialty medical care relates to HIV and/or conditions arising from the use of HIV medications resulting in side effects
• Services are consistent with HHS guidelines

Please refer to the Outpatient Ambulatory Medical Care Standards of Care for additional information on Peer Review 

SUB-RECIPIENT RESPONSIBILITY

1. Ensure that client medical records document services provided, the dates and frequency of services provided, that services are for the treatment of HIV.
2. Include clinician notes in client records that are signed by the licensed provider of services.
3. Maintain professional certifications and licensure documents and make them available to the Recipient on request.
4. Standing Delegation Orders are available to staff and are reviewed annually, dated and signed.
5. Follow Texas Medical Board guidelines for client notification and posting of guidance to file complaints for in-person care and telemedicine (English and Spanish)
6. Peer review will be conducted and documented annually for all levels of licensed/credentialed providers (e.g. MD, NP, PA).
7. Service providers shall employ clinical staff with experience* regarding their area of clinical practice as well as knowledgeable in the area of HIV clinical practice, and personnel records/resumes/applications for employment will reflect requisite experience/education.
8. All staff with less than one (1) year experience working with HIV must be supervised by an employee with at least one (1) year of experience.

LIMITATIONS

Service is NOT being provided in an emergency room, urgent care, hospital or any other type of inpatient treatment center

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.1
• PCN 18-01; PCN 13-04; PCN 16-02; PCN 18-01 FAQ General #1, 11
• 22 Texas Administrative Code §178.3

HRSA/DSHS STANDARD

Local AIDS Pharmaceutical Assistance Program (LPAP): RWHAP Part B recipients using the LPAP service category must establish the following:

• Uniform benefits for all enrolled clients throughout the service area;
• A recordkeeping system for distributed medications;
• An LPAP advisory board;
• A drug formulary approved by the local advisory committee/board;
• A drug distribution system;
• A client enrollment and eligibility determination process that includes screening for ADAP and LPAP eligibility with rescreening at a minimum of every six months;
• Coordination with the state’s RWHAP Part B ADAP (Statement of Need)
• Implementation in accordance with requirements of the 340B Drug Pricing Program and the Prime Vendor Program

PERFORMANCE MEASURE/METHOD

Documentation that the LPAP program’s drug distribution system has:

• A client enrollment and eligibility determination process that includes ADAP and LPAP eligibility with rescreening every six months
• An LPAP advisory board
• Uniform benefits for all enrolled clients through the region(s)
• Compliance with RWHAP requirement of payor of last resort
• A recordkeeping system for distributed medications
• A drug distribution system that includes a drug formulary approved by the local advisory committee/ board
• Medications are secured and locked/stored appropriately
• System for drug therapy management
• Policy for timeliness of services
• MOUs with local pharmacies to ensure cost efficiency with established dispensing fees.

SUB-RECIPIENT RESPONSIBILITY

1. Provide to the Recipient upon request, documentation that the LPAP program meets HRSA/HAB requirements.
2. Maintain documentation, and make available to the Recipient upon request, proof of client LPAP eligibility.
3. Only authorized personnel dispense/ provide prescription medication.
4. Medications and supplies are secured in a locked area and stored appropriately.
5. Agency has a system for drug therapy management.
6. Policy for timeliness of services.
7. MOUs ensuring cost efficient methods are in place.
8. MOUs ensure dispensing fees are established and implemented.
9. Active pharmacy license is onsite and is renewed every two years.
10. Pharmacies and pharmacy staff will adhere to the Texas State Board of Pharmacy rules and regulations.
11. Documentation on file that pharmacy owner if not a Texas licensed pharmacist, is consulting with a pharmacist in charge (PIC) or with another licensed pharmacist.
12. Pharmacy technicians and other personnel authorized to dispense medications are under the supervision of a licensed pharmacist.
13. A licensed nurse or practitioner designated by the pharmacist in charge (PIC) as supportive personnel may provide unit of use-packaged medications.
14. Prescriptions are filled with most cost-effective medications as evidenced by receipts.

LIMITATIONS

Only 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:

1. A result or component of a primary medical visit
2. A single occurrence of short duration (an emergency) without arrangements for longer term access to medications
3. Vouchers to clients on a single occurrence without arrangements for longer-term access to medications 

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.4
• PCN 16-02
• LPAP Policy Clarification Memo
• FY 2017 FOA, p. 19

HRSA/DSHS STANDARD

Oral 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/METHOD

Documentation that:

1. Oral health services are provided by general dental practitioners, dental specialists, dental hygienists and auxiliaries and meet current dental care guidelines.
2. Oral health professionals providing the services have appropriate and valid licensure and certification, based on State and local laws.
3. Services fall within specified service caps, expressed by dollar amount, type of procedure, limitations on the procedures, or a combination of any of the above, as determined by the State and/or local communities.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain dental files for all clients.
2. Maintain and provide to Recipient upon request, copies of professional licensure and certification.
3. X-rays are taken by dental assistants who are registered with the State Board of Dental Examiners.
4. A Texas dentist practicing dentistry in Texas shall notify dental clients that complaints concerning dental services can be directed to the Texas Dental Board.
5. OH caps are documented at the regional level and are tracked for each client in the service area that receives OH services.
6. If cost of dental care exceeded regional caps set, documentation of reason is in the client record. 

