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Universal Standards

Universal Standards print version

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

The Universal Standards listed below apply to all service categories funded under the Ryan White Part B Program for direct care service providers. These Universal Standards are taken directly from the HRSA Standards listed in the Part B HIV/AIDS Bureau (HAB) National Monitoring Standards (NMS) and expanded to include DSHS program requirements for all Ryan White Part B and State Service sub-recipients.

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

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

  1. Documentation of Consumer Advisory Board (CAB) and public meetings – minutes, or
  2. Documentation of existence and appropriateness of a suggestion box or other client input mechanism, or
  3. Documentation of content, use, and confidentiality of a client satisfaction survey or focus groups conducted at least annually
HRSA/DSHS STANDARD: Provision of services regardless of an individual’s ability to pay for the service
2 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
HRSA/DSHS STANDARD: Provision of services regardless of the current or past health condition of the individual to be served
3 Documentation of eligibility and clinical policies to ensure that they do not: (1) permit denial of services due to preexisting conditions; (2) permit denial of services due to non HIV-related conditions (primary care); or (3) provide any other barrier to care due to a person’s past or present health condition.
HRSA/DSHS STANDARD: Provision of services regardless of English proficiency or other barriers to communication
4 Provide culturally and linguistically appropriate goals and policies that ensure management accountability that language assistance is provided to individuals who have limited English proficiency or other communication needs at no cost to them in order to facilitate timely access to all health care and services.
5 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.
HRSA/DSHS STANDARD: Provision of services in a setting accessible to low-income individuals with HIV
6 A facility that is handicapped accessible, accessible by public transportation.
7 Policies and procedures that provide, by referral or vouchers, transportation if facility is not accessible to public transportation.
8 No policies that may act as a barrier to care for low-income individuals.
HRSA/DSHS STANDARD: Efforts to inform low-income individuals of the availability of HIV-related services and how to access them
9 Availability of informational materials about sub-recipient’s services and eligibility requirements such as: newsletters; brochures; posters; community bulletins; or any other types of promotional materials.
HRSA/DSHS STANDARD: Use of Telehealth, Telemedicine, and Teledentistry
10 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. 
IMPOSITION AND ASSESSMENT OF CLIENT CHARGES
HRSA/DSHS STANDARD: Publicly available schedule of charges
11 Establish, document, and have available for review: (Pilot Measure 2024-2025)
  • A written imposition of charges policy that includes a current schedule of charges. Placement on the schedule of charges must be based on a client’s individual annual gross income, although client eligibility for services may be based on family income. 
  • Fees charged by the provider and payments made to that provider by clients. 
  • Process for obtaining and documenting client charges and payments through an accounting system manual or electronic. 
12 Documentation that a schedule of charges is publicly available. (Pilot Measure 2024-2025)
13 Policies and procedures in place to inform clients of their responsibility to track their expenditures to ensure that they are not charged beyond the annual cap on charges based upon their federal poverty level (FPL). (Pilot Measure 2024-2025)
HRSA/DSHS Standard: No charges are imposed on clients with individual incomes less than or equal to 100 percent of the FPL
14 Policies and procedures document that: (Pilot Measure 2024-2025)
  • The schedule of charges does not allow clients with individual annual gross income less than or equal to 100 percent of FPL to be charged for RWHAP services. 
  • RWHAP clients with individual annual gross incomes less than or equal to 100 percent FPL are not charged for RWHAP services.
HRSA/DSHS Standard: Charges imposed for RWHAP services on clients with individual annual gross incomes greater than 100 percent of the FPL are determined by the schedule of charges
15 Policies and procedures limit annual aggregate charges in a calendar year for RWHAP services based on the percent of the client’s annual individual gross income, as follows: (Pilot Measure 2024-2025)
