• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (737) 255-4300

    Email the HIV/STD Program

    Email data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

Quality Management Core Tool - Monitoring Instructions

The DSHS Routine Screening Project is required to report to the Centers of Disease Control and Prevention the following Performance Measures:

  • Report number of routine HIV tests conducted through the support of contracted healthcare programs, e.g. emergency departments, urgent care centers, primary care/community health centers, jails, etc.
  • Report a positivity rate of 0.5%
  • Ensure that 85% of HIV positive patients receive their test results
  • Ensure that 80% of HIV positive patients are confirmed to medical care
  • Ensure that 70% of HIV positive patients receive partner services
Monitoring Instructions
Review Criteria Instructions
I. Laws, Regulations and Policies Implemented (I), Partially Implemented (P), Not Implemented (N), Not Applicable (NA), Not Reviewed (NR)
1) Routine HIV screening is carried out according to the CDC's Revised Recommendations for HIV Screening for Adults, Adolescents and Pregnant Women in Health Care Settings. www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

Prior to the review, the monitoring staff will inquire as to whether changes have been made to agency policies/procedures and protocol/scope of work. If so, the agency shall provide copies of related policies to the monitor prior to the site visit. The following criteria should be included:

  • Definition of the population eligible for routine HIV screening.
  • Screening technology – conventional blood draw, rapid test or both.
  • Routine HIV Screening Protocols/Standing Delegation Orders.
  • Screening goals, including the number of tests to be performed and number of positive patients identified.

The monitoring staff will observe and document that:

  • Contractor adheres to the routine HIV screening policies/procedures, protocols/scope of work.
2) Consent for HIV screening is obtained in accordance with Texas law: Health and Safety Code 81.105—Informed Consent and 81.106—General Consent. Oral consent with documentation is allowed; a separate consent form is not required for HIV screening. www.statutes.legis.state.tx.us/Docs/HS/htm/HS.81.htm

Prior to the review, the monitoring staff will request current or updated policies related to general and informed consent and the forms/documentation used for the consent for or denial of HIV screening.

The monitoring staff will review:

  • Documentation used by staff to obtain consent, or denial, for HIV screening.
3) At least 85% of persons who test HIV positive receive their results, preliminary and confirmatory, in accordance with Texas law: Health and Safety Code 81.109. www.statutes.legis.state.tx.us/Docs/HS/htm/HS.81.htm

Prior to the review, the monitoring staff will request current/updated policies/procedures and ensure that:

  • Protocol identifies appropriate procedures and staff responsible for informing patients of their preliminary and confirmatory positive test results.

The monitoring staff will review and confirm with the Contractor:

  • The process for delivering preliminary and confirmatory positive test results.
  • If 85% or more of HIV positive patients receive their test results.
4) Reporting HIV test results to appropriate local/regional health authority is in accordance with Texas law: Health and Safety Code 81.043-44 and TAC 97.132-134: www.statutes.legis.state.tx.us/Docs/HS/htm/HS.81.htm and info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=5&ti=25&pt=1&ch=97&sch=F&rl=Y

Prior to the review, the monitoring staff will request current/updated policies/procedures to ensure reporting of positive HIV test results to the appropriate local/regional health authority.

The monitoring staff will review the following processes with the Contractor to ensure:

  • Positive test results are documented and reported to appropriate health authority within stated timeframe. For more information visit the DSHS website at www.dshs.texas.gov/hivstd/reporting.
  • Contractor has identified staff and back-up staff responsible for reporting positive HIV tests, including laboratory and provider reporting to appropriate health authority.
  • Contractor has developed a protocol that identifies staff responsible for initiating public health follow up and documentation.
II. Personnel  
5) Contractor reports to DSHS any changes or reassignment of staff funded through the HIV/ROUTN grant within 10 business days, and vacancies are filled within 90 days. Prior to the review, the monitoring staff will request the current/updated listing of HIV/ROUTN funded staff and verify all positions are filled, and/or vacant positions have been posted for employment through the Human Resources Department to ensure best efforts to fill vacancies within 90 days.
6) Maintain current Contact List with appropriate back-up staff to ensure timely communication between Contractor and DSHS. Prior to the review, the monitoring staff will request the current/updated Contact List including In-Kind and DSHS funded staff dedicated to the HIV/ROUTN Grant.
III. Training  
7) Routine HIV screening services are carried out by qualified staff, which is ensured through appropriate and on-going trainings.

The monitoring staff will review with the Contractor and determine if:

  • 85% or more of health care organization routine screening staff receive at least one training and/or continuing education opportunity relevant to the routine HIV screening project each year.
  • 85% or more of health care providers that participate in the routine screening project receive training about the health disparities and biases related to persons living with HIV.
  • 85% or more of the health care organization providers and staff are knowledgeable about the routine screening program, HIV transmission and prevention.
8) Contractor provides or has made available appropriate training for staff to perform routine HIV screening and related services.

The monitoring staff will review with Contractor a sample of trainings offered to routine HIV staff. Trainings may include, but are not limited to:

  • Annual training and educational updates related to HIV screening and services.
  • Annual cultural competency training.
  • Job skills training to staff in their respective roles to performing duties including:
    • Informing patients of routine HIV screening and obtaining consent;
    • Providing test results;
    • Referrals and confirming to medical care, providing or referring patients to prevention counseling, partner services and other related services; and
    • Reporting test results to local/regional health authority.
9) Contractor has a written orientation plan for new staff. A written orientation plan is designed to familiarize new staff with the goals, policies, and clinical operations related to the routine HIV screening project.
10) Contractor provides staff development based on employee needs.