LIMITATIONS

N/A

SOURCE CITATION

• PHS ACT 2612(b)(3)(D); RWHAP Part B Program National Monitoring Standards, Section B.5; PCN 16-02 FAQ General #1
• 22 Texas Administrative Code §108.3
• 22 Texas Administrative Code §108.11
• 22 Texas Administrative Code §114.2

HRSA/DSHS STANDARD

Early Intervention Services: includes identification of individuals at points of entry and access to services and provisions of:

• HIV testing and focused counseling to help those unaware of HIV status
• Referral services to improve HIV care at key points of entry
• Linkage to care such as OAHS, MCM, and Substance Abuse Care
• Outreach and Health Education/Risk Reduction related to HIV diagnosis

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/METHOD

Documentation that:

1. Part B funds are used for HIV testing only where existing federal, state, and local funds are not adequate, and RW funds will supplement, and not supplant, existing funds for testing
2. Individuals who test positive are referred for and linked to health care and supportive services
3. Health education and literacy training is provided that enables clients to navigate the HIV system
4. EIS is provided at or in coordination with documented key points of entry
5. EIS services are coordinated with HIV prevention efforts and programs

SUB-RECIPIENT RESPONSIBILITY

1. MOUs are in place with key points of entry into care
2. All four required EIS service components are documented in the RWHAP Part B EIS program policies both at local and regional systems of care
3. Document that HIV testing activities and methods meet CDC and state requirements, including licensure to conduct phlebotomy services where applicable.
4. Establish linkage agreements with testing sites where Part B is not funding testing but is funding referral and access to care
5. Ensure agencies have capacity and training to document number of tests (if applicable), number of referrals, and results of testing.
6. Documentation that EIS program funds will supplement, not supplant, other funds available to the entity for the provision of providing EIS services in the fiscal year involved.

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.6
• PCN 16-02; PCN 16-02 #8
• PHS Act section 2612(d)(2)

HRSA/DSHS STANDARD

Health 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:

• Ensure clients are buying health coverage that, at a minimum, includes at least one drug in each class of core ART from the HHS treatment guidelines along with appropriate HIV OAHS
• Must assess and compare the aggregate cost of paying for the health coverage option versus paying for the aggregate full cost for medications and other appropriate HIV OAHS, and allocate funding to HIPCSA only when determined to be cost effective.
• HIV insurance continuation funds will only be used for payment of insurance premiums, deductibles, co-insurance payments, copayments, and related administrative costs. HIV insurance assistance shall be provided directly to the insurance carrier, insurance administrator, or health provider, rather than to the client. Insurance premiums may be prepaid, including that part of the coverage period, which extends beyond the Contract term.

PERFORMANCE MEASURE/METHOD

Documentation that:

• Where funds are covering premiums, documentation that the insurance plan purchased provides comprehensive primary care and a full range of HIV medications
• Assurance that any cost associated with the creation, capitalization, or administration of a liability risk pool is not being funded by RW
• Assurance that RW funds are not being used to cover costs associated with Social Security
• Documentation of clients’ low-income status
• Documentation that HIV insurance continuation funds will only be used for payment of insurance premiums, deductibles, co-insurance payments, copayments, and related administrative costs. HIV insurance assistance shall be provided directly to the insurance carrier, insurance administrator, or health provider, rather than to the client.

SUB-RECIPIENT RESPONSIBILITY

1. Provide upon request:
   • Where premiums are covered by RW funds, provide proof that the insurance policy provides comprehensive primary care and a formulary with a full range of HIV medications
   • Maintain proof of low-income status
   • Provide documentation that demonstrates that funds were not used to cover costs associated with the creation, capitalization, or administration of a liability risk pool, or social security costs
2. Agency has policy that outlines caps on assistance/payment limits and adheres to DSHS Policy.
3. Agency has policy that details the expectation for client contribution and tracks these contributions under client charges.
4. Agency has policy that requires referral relationships with organizations or individuals who can provide expert assistance to clients on their health insurance coverage options and available cost reductions.
5. Agency has policy that ensures referral relationships with organizations or individuals who can provide income tax preparation assistance for clients.
6. Agency has policies and procedures detailing process to make premium and out-of-pocket payments.
7. Documentation is maintained at the agency level as to number of clients served by:
   1. Premium assistance/out of pocket costs;
   2. IRS payments. 

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.7
• PCN 13-04; PCN 14-01 revised 4/3/2015; PCN 16-02; PCN 16-02 Standalone Dental Insurance FAQ; PCN 18-01
• DSHS Policy 260.002
• DSHS Policy 270.001 (Calculation of Estimated Expenditures on Covered Clinical Services)

HRSA/DSHS STANDARD

Home 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:

• Administration of prescribed therapeutics
• Preventive and specialty care
• Wound care
• Routine diagnostics testing administered in the home
• Other medical therapies

The provision of Home Health Care is limited to clients that are homebound.

PERFORMANCE MEASURE/METHOD

Assurance that:

• Services are limited to medical therapies in the home and exclude personal care services
• Services are provided by home health care workers with appropriate licensure as required by State and local laws

SUB-RECIPIENT RESPONSIBILITY

1. Maintain on file and provide to the recipient upon request, copies of the licenses of home health care workers.
2. Agency policy on operation and procedures to contact agency after hours for urgent and/or emergency care is current and evident.