  • Five percent for patients with individual annual gross incomes between 101 percent and 200 percent of the FPL. 
  • Seven percent for patients with individual annual gross incomes between 201 percent and 300 percent of the FPL. 
  • Ten percent for patients with individual annual gross incomes greater than 300 percent of the FPL.
16 Imposition of charges policy includes: (Pilot Measure 2024-2025)
  • A process for alerting the billing system that the client has reached the cap and should not be further charged for the remainder of the year. 
  • A client eligibility determination process to establish individual fees and limitations on annual aggregate charges for RWHAP services. 
  • A process for tracking all RWHAP charges or medical expenses, inclusive of enrollment fees, deductible, copayments, etc., if applicable
ELIGIBILITY DETERMINATION
HRSA/DSHS STANDARD: Eligibility determination and reassessment of clients to determine eligibility as specified by the jurisdiction (in this case State) or ADAP
17 Document that the process and timelines for establishing initial client eligibility, assessment, and recertification takes place at a minimum of every six months.
18 Document that all staff involved in eligibility determination have participated in required training.
HRSA/DSHS STANDARD: Ensure military veterans with Department of Veterans Affairs (VA) benefits are deemed eligible for Ryan White services
19 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.”
HRSA/DSHS STANDARD: Payor 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
20 Agencies have written policies or protocols for ensuring RWHAP Part B and State Services funds are used as PoLR for eligible services and eligible clients.
HRSA/DSHS STANDARD: Vigorous Pursuit of Third-Party Payers
21 Sub-recipients have policies in place and maintain documentation that agency educated client on available health insurance options in area.
22 Sub-recipients 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.
ANTI-KICKBACK STATUTE
HRSA/DSHS STANDARD: Demonstrated structured and ongoing efforts to avoid fraud, waste, and abuse (mismanagement) in any federally funded program
23 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
STANDARD: 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
24 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.
QUALITY MANAGEMENT
HRSA/DSHS STANDARD: Implementation of a Clinical Quality Management (CQM) Program 
25 Documentation that the subrecipient is actively participating in the regional Clinical Quality Management (CQM) Program, including an agency-level CQM plan or inclusion in a regional CQM plan with the following elements: (Pilot Measure 2024-2025)
  • Performance measurement per HRSA Policy Clarification Notice (PCN) 15-02.
  • Focus on improvement to one or more of the following Ryan White Part B CQM domains: improving access to care and support services, improving health outcomes, improving the client or patient experience, or reducing health disparities.
OTHER SERVICE REQUIREMENTS
HRSA/DSHS STANDARD: 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 
26 Documentation that written referral relationships exist between Part B service providers and key points of entry.
PROHIBITION ON CERTAIN ACTIVITIES
HRSA/DSHS STANDARD: 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)
27 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).
28 Where vehicles were purchased, review of files for written permission from GMO.
HRSA/DSHS STANDARD: Lobbying Activities: Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel
29 Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel.
30 Include in personnel manual and employee orientation information on regulations that forbid lobbying with federal funds. 
HRSA/DSHS STANDARD: Direct Cash Payments: No use of Ryan White program funds to make direct payments of cash to service recipients
31 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 copays and deductibles, food and nutrition).
HRSA/DSHS STANDARD: Employment and Employment-Readiness Services: Prohibition on the use of Ryan White program funds to support employment, vocational, or employment-readiness services
32 Prohibition on the use of Ryan White program funds to support employment, vocational, or employment-readiness services.
HRSA/DSHS STANDARD: 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 
33 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.
HRSA/DSHS STANDARD: 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
34 Documentation that Ryan White funds are not being used for programs related to sterile needles or syringe exchange for injection drug use.
HRSA/DSHS STANDARD: Additional Prohibitions
35 Documentation that no Part B funds are used to purchase or improve land, or purchase, construct, or permanently improve (other than minor remodeling) any building or other facility. (Pilot Measure 2023-2024)
 