The monitoring staff verifies that the staff development plan is based on an assessment of training needs, quality management indicators, and changing regulations or requirements.

Indicators for staff training needs assessments may be surveys, discussions at staff meetings, employee suggestions, and performance evaluations. Staff development is documented to include continuing education for professional staff.

IV. Screening and Linkage to Care  
11) At least 90% of all eligible patients, as defined by the Contractor, receive an HIV test, unless they decline.

Prior to the review, the monitoring staff will request the current/updated definition of the population eligible for routine HIV screening, the total number of patients potentially eligible to receive an HIV test, and screening goals including total number of HIV tests to be performed during the contract period and the number of new HIV positives patients identified, as defined in the Contract Program Attachment, Section II. Performance Measures.

The monitoring staff will review with Contractor staff to determine:

  • The percent of eligible patients that have had an HIV test to date.
  • If the Contractor is on tract to meet their screening goals, including number of new HIV positive patients identified.
12) At least 80% of persons who test HIV positive are confirmed to medical care and referred to other services, including housing, legal assistance and violence prevention.

Prior to the review, the monitoring staff will request current/updated protocols regarding confirming persons who test positive for HIV to medical care and other services.

The monitoring staff will review the following:

  • Protocols to ensure confirmation to medical care.
  • Protocols to ensure appropriate referrals are made and documented.
  • If 80% or more of HIV positive patients are confirmed to care.
13) Resources are available and procedures are documented to ensure that services are provided in a culturally and linguistically appropriate manner.

The monitoring staff will determine that services are provided in a culturally and linguistically appropriate manner, which may include but are not limited to:

  • Employment of personnel that speak the language/s of persons served.
  • Employment of the AT&T 24/7 Language Line Services.
  • Contracting with appropriate interpreters including signers for the deaf or hearing impaired.
  • Patient/client information/education materials are available in appropriate language/s.
V. Quality Assurance and Monitoring Plan  
14) Contractor has a written and implemented internal Quality Management (QM) Plan to evaluate all services, processes and operations including routine HIV screening within the agency on an annual basis that includes:

The QM Plan describes the process for conducting quality assurance activities including:

  • The schedule to conduct quality assurance activities (conducted annually at a minimum)
  • The procedure to be used (i.e. self-monitoring tool)
  • The actions to be taken based on the results.
  • Documentation of results, corrective actions taken for improving services and follow-up are reflected in reports to the QM Committee or in committee meeting minutes.
  • Note DSHS Contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance policies and basic standards will be assessed with the subcontracting entities.

QM Plan provides for an oversight process of sub-contractors, if applicable, for the routine screening services provided with DSHS funds.

a) QM Committee

The QM plan describes the establishment of a multidisciplinary QM Committee such as:

  • Key leadership of the organization including the Executive Director/Chief Executive Officer and Medical Director, as applicable, and key staff responsible for the routine screening project.
  • Meets at least quarterly or more often as needed
b) Screening/laboratory procedures QA Plan ensures maintenance of CLIA certification, if applicable, and/or screening is conducted in accordance with manufacturer’s instructions.
15) Contractor submits semi-annual and annual reports to DSHS by required submission date. This activity is part of the DSHS desk audit and will be reviewed with the Contractor as needed.
VI. Data Collection and Submission  
16) Contractor submits required data set to the Texas Department of State Services. The following criteria will be monitored: DSHS will prepare and share with contractor a retrospective report of data submission history.
a) Data is submitted by the 20th of each month 90% of the time. This activity is part of the DSHS desk audit performed monthly, which will be reported to the Contractor on a monthly basis. Contractor submits required program reports and data by the due date 90% of the time.
b) Data submission is accurate and complete. This activity is part of the DSHS desk audit performed monthly, which will be reported to the Contractor on a monthly basis.
VII. Financial  
17) Contractor submits financial reports to DSHS by required submission dates. These activities are part of the DSHS desk audit performed monthly, which will be reported to the Contractor on a quarterly basis
a) Vouchers are submitted no more than 30 days after services were delivered. This activity is part of the DSHS desk audit performed monthly, which will be reported to the Contractor on a quarterly basis.
b) FSRs are submitted by required due dates documented in the current contract. This activity is part of the DSHS desk audit; DSHS will follow-up with the Contractor as needed.
c) Expenditures are in accordance with line item budget. This activity is part of the DSHS desk audit; DSHS will follow-up with the Contractor as needed.
VIII. Sustainability  
18) Contractor has implemented systems changes to work towards sustainability of routine HIV screening as a standard of care.
  • Contractor has made policy and procedure changes to integrate routine HIV screening as a standard of care for all eligible patients.
  • All patients that are eligible will receive a HIV test, unless they decline.
  • All patients that are eligible for routine HIV screening are offered education materials about HIV transmission, prevention and services for persons living with HIV.
  • Information Technology has made or is working to incorporate changes that support data collection and reporting, project tracking including electronic medical records, lab orders and reporting, delivery of results and medical/services referrals, confirmation to medical care, and quality assurance improvement activities.
  • Quality Assurance Activities identify barriers encountered and actions taken to ensure routine HIV screening.
  • Contractor is working towards sustaining routine screening project when DSHS funds are longer available through pursuing billing and reimbursement for HIV screening.
  • Contractor is working with community partners through networks and collaborations to ensure sustainability of routine HIV screening.

Last updated October 3, 2017