LIMITATIONS

Home settings do NOT include nursing facilities or inpatient mental health/substance abuse treatment facilities

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.8
• PCN 16-02; PCN 16-02 FAQ General #1, 12
• 40 Texas Administrative Code §97.211

HRSA/DSHS STANDARD

Home 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:

• Appropriate mental health, development, and rehabilitation services
• Day treatment or other partial hospitalization services
• Durable medical equipment
• Home health aide services and personal care services in the home 

PERFORMANCE MEASURE/METHOD

1. Provide assurance that the services are provided in accordance with allowable modalities and locations under the definition of home and community based health services.
2. Documentation of appropriate licensure and certifications for individuals providing the services, as required by local and state laws.

SUB-RECIPIENT RESPONSIBILITY

Assurance of:

1. Services are being provided in an HIV-positive client’s home, and/or a day treatment or other partial hospitalization services program as licensed by the State.
2. Maintain, and make available to recipient, copies of appropriate licenses and certifications for professionals providing services.
3. Documented policy on operation and procedures to contact agency after hours for urgent and/or emergency care.
4. The agency shall have policies/procedures for the following:
   • Referral resources and procedures that ensure access to a continuum of services
   • All appropriate consent forms (e.g., consent to share information, shared client data/registration system (ARIES), HIPAA requirements)
   • Consent to treatment signed by the client annually
   • Data collection procedures and forms, including data reporting
   • Quality assurance/quality improvement
   • Guidelines for language accessibility
5. All agency professional staff, contractors, and consultants who provide direct-care services, and who require licensure, shall be properly licensed by the State of Texas, or documented to be pursuing Texas licensure while performing tasks that are legal within the provisions of the Texas Medical Practice Act (or in the case of a nurse, the Nursing Practice Act), including satisfactory arrangements for malpractice insurance with evidence of such in the personnel file.
6. Provider will document provision of in-service education to staff regarding current treatment methodologies and promising practices.

LIMITATIONS

Inpatient 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

• RWHAP Part B Program National Monitoring Standards, Section B.9
• PCN 16-02

HRSA/DSHS STANDARD

Hospice Services: End of life care services provided to clients in the terminal stage of an HIV-related illness. Allowable services are:

• Mental health counseling
• Nursing care
• Palliative therapeutics
• Physician services
• Room and board.

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/METHOD

Documentation including:

1. Physician certification that the client’s illness is terminal as defined under Medicaid hospice regulations.
2. Appropriate and valid licensure of provider as required by the State in which hospice care is delivered.
3. Types of services provided, and assurance that they include only allowable services.
4. Locations where hospice services are provided, and assurance that they are limited to a home or other residential setting or a non-acute care section of a hospital designated and staffed as a hospice setting.
5. Assurance that services meet Medicaid or other applicable requirements.

SUB-RECIPIENT RESPONSIBILITY

1. Obtain and have available for inspection appropriate and valid licensure to provide hospice care.
2. Maintain and provide the recipient access to program files and client records.
3. Documentation that staff attended continuing education on HIV and end of life issues.
4. Documentation that supervisory provider or registered nurse provided supervision to staff.
5. Agency has a policy detailing the reasons the Agency may rely upon for refusal of referral.
6. Agency has a policy for client discharge.

LIMITATIONS

Does NOT extend to skilled nursing facilities or nursing homes.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.10
• PCN 16-02; PCN 16-02 FAQ General #1
• 40 Texas Administrative Code §97.211

HRSA/DSHS STANDARD

Mental 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

1. Documentation of appropriate and valid licensure and certification of mental health professionals as required by the State, including supervision of licensed staff.
2. Documentation of the existence of a detailed treatment plan for each eligible client.
3. MOUs to provide services if specific service is not available.
4. Agency has emergency/crisis intervention plan.

SUB-RECIPIENT RESPONSIBILITY

1. Obtain and have on file and available for recipient review appropriate and valid licensure and certification of mental health professionals, including supervision of licensed staff.
2. Maintain client records that include detailed treatment plans and documentation of services provided.
3. MOUs are available for referral needs.
4. Agency has policies/procedures in place for emergency/crisis intervention plan.
5. Agency has a policy for clinical supervision per licensure standards.
6. Agency/Provider has a discharge policy and procedure.
7. Agency/Provider has a policy/procedure documenting how clients are introduced to program services either in writing or orally.

LIMITATIONS

Only for HIV clients.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.11
• PCN 16-02; PCN 16-02 FAQ General #1

HRSA/DSHS STANDARD

Medical 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/METHOD

Documentation of:

1. Licensure and registration of the dietitian as required by the State
2. Staff has the knowledge, skills and experience appropriate to providing food or nutritional counseling/education services.
3. Licensed Registered Dietitians will maintain current professional education (CPE) units/hours, including HIV nutrition and other related medical topics approved by the Commission of Dietetic Registration.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain and make available to the recipient copies of the dietitian’s license and registration
2. Personnel records/resumes/ applications for employment will reflect requisite education, skills and experience.
3. Documentation in personnel records of professional education.
4. Agency has a policy and procedure for determining frequency of contact with the licensed Registered Dietitian based on the level of care needed.
5. Agency has a policy and procedure on obtaining, tracking inventory, storing, and distributing supplemental nutrition products if applicable.
6. Agency has a policy and procedures on discharging a client from medical nutrition therapy and the process for discharge/referral.