SECTION 2: STATEWIDE PROGRAMMATIC STANDARDS
GENERAL HIV POLICIES AND PROCEDURES
Grievance Policies
36 Agency has a policy or procedure for handling client grievances.
Delivery of Client Services
37 Agency has written procedures to deal with clients who may be disruptive or uncooperative.
38 Agency has written procedures to deal with clients who are violent or exhibit threatening behavior. 
Non-Discrimination Policy
39 Agency has comprehensive non-discrimination policies, which prohibit discrimination on the basis of race, color, national origin, religion, sex, and any other non-discrimination provision in specific statutes under which application for federal or state assistance is being made.
Confidentiality Regarding Patient Information
40 All staff, management, and volunteers have completed a signed confidentiality agreement annually affirming the individual's responsibility for keeping client information and data confidential.
41 All staff, management, and volunteers have successfully completed confidentiality and security training.
Breach of Confidentiality
42 Agency has detailed policies outlining how to address negligent or purposeful release of confidential client information in accordance with the Texas Health and Safety Code and HIPAA regulations.
Child Abuse Reporting
43 Agencies will have detailed policies outlining how to address suspected child abuse in accordance with Texas law and DSHS policy.
44 Agencies have documented evidence of training provided to all staff on reporting child abuse.
Incarcerated Persons in Community Facilities
45 Agency has 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.
Conflict of Interest
46 Agency has written conflict of interest policies and procedures.
47 All employees and board members of the agency have completed and signed an annual Conflict of Interest Disclosure Form, which contains, at a minimum, the content in the sample provided by DSHS.
Personnel Policies and Procedures
48 Personnel and human resources policies are available that address new staff orientation, ongoing training plan and development, employee performance evaluations, and employee/staff grievances.
Required Training
49 49    Agency maintains documentation of staff trainings, conferences, and meetings to ensure program compliance.
50 Providers shall complete cultural competency training to include cultural awareness of youth and the aging population or relevant local priority populations based on epidemiological data and service priorities.
Take Charge Texas (TCT)
TCT Security Policy
51 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 TCT information is protected and maintained to ensure client confidentiality. (Pilot Measure 2023-2024)
TCT Data Managers Core Competencies
52 Agency has local policies and procedures in place relating to TCT and the data collected through TCT. (Pilot Measure 2023-2024)
CORE SERVICES ADDITIONAL POLICIES AND PROCEDURES
Outpatient/Ambulatory Health Services
53

Ensure that client medical records document services provided, the dates and frequency of services provided, that services are for the treatment of HIV.

Texas Administrative Code:
TITLE 22 EXAMINING BOARDS PART 9 TEXAS MEDICAL BOARD CHAPTER 165 MEDICAL RECORDS, RULE §165.1
54

Include clinician notes in client records that are signed by the licensed provider of services. 

Texas Administrative Code:
TITLE 22 EXAMINING BOARDS PART 9 TEXAS MEDICAL BOARD, CHAPTER 165 MEDICAL RECORDS, RULE §165.1
55

Maintain professional certifications and licensure documents and make them available to the Recipient on request. 

Texas Administrative Codes:
TITLE 22 EXAMINING BOARDS, PART 9 TEXAS MEDICAL BOARD, CHAPTER 163 LICENSURE, RULE §163.5 

TITLE 22 EXAMINING BOARDS
PART 11 TEXAS BOARD OF NURSING, CHAPTER 221 ADVANCED PRACTICE NURSES, RULE §221.4 

TITLE 22 EXAMINING BOARDS
PART 9 TEXAS MEDICAL BOARD, CHAPTER 185 PHYSICIAN ASSISTANTS, RULE §185.12
56

Standing Delegation Orders are available to staff and are reviewed annually, dated and signed.