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.12
• PCN 16-02; PCN 16-02 FAQ General #1

HRSA/DSHS STANDARD

Medical 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

1. Documentation that service providers are trained professionals, either medically credentialed persons or other health care staff who are part of the clinical care team.
2. Documentation that all activities are being carried out for all clients.
3. Documentation of case management services and encounters.
4. Documentation in client records of services provided.
5. Minimum qualifications are established regionally by the Administrative Agencies. DSHS preferred qualifications for staff: a degree in health, human or education services and one year of case management experience with people living with HIV and/or persons with a history of mental illness, homelessness, or substance use.
6. Minimum qualifications for Medical Case Management supervisors: degreed or licensed in the fields of health, social services, mental health or a related area (preferably Masters’ level). Additionally, case manager supervisors must have 3 years’ experience providing case management services, or other similar experience in a health or social services related field (preferably with 1 year of supervisory or clinical experience).
7. Mandatory agency training should include the provision of agency’s policy and procedure manual and employee handbook to familiarize new staff with the internal workings and processes of their new work environment.
8. Supervisors should expect to expend more time in providing such training to staff during their probationary period of employment. During the probationary period, new case managers should be monitored for satisfactory completion of core, case management specific tasks (e.g., assessments, care planning and interventions). These activities should be monitored in person by appropriate supervisory staff -- or qualified designees -- at least once weekly for the entire probationary period before the case manager is approved to provide services independently.
9. New Medical Case Managers must complete all components of the MCM Competency Training Course within six (6) months of hire. This course addresses the following core competencies:
   • STD Facts & Fallacies: Chlamydia, Gonorrhea & Pelvic Inflammatory Disease (PID)*
   • STD Facts & Fallacies: Syphilis*
   • Perinatal HIV Prevention Online Program*
   These courses are all available through the TRAIN (Training Finder Real-time Affiliate Integrated Network) Texas learning management system (train.org/texas/).
10. Core training of staff, using supportive supervision techniques (e.g. job shadowing, performance evaluation, and immediate (responsive) job counseling/training) should be provided on an ongoing basis -- frequency based on staff experience and performance -- by supervisors.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain documentation showing that MCM services are provided by trained professionals who are either medically credentialed or trained health care staff and operate as part of the clinical care team.
2. Maintain client records that include all required elements for compliance with contractual and RW programmatic requirements.
3. Policies and procedures are in place for conducting MCM services, including the following:
   • Data collection procedures and forms, including data reporting
   • Initial Comprehensive Assessment
   • MCM Case Management Acuity Level and Client contact
   • Care Planning
   • Viral Suppression/Treatment Adherence
   • Referral and follow-Up
   • Case Closure/Graduation
   • Case Conferencing
   • Caseload Management
   • Case Closure and Graduation
   • Case Transfer (internal/external)
   • Probationary Period (new hire)
   • Staff Supervision
   • Staff Training, including agency specific training
4. All MCM staff must meet the minimum training requirements established in this document. Training expectations for newly hired case managers can be found at: /hivstd/contractor/cm.shtm
5. Each agency is responsible for providing new staff members and supervisors with job-related training that commences within 15 working days of hire and is completed no later than 90 days following hire.
6. All staff at agencies receiving Ryan White Part B or State Services case management funds (both medical and non-medical) must complete (or have completed prior) the required MCM training within six (6) months of hire.
7. Staff performing MCM at agencies receiving Ryan White Part B or State Services case management funds must fulfill the below training requirements.
8. All case management staff must complete a minimum of 12 hours of continuing education annually in relevant topics. Relevant topics include, but are not limited to:
   • HIV Confidentiality and the Law
   • Working with Special Populations (undocumented, LGBT, Women, African-American/Black, Latino/a, aging population, youth)
   • Domestic Violence/Family Violence/Intimate Partner Violence
   • Assessment
   • Monitoring/Outcomes
   • Records Management
   • Resources Development/Use
   • Safety
   • Care Planning and Implementation
   • Ethics and HIV
   • Hepatitis A, B, C
   • Screening Tools (Substance Use, Mental Health, Sexual Health)
   • HIV disclosure, Partner Notification Services
   • Sexual Health Promotion
   • Healthy Behavior Promotion

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section B.13
• PCN 16-02; PCN 16-02 FAQ #10, 11

HRSA/DSHS STANDARD

Substance Abuse Outpatient Care: Provision of outpatient services for the treatment of alcohol or other drug use disorders. Services include:

• Screening
• Assessment
• Diagnosis, and/or
• Treatment of substance use disorder

PERFORMANCE MEASURE/METHOD

1. Documentation that services are provided by or under the supervision of a physician or by other qualified personnel with appropriate and valid licensure and certification as required by the State.
2. Documentation through program files that services provided meet the service category definition.
3. All services provided are allowable under RW
4. Assurance that RW funds are used to expand HIV-specific capacity of programs only if timely access would not otherwise be available to treatment and counseling.
5. Assurance that services provided include a treatment plan that calls for only allowable activities
6. Facilities providing substance use treatment services will be licensed by the Texas Department of State Health Services (Department) or be registered as a faith-based exempt program.
7. Supervisors’ files reflect notes of weekly supervisory conferences.