Texas Administrative Code:
TITLE 22 EXAMINING BOARDS, PART 9 TEXAS MEDICAL BOARD, CHAPTER 193 STANDING DELEGATION ORDERS, RULE §193.2
57

Follow Texas Medical Board guidelines for client notification and posting of guidance to file complaints for in-person care and telemedicine (English and Spanish).  (Pilot Measure 2023-2024)

22 Texas Administrative Code §178.3 
58 Service providers shall employ clinical staff who are experienced regarding their area of clinical practice as well as knowledgeable in the area of HIV/AIDS clinical practice. Personnel records/resumes/applications for employment will reflect requisite experience/education.
59 All staff without experience with HIV/AIDS shall be supervised by an employee with at least one (1) year of experience. Reviewers will look for evidence of: (1) a policy that states the supervision requirements; (2) language in contracts/MOUs stating that this will occur; or (3) a verification process of staff and staff supervisors in personnel files.
60 When the subrecipient is utilizing OAHS funding to only pay for specialty visits or preventive care and screening that the primary clinic does not cover: (1) limitations of the use of funds is documented in the contract between the subrecipient and the Administrative Agency; and (2) the established guidelines are written into agency policies regarding the use of OAHS funds. (Pilot Measure 2023-2024)
Local AIDS Pharmaceutical Assistance Program (LPAP)
61 Agency has an LPAP policy that meets HRSA/HAB requirements.
62

Only authorized personnel dispense/provide prescription medication.  

Texas Administrative Code:
Title 22, Part 15, Rule: Rules §291.1 to  §293.3
63

Medications and supplies are secured in a locked area and stored appropriately.

Texas Administrative Code:
Title 22, Part 15, Rule: Rules §291.1 to §293.3
64 Agency has a system for drug therapy management, if applicable.
65 Policy for timeliness of services—prescriptions should be available and approved for LPAP assistance within 2 business days, per LPAP service standard.
66 MOUs ensuring cost efficient methods are in place.
67 MOUs ensure dispensing fees are established and implemented.
68

Pharmacy technicians and other personnel authorized to dispense medications are under the supervision of a licensed pharmacist.

Texas Administrative Code: 
Title 22, Part 15, Rule: Rules §291.1 to  §293.3
69

Active pharmacy license is onsite and is renewed every two years.

Texas Administrative Code:
Title 22, Part 15, Rule: §291.14 Pharmacy License Renewal
70

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.

Texas Administrative Code:
Title 22, Part 15, Rule: Rules §291.1 to §293.3
Oral Health Care
71 Oral health services are provided by general dental practitioners, dental specialists, dental hygienists, and auxiliaries and meet current dental care guidelines.
72 Oral health professionals providing the services have appropriate and valid licensure and certification, based on State and local laws.
73 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 local communities.
Early Intervention Services
74 Documentation that Part B funds are used for HV testing only where existing federal, state, and local funds are not adequate, and RW funds will supplement, and not supplant, existing funds for testing.
75 Documentation that individuals who test positive are referred for and linked to health care and supportive services.
76 Documentation that health education and literacy training is provided that enables clients to navigate the HIV system.
77 Documentation that EIS is provided at, or in coordination with, documented key points of entry.
78 Documentation that EIS services are coordinated with HIV prevention efforts and programs.
Health Insurance Premium and Cost-sharing Assistance
79 Agency has policy that outlines caps on assistance/payment limits and adheres to DSHS Policy 270.001 (Calculation of Estimated Expenditures on Covered Clinical Services).
80 Agency has policy that details the expectation for client contribution and tracks these contributions under client charges.
81 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. 
82 Agency has policies and procedures detailing process to make premium and out-of-pocket payments or IRS payments.
83 Where funds are used for copays of eyewear, agency must maintain documentation of the physician's statement that the eye condition is related to HIV. (Pilot Measure 2023-2024)
Home Health Care
84

Maintain on file and provide to the Recipient upon request, copies of the licenses of home health care workers.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE, PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES, CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE, RULE §97.11
85 Agency policy on operation and procedures to contact agency after hours for urgent or emergency care is current and evident.
Home and Community-based Health Services
86 Services are being provided only in an HIV-positive client’s home, or a day treatment or other partial hospitalization services program as licensed by the State. (Pilot Measure 2023-2024)
87

Maintain, and make available to Recipient, copies of appropriate licenses and certifications for professionals providing services.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE, PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES, CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER B CRITERIA AND ELIGIBILITY, APPLICATION PROCEDURES, AND ISSUANCE OF A LICENSE, RULE §97.11
88

License or certification is posted in a conspicuous place at the agency's main office.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE, PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES, CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, DIVISION 2 CONDITIONS OF A LICENSE, RULE §97.211
89 Documented policy on operation and procedures to contact agency after hours for urgent or emergency care.
90

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.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE, PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER D ADDITIONAL STANDARDS SPECIFIC TO LICENSE CATEGORY AND SPECIFIC TO SPECIAL SERVICES, RULE §97.401
91 Provider will document provision of in-service education to staff regarding current treatment methodologies and promising practices.
Hospice Services
92

Obtain and have available for inspection appropriate and valid licensure to provide hospice care.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE
PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES, CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER C MINIMUM STANDARDS FOR ALL HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, DIVISION 2 CONDITIONS OF A LICENSE, RULE §97.211
93 Maintain and provide the Recipient access to program files and client records.
94 Documentation that staff attended continuing education on HIV/AIDS and end-of-life issues.
95

Documentation that supervisory provider or registered nurse provided supervision to staff.

Texas Administrative Code:
TITLE 40 SOCIAL SERVICES AND ASSISTANCE, PART 1 DEPARTMENT OF AGING AND DISABILITY SERVICES, CHAPTER 97 LICENSING STANDARDS FOR HOME AND COMMUNITY SUPPORT SERVICES AGENCIES, SUBCHAPTER H STANDARDS SPECIFIC TO AGENCIES LICENSED TO PROVIDE HOSPICE SERVICES, DIVISION 4 HOSPICE CORE SERVICES, RULE §97.832 
96 Agency has a policy regarding reasons for refusal of referral.
97 Agency has a policy for patient discharge.
Mental Health Services
98 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.
99 MOUs are available for referral needs.
100 Policies/procedures in place for emergency/crisis intervention plan. (Pilot Measure 2023-2024)
101 If mental health services are provided in-house, agency has a policy for regular supervision of all licensed staff.
102 If mental health services are provided in-house, agency has a policy for regular supervision of all licensed staff.
103 Agency/provider has a discharge policy and procedure.
Medical Nutrition Therapy
104

Maintain and make available copies of the dietitian’s license and registration.