SUB-RECIPIENT RESPONSIBILITY

Maintain and provide:

1. Provider licensure or certifications as required by the State
2. Staffing structure showing supervision by a physician or other qualified personnel
3. Evidence that all services are provided on an outpatient basis
4. Program files and client records that include treatment plans
5. Agency will have documentation on site that license is current for the physical location of the treatment facility, if applicable.
6. Documentation of supervision during client interaction with Counselors In Training (CIT) or Interns as required by the Texas Department of State Health Services (DSHS).
7. Each staff member will have documentation of minimum experience to include:
   • Two years of experience in HIV or other catastrophic illness and continuing education in HIV
   • One year of experience in family counseling as pertaining to substance use
   • Non-violent crisis intervention training
   • Training in mental health issues and knowing when to refer a client to a mental health program/counselor.
8. Documentation of professional liability for all staff and agency.
9. Agency shall have a policy and procedure to conduct Interdisciplinary Case Conferences held for each active client at least once every 6 months. Case Conference documentation, signed by the supervisor, in client record will include:
   • Date, name of participants and name of client
   • Issues and concerns
   • Follow-up plan
   • Clinical guidance provided
10. Provider agency must have and implement 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 client admission
    • Follow-up contacts
    • Continuity of services in the event of a facility emergency
11. Agency will have a policy and procedure for clients to follow if they need after-hours assistance. This procedure will be included in the client orientation process.
12. Written policies and procedures for staff to follow in psychiatric or medical emergencies.
13. Policies and procedures define emergency situations, and the responsibilities of key staff are identified.

LIMITATIONS

Syringe 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

• RWHAP Part B Program National Monitoring Standards, Section B.14
• PCN 16-02; PCN 16-02 General #1

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 STANDARD

Non-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

1. Documentation that scope of activity includes advice and assistance to clients in obtaining medical, social, community, legal, financial, and other needed services.
2. Services cover all types of encounters and communications.
3. Where transitional case management for incarcerated persons is provided, assurance that such services are provided either as part of discharge planning or for individuals who are in the correction system for a brief period.
4. Supervisor signature and date, signifying review and approval of initial comprehensive assessment, for case managers during their probationary period.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain client records that include the required elements as detailed by the Recipient.
2. Provide assurances that any transitional case management for incarcerated persons meets contract requirements.
3. Policies and procedures are in place for conducting NMCM services.
4. Non-medical case managers will complete annual trainings per DSHS

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.2
• PCN 16-02; PCN 16-02 FAQ #10

HRSA/DSHS STANDARD

Child 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

1. Documentation of parent’s eligibility as defined by the State.
2. Appropriate and valid licensure and registration of childcare providers under applicable State and local laws where services are provided in a day care setting.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain documentation of childcare services provided.
2. Maintain valid licensure and registration of childcare providers.
3. Informal childcare arrangements are in compliance with Recipient requirements.
4. Agency will establish a policy and procedure to address liability issues addressed through liability release forms designed to protect the client, provider and the RW program.

LIMITATIONS

No cash to clients or primary caregivers to pay for these services.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.3
• PCN 16-02; PCN 16-02 FAQ #16

HRSA/DSHS STANDARD

Emergency 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

1. Documentation of services and payments to verify that EFA to individual clients is provided with limited frequency and for limited periods of time, with frequency and duration of assistance specified by the Recipient.
2. Documentation ensuring assistance is provided only for the following essential services: utilities, housing, food, or medications through a voucher program or short-term payments to the service entity.
3. Emergency funds are allocated, tracked, and reported by type of assistance.
4. No more than a 30-day supply of medications are purchased at a time.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain client records that document client eligibility, types of EFA provided, dates of EFA, and method of providing EFA.
2. Maintain and provide documentation of assistance provided to clients.
3. Provide assurance to State that all EFA was for allowable types of assistance, was used where RW was payor of last resort, met State or local specified limitations on amount and frequency of assistance to an individual, and provided through allowable payment methods.
4. Policies include medication purchase limitations.
5. Agencies providing EFA medications must have policies and procedures to pursue all feasible alternative revenues systems (e.g., pharmaceutical company patient assistance programs) before requesting reimbursement through EFA.
6. Agency may reimburse the pharmacy a minimal dispensing fee per prescription as outlined in a MOU.

LIMITATIONS

• Must be a direct payment to an agency or through a voucher program.
• Continuous provision of an allowable service to a client should not be funded through EFA.
• Grocery/Food vouchers cannot be used for the purchase of alcohol and/or tobacco products.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.4
• PCN 16-02; PCN 16-02 FAQ #4, 17

HRSA/DSHS STANDARD

Food 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:

• Personal hygiene products
• Household cleaning supplies
• Water filtration/purification systems in communities where issues of water safety exist

PERFORMANCE MEASURE/METHOD

1. Documentation that services supported are limited to food bank, home-delivered meals, and/or food voucher programs.
2. Documentation of types of non-food times provided. If water filtration/purification systems are provided, community has documented water purity issues.
3. Assurance of compliance with federal, state, and local regulations including any required licensure or certification for the provision of food banks and/or home-delivered meals.
4. Monitoring of providers to document actual services provided, client eligibility, number of clients served, and level of services.
5. Food pantry program will meet regulations on Food Service Sanitation as set forth by Texas Department of State Health Services, Regulatory Licensing Unit and/or local city or county health regulating agencies

SUB-RECIPIENT RESPONSIBILITY

1. Maintain documentation of:
   • Services provided by type
   • Amount and use of funds for purchase of non-food items
   • Compliance with all federal, state, and local laws regarding the provision of food bank, home-delivered meals and food voucher programs, including any required licensure and/or certifications (displayed on site).
   • Assurance that RW funds were used only for allowable purposes and RW was the payor of last resort.
   • Records of local health department food handling/food safety inspection are maintained on file.
2. Agency will be licensed for non-profit salvage by the Texas Department of State Health Services Regulatory Licensing Unit and/or local city, or county health regulating agencies.
3. Food Pantry must display "And Justice for All" posters that inform people how to report discrimination.
4. There must be a method to regularly obtain client input about food preference and satisfaction. Such input shall be used to make program changes.
5. Director of meal program must complete and pass Service Safety certification every three (3) years.
6. An application form is completed for each volunteer.
7. Each staff and volunteer position has written job descriptions.
8. Personnel files reflect completion of applicable trainings and orientation.

LIMITATIONS

Unallowable costs include household appliances, pet foods, and other non-essential products.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.5
• PCN 16-02

HRSA/DSHS STANDARD

Health 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/METHOD

Documentation that:

1. Clients are educated about HIV transmission and how to reduce the risk of HIV transmission to others.
2. Clients receive information about available medical and psychosocial support services.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain records of services provided.
2. Document in client files client eligibility, information provided on available services, education about HIV transmission, counseling on how to improve their health status and reduce risk of HIV transmission.
3. Documentation that staff has visited collaborating service agencies/has knowledge of local resources.
4. Documentation that supervisors reviewed 10 percent of each HE/RR staff client records each month.
5. Documentation that supervisor/program manager has reviewed pre-post tests and program evaluations.

LIMITATIONS

HE/RR services cannot be delivered anonymously.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.6
• PCN 16-02

HRSA/DSHS STANDARD

Housing 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

1. Must have mechanisms in place to allow newly identified clients access to housing services.
2. Documentation that funds are used only for allowable purposes.
3. Services are provided by case managers or other housing professionals.
4. Policies and procedures to provide individualized written housing plans, consistent with Housing Policy, covering each client receiving short term, transitional, and emergency housing services.
5. Agency established payment methodology to issue direct payment to housing vendor or voucher system.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain documentation of services provided.
2. Ensure staff providing housing services are case managers or other professionals who possess knowledge of local, state, and federal housing programs and how to access those programs.
3. Policies and procedures are written ensuring individualized written housing plans are consistent with Housing Policy.
4. Agency will establish payment methodology to include either direct payment to a housing vendor or a voucher system with no direct payments to clients. Payment process will include documentation of lease/mortgage, utility bill, fees (late fees, legal), utility bill, IRS Form W-9.
5. Documentation of required initial training by staff as outlined in the Standards of Care for Housing Services completed within three (3) months of hire is located in the personnel file. All professional housing providers must complete the following within three (3) months of hire:
   • Effective Communication
   • 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
   • How to access housing programs
6. Client eligibility for services, actual services provided by type of service, number of clients served, and level of services will be collected.

LIMITATIONS

Housing services cannot be in the form of direct cash payments to clients and cannot be used for mortgage payments.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.7
• PCN 16-02; PCN 16-02 FAQ #18

HRSA/DSHS STANDARD

Linguistic 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

1. Documentation that linguistic services are being provided as a component of HIV service delivery between the provider and the client, to facilitate communication between the client and provider and the delivery of RW-eligible services in both group and individual settings.
2. Services are provided by appropriately trained and qualified individuals holding appropriate State or local certification.

SUB-RECIPIENT RESPONSIBILITY

1. Document the provision of linguistic services.
2. Maintain documentation showing that interpreters and translators employed with RW funds have appropriate training and hold relevant State and/or local certification.

LIMITATIONS

Services provided must comply with the National Standards for Culturally and Linguistically Appropriate Services (CLAS).

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.8
• PCN 16-02; PCN 16-02 FAQ #19

HRSA/DSHS STANDARD

Other 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:

• Legal services provided to and/or on behalf of the individual living with HIV and involving legal matters related to or arising from their HIV.
• Permanency planning to help clients/families make decisions about the placement and care of minor children after their parents/caregivers are deceased or are no longer able to care for them

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

1. Documentation that funds are used only for allowable services as indicated in Standard.
2. Assurance that program activities do not include any criminal defense or class-action suits unrelated to access to services eligible for funding under the RWHAP Part B program.
3. Maintain client files that include: client eligibility; description of how service is necessitated by individual’s HIV status; types of services provided; and hours spent in provision of such services.

SUB-RECIPIENT RESPONSIBILITY

1. Document services provided, including specific types of services.
2. Provide assurance that funds are being used only for services directly necessitated by an individual’s HIV status.
3. All licensed agency professional staff, contractors, and consultants who provide legal services shall be currently licensed by the State Bar of Texas.
4. Law students, law school graduates and other legal professionals will be supervised by a qualified licensed attorney.
5. Agency paid legal staff and contractors must complete two (2) hours of HIV-specific training annually.
6. Agency maintains system for dissemination of HIV information relevant to the legal assistance needs of PLWH to staff and volunteers.