Texas Administrative Code:
TITLE 16, ECONOMIC REGULATION, PART 4, TEXAS DEPARTMENT OF LICENSING AND ADMINISTRATION, CHAPTER 116, DIETICIANS, RULE §116.52.
Texas Occupations Code:
TITLE 3, HEALTH PROFESSIONS, SUBTITLE M, REGULATION OF OTHER HEALTH PROFESSIONS, CHAPTER 701, DIETICIANS, RULE §701.351.
105 Staff has the knowledge, skills, and experience appropriate to providing food or nutritional counseling/education services. Personnel records/resumes/applications for employment will reflect requisite education, skills, and experience.
106 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. Documentation in personnel records of professional education.
107 Agency has a policy and procedure for determining frequency of contact with the licensed Registered Dietitian based on the level of care needed.
108 Agency has a policy and procedure on obtaining, tracking inventory, storing, and administering supplemental nutrition products, if applicable.
109 Agency has a policy and procedure on discharging a patient from medical nutrition therapy and the process for discharge/referral.
Medical Case Management, including Treatment Adherence
110 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.
111 Policies and procedures are in place for conducting MCM services, including data collection procedures and forms, data reporting.
112 Staff Qualifications: 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).
113 Required MCM trainings are documented in personnel files. 
114 The agency shall have policies/procedures for: Initial Comprehensive Assessment.
115 The agency shall have policies/procedures for: MCM Case Management Acuity Level and Client contact.
116 The agency shall have policies/procedures for: Care Planning.
117 The agency shall have policies/procedures for: Viral Suppression/Treatment Adherence. 
118 The agency shall have policies/procedures for: Referral and Follow-up.
119 The agency shall have policies/procedures for: Case Closure/Graduation.
120 The agency shall have policies/procedures for: Case Conferencing. 
121 The agency shall have policies/procedures for: Caseload Management.
122 The agency shall have policies/procedures for: Case Transfer (internal/external).
123 The agency shall have policies/procedures for: Probationary Period (new hire).
124 The agency shall have policies/procedures for: Staff Supervision.
125 The agency shall have policies/procedures for: Staff Training, including agency specific training.
Substance Abuse Outpatient Care
126 Maintain and provide provider licensure or certifications as required by the State of Texas.
127 If applicable, facilities providing substance use treatment services will be licensed by the Texas Department of State Health Services (DSHS) or be registered as a faith-based exempt program.
128 If applicable, agency will have documentation on site that license is current for the physical location of the treatment facility.
129 Documentation of supervision during client interaction with Counselors In Training (CIT) or Interns as required by the Texas Department of State Health Services (DSHS).
130 Documentation of professional liability for all staff and agency.
131 Provider agency must develop 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 patient admission
  • Follow-up contacts
  • Continuity of services in the event of a facility emergency
132 Agency will have a policy and procedure for clients to follow if they need after-hours assistance.
133 There will be written policies and procedures for staff to follow in psychiatric or medical emergencies.
134 Policies and procedures define emergency situations, and the responsibilities of key staff are identified.
SUPPORT SERVICES POLICIES AND PROCEDURES
Non-Medical Case Management
135 Maintain client records that include the required elements as detailed by the Recipient.
136 Provide assurances that any transitional case management for incarcerated persons meets contract requirements.
137 Policies and procedures are in place for conducting NMCM services.
138 Non-medical case managers will complete annual trainings per DSHS.
Child Care Services
139 Maintain documentation of child care services provided.
140 Maintain documentation of child care services provided.
141 Informal child care arrangements are in compliance with Recipient requirements.
142 Agency has a policy and procedure to address liability issues addressed through liability release forms designed to protect the client, provider, and the RW program.
Emergency Financial Assistance
143 Agency has a policy for documenting client eligibility, types of EFA provided, dates of EFA, and method of providing EFA.
144 Policies include medication purchase limitations.
145 Agencies providing EFA medications must develop policies and procedures to pursue all feasible alternative revenues systems (e.g., pharmaceutical company patient assistance programs) before requesting reimbursement through EFA.
Food Bank/Home-Delivered Meals
146 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 or certifications.
•    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.   
147 Food pantry program will meet regulations on Food Service Sanitation as set forth by Texas Department of State Health Services, Regulatory Licensing Unit, and local city or county health regulating agencies.
148 Current license(s) will be on display at site.
149 Records of local health department food handling/food safety inspections are maintained on file.
150 Agency will be licensed for non-profit salvage by the Texas Department of State Health Services Regulatory Licensing Unit and local city or county health regulating agencies.
151 Food Pantry must display "And Justice for All" posters that inform people how to report discrimination.
152 There must be a method to regularly obtain client input about food preference and satisfaction. Such input shall be used to make program changes.
153 Director of meal program must complete and pass Service Safety certification every three (3) years.
154 An application form is completed for each volunteer.
155 Each staff and volunteer position has written job descriptions.
156 Staff/Volunteer Education - Personnel files reflect completion of applicable trainings and orientation.
Health Education/Risk Reduction
157 Maintain records of services provided.
158 Documentation that supervisors reviewed 10 percent of each HE/RR staff client records each month.
Housing Services
159 Maintain documentation of services provided.