LIMITATIONS

Exclude criminal defense and class-action suits unless related to access to services eligible for funding under the RWHAP.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.7 (formerly Legal Services)
• PCN 16-02; PCN 16-02 FAQ #13
• 45 CFR §75.459

HRSA/DSHS STANDARD

Medical 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

1. May be provided through contracts with providers of transportation services.
2. Mileage reimbursement (through a non-cash system) that enables clients to travel to needed medical or support services, but should not in any case exceed the established rates for federal programs.
3. Purchase or lease of organizational vehicles for client transportation programs, provided recipient receives prior approval for the purchase of vehicle.
4. Organization and use of volunteer drivers (through reliance upon established programs that ensure auto insurance and other liability issues specifically addressed).

SUB-RECIPIENT RESPONSIBILITY

1. Maintain program files.
2. Maintain documentation that the provider is meeting stated contract requirements with regard to methods of providing transportation.
3. Collection and maintenance of data documenting that funds are used only for transportation designed to help eligible individuals remain in medical care by enabling them to access medical and support services.
4. Obtain HRSA and State approval prior to purchasing or leasing a vehicle(s).
5. Voucher or token systems.

LIMITATIONS

No 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

• RWHAP Part B Program National Monitoring Standards, Section C.9
• PCN 16-02
• DSHS HIV Care Services Medical Transportation Services Standard

HRSA/DSHS STANDARD

Outreach Services: Provision of the following three activities:

• Identification of people who do not know their HIV status and linkage into OAHS
• Provision of additional information and education on health care coverage options
• Reengagement of people who know their status into OAHS

PERFORMANCE MEASURE/METHOD

1. Conducted at times and in places where there is a high probability that individuals with HIV infection are present and/or high-risk behaviors are being exhibited
2. Designed to provide quantified program reporting of activities and outcomes to accommodate local evaluation of effectiveness
3. Planned and delivered in coordination with local and state HIV prevention outreach programs to avoid duplication of effort.
4. Focused on populations known, through local epidemiological data or review of service utilization data or strategic planning processes, to be at disproportionate risk for HIV

SUB-RECIPIENT RESPONSIBILITY

1. Document the design, implementation, priority areas and populations, and outcomes of outreach activities.
2. Document and provide data showing that all RFP and contract requirements are being met with regard to program design, targeting, activities, and use of funds.
3. Provide financial and program data demonstrating that no outreach funds are being used to pay for HIV counseling and testing, to support broad-scope awareness activities, or to duplicate HIV prevention outreach efforts.
4. Within the first (3) months of hire, 16 hours of training for new staff and volunteers shall be given which includes but not limited to:
   • Specific HIV-related issues
   • Substance use and treatment
   • Mental health issues
   • Domestic violence
   • Sexually transmitted infections (STIs)
   • Partner notification
   • Housing Services
   • Adolescent health issues
   • Sex workers
   • Incarcerated/recently released
   • Gay/lesbian/bisexual/transgender concerns
5. Each outreach supervisor, staff and volunteer shall hold a valid Texas driver’s license and proof of liability insurance, if needed, to carry out work responsibilities.

LIMITATIONS

• Recipients and sub-recipients may use Outreach Services funds for HIV testing when RWHAP resources are available, however testing must not supplant other existing funding.
• No use of Part B funds for outreach activities that have HIV prevention education as their exclusive purpose.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.10; RW Part B Fiscal National Monitoring Standards, Section B.7; Part B Manual
• PCN 12-01; PCN 16-02; HAB Policy Notice 07-06, Policy Notice 97-01

HRSA/DSHS STANDARD

Psychosocial Support Services: Provide group or individual support and counseling services to assist eligible PLWH to address behavioral and physical health concerns. Services include:

• Bereavement counseling
• Child abuse and neglect counseling
• HIV support groups
• Nutrition counseling provided by a non-registered dietitian
• Pastoral care/counseling services

PERFORMANCE MEASURE/METHOD

1. Documentation that psychosocial services funds are used only to support eligible services.
2. Documentation that pastoral care/ counseling services meet the following:
   • Provided by an institutional pastoral care program;
   • Provided by a licensed or accredited provider wherever such licensure or accreditation is either required or available;
   • Available to all individuals eligible for RW services.
3. Assurance that no funds under this service are used for the provision of nutritional supplements.

SUB-RECIPIENT RESPONSIBILITY

1. Document the provision of psychosocial support services.
2. Maintain documentation that demonstrates funds are used for allowable services only, no funds are used for provision of nutritional supplements, and any pastoral care/ counseling services meet all stated requirements.
3. Program staff conducting nutritional counseling will be trained to perform nutritional assessments.
4. All non-professional staff delivering support group facilitation must be supervised by a licensed professional.

LIMITATIONS

• Funds may not be used to provide nutritional supplements.
• Funds may not be used for social/recreational activities or to pay for a client’s gym membership.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.11
• PCN 16-02

HRSA/DSHS STANDARD

Referral 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

1. Documentation that funds are used only for allowable services.
2. Documentation of method of client contact; method of providing referrals; and referrals and follow up provided.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain program files.
2. Maintain client records that include required elements as detailed by the State.
3. Maintain documentation demonstrating that services and circumstances of referral services meet contract requirements.

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.12
• PCN 16-02

HRSA/DSHS STANDARD

Rehabilitation 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/METHOD

Documentation that services:

1. Intended to improve or maintain a client’s quality of life and optimal capacity for self-care.
2. Limited to allowable activities.
3. Provided by a licensed or authorized professional.
4. Provided in accordance with an individualized plan of care that includes components specified by the State.
5. Rehabilitative services must be provided in an outpatient setting.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain and share all program and financial records that document types of services provided, type of facility, provider licensing, use of funds only for allowable services.
2. Maintain client records that include the required elements as detailed by the State.
3. Rehabilitative services must be provided in an outpatient setting. This may include outpatient ambulatory or home setting. Contracts or Memorandums of Agreement/Understanding are in place with these agencies/individual providers to provide services in an outpatient setting.
4. Direct supervision by a licensed/certified professional during client interaction is required if assistants or students are providing care.
5. Staff participating in the direct provision of services to clients must satisfactorily complete all appropriate continuing education units (CEUs) based on license requirement for each licensed/ certified therapist.

LIMITATIONS

N/A

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.13
• PCN 16-02; PCN 16-02 FAQ #14

HRSA/DSHS STANDARD

Respite 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. 
Recreational and social activities are allowable program activities as part of a respite care service provided in a licensed or certified provider setting including drop-in centers within OAHS or satellite facilities.
 

PERFORMANCE MEASURE/METHOD

1. Documentation that funds are used only for allowable services.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain program files that include number of clients served, and settings/methods of providing care.
2. Maintain client files that include: eligibility and services provided.
3. Staff will have the skills, experience, and qualifications appropriate to providing respite care services. When the client designates a community respite caregiver who is a member of his or her personal support network, this designation suffices as the qualification.
4. All non-professional staff must be supervised by a degreed or licensed individual in the fields of health, social services, mental health, or a related area, preferably Master’s Level. A person with equivalent experience may be used.
5. Supervisors must review a 10 percent sample of each staff records each month for completeness, compliance with these standards, and quality and timeliness of service delivery.
6. Each supervisor must maintain a file on each staff member supervised and hold supervisory sessions on at least a weekly basis. The file on the staff member must include, at a minimum:
   • Date, time, and content of the supervisory sessions
   • Results of the supervisory case review addressing, at a minimum of completeness and accuracy of records, compliance with standards, and effectiveness of service.
7. Funds may be used to support informal respite care if:
   • Liability issues have been addressed
   • Appropriate releases obtained that protect the client, provider of respite care, and the Program
   • Payment for services (reimbursement) is made for actual costs and no cash payments are made to clients or primary caregivers
   • Voucher or gift card may be used as reimbursement

LIMITATIONS

Funds may not be used for off premise social/recreational activities or to pay for a client’s gym membership.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.14
• PCN 16-02

HRSA/DSHS STANDARD

Substance 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

1. Documentation that services are provided by or under the supervision of a physician or by other qualified personnel with appropriate and valid licensure and certification as required by the State.
2. Documentation that services provided meet the service category definition.
3. Documentation that services are provided in accordance with a written treatment plan.
4. Assurance that services are provided only in a short-term residential setting.
5. Documentation that if provided, acupuncture services are limited through some financial cap, are provided only with a written referral from the client’s primary care provider, and are offered by a provider with appropriate State license and certification, if it exists.

SUB-RECIPIENT RESPONSIBILITY

1. Maintain documentation of provider licensure or certifications as required by the State. This includes licensures and certifications for a provider of acupuncture services.
2. Documentation of staffing structure showing supervision by a physician or other qualified personnel.
3. Provide assurance that all services are provided in a short-term residential setting.
4. Maintain program files that document allowable services provided, and the quantity/frequency/modality of treatment services.
5. Maintain client records.
6. Agency will have documentation on site that license is current for the physical location of the treatment facility.
7. Documentation of supervision during client interaction with Counselors In Training (CIT) or Interns as required by DSHS.
8. Each staff member will have documentation of minimum experience to include:
   • Continuing Education in HIV
   • One (1) year of experience in family counseling as pertaining to substance use disorders
   • Non-violent crisis intervention training
   • Training in mental health issues and knowing when to refer a client to a mental health program/counselor
9. 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.
10. Documentation of professional liability for all staff and agency.
11. Agency shall have a policy and procedure to conduct Interdisciplinary Case Conferences held for each active client at least once every six (6) months.
12. Agency shall have 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 client admission
    • Follow-up contacts
    • Continuity of services in the event of a facility emergency
13. Agency will have a policy and procedure for clients to follow if they need after-hours assistance.
14. There will be written policies and procedures for staff to follow for psychiatric or medical emergencies.
15. Policies and procedures define emergency situations, and the responsibilities of key staff are identified.

LIMITATIONS

Funds may not be used for inpatient detoxification in a hospital setting, unless the detoxification facility has a separate license.

SOURCE CITATION

• RWHAP Part B Program National Monitoring Standards, Section C.15
• PCN 16-02