160 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.
161 Policies and procedures are written ensuring individualized written housing plans are consistent with Housing Policy.
162 Agency established payment methodology to issue direct payment to housing vendor or voucher system. 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.
163 Documentation of required initial training by staff as outlined for Housing Services completed within three (3) months of hire is located in personnel files. 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; and how to access housing programs.
164 Client eligibility for services, actual services provided by type of service, number of clients served, and level of services will be collected.
Linguistic Services
165 Policy outlining documentation procedures for the provision of linguistic services.
166 Maintain documentation showing that interpreters and translators employed with RW funds have appropriate training and hold relevant State and local certification.
Other Professional Services
167 Document services provided, including specific types of services.
168 Provide assurance that funds are being used only for services directly necessitated by an individual’s HIV status.
169 All licensed agency professional staff, contractors, and consultants who provide legal services shall be currently licensed by the State Bar of Texas.
170 Law students, law school graduates, and other legal professionals will be supervised by a qualified licensed attorney.
171 Agency-paid legal staff and contractors must complete two (2) hours of HIV-specific training annually.
172 Agency maintains system for dissemination of HIV/AIDS information relevant to the legal assistance needs of PLWH to staff and volunteers.
Medical Transportation Services
173 Maintain program files.
174 Maintain documentation that the provider is meeting stated contract requirements with regard to methods of providing transportation.
175 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.
176 Obtain HRSA and State approval prior to purchasing or leasing a vehicle(s).
177 Maintains voucher or token system(s).
Outreach Services
178 Document the design, implementation, priority areas and populations, and outcomes of outreach activities.
179 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.
180 Within the first (3) months of hire, 16 hours of training for new staff and volunteers shall be given, which includes, but is not limited to:
  • Specific HIV-related issues
  • Substance abuse and treatment
  • Mental health issues
  • Domestic violence
  • Sexually transmitted diseases
  • Partner notification
  • Housing Services
  • Adolescent health issues
  • Sex workers
  • Incarcerated/recently released
  • Gay/lesbian/bisexual/transgender concerns
181 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.
Psychosocial Support Services
182 Program staff conducting nutritional counseling will be trained to perform nutritional assessments.
183 All non-professional staff delivering support group facilitation must be supervised by a licensed professional.
Referral for Health Care/Supportive Services
184 Maintains program files.
185 Maintains client records that include required elements as detailed by the State.
186 Maintains documentation demonstrating that services and circumstances of referral services meet contract requirements.
Rehabilitation Services
187 Maintains client records that include the required elements as detailed by the State.
188 Rehabilitative services must be provided in an outpatient setting.  This may include ambulatory outpatient or home setting.  Contracts or Memoranda of Agreement/Understanding are in place with these agencies/individual providers to provide services in an outpatient setting.  
189 Direct supervision by a licensed/certified professional during client interaction is required if assistants or students are providing care.
190 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. Courses in HIV disease and transmission should be part of continuing education. 
Respite Care
191 Staff will have the skills, experience, and qualifications appropriate to providing respite care services. When the client designates a community respite care giver who is a member of his or her personal support network, this designation suffices as the qualification.
192 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.
193 Supervisors must review a 10 percent sample of each employee's records each month for completeness, compliance with these standards, and quality and timeliness of service delivery.
194 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, completeness and accuracy of records, compliance with standards, and effectiveness of service.
Substance Abuse Services (residential)
195 Maintain documentation of provider licensure or certifications as required by the State. This includes licensures and certifications for a provider of acupuncture services.
196 Documentation of staffing structure showing supervision by a physician or other qualified personnel.
197 Provide assurance that all services are provided in a short-term residential setting.
198 Maintain program files that document allowable services provided, and the quantity/frequency/modality of treatment services.
199 Agency maintains client records.
200 Agency will have documentation on site that license is current for the physical location of the treatment facility.
201 Documentation of supervision during patient interaction with Counselors in Training (CIT) or Interns as required by DSHS.
202 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 patient to a mental health program/counselor.

203

 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.
204 Documentation of professional liability for all staff and agency.
205 Agency shall have a policy and procedure to conduct Interdisciplinary Case Conferences held for each active patient at least once every six (6) months.
206 Agency must develop 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 patient admission
  • Follow-up contacts
  • Continuity of services in the event of a facility emergency
207 Agency will have a policy and procedure for patients to follow if they need after-hours assistance.
208 There will be written policies and procedures for staff to follow for psychiatric or medical emergencies.
209 Policies and procedures define emergency situations, and the responsibilities of key staff are identified.

 

HIV/STD Program

HIV/STD Program

HIV Medical and Support Service Categories