Grantee Name: Region: Reviewer Name: Sites Evaluated: ____ ____ ____ Regional Project Officer: Dates of Review: 8: Project Management and Administration All projects receiving Title X funds must provide services of high quality and be competently and efficiently administered. 8.1: Voluntary Participation Section 8.1.1: Voluntary and Non-Coercive Services Family planning services are to be provided solely on a voluntary (Sections 1001 and 1007, PHS Act; 42 CFR 59.5 (a)(2)). Clients cannot be coerced to accept services or to use or not use any particular method of family planning (42 CFR 59.5 (a)(2)). Grantees should institutionalize administrative procedures (i.e., staff training, clinical protocols, and consent forms) to ensure clients receive services on a voluntary basis. Reviewer Code Met Not Met Sub-Recipient/ Service Site Score Implementation Strategy Comments A Grantee has written policies and procedures that specify services are to be provided on a voluntary If the grantee does not provide all services directly, and for services to be performed, the grantee’s policies and procedures and contract language specifies that all sub-recipients provide services solely on a voluntary basis. A Site A: ___ Site B: ___ Site C: ___ Documentation at service sites demonstrates (e.g., staff circulars, training curriculum and records) staff has been informed at least once during the current project period that services must be provided on a voluntary basis. contracts
F Site A: ___ Site B: ___ Site C: ___ Documentation at service sites demonstrates that clients’ services remain confidential when billing and collecting payments. Section 8.4.9: Voluntary Donations Voluntary donations from clients are permissible; however, clients must not be pressured to make donations, and donations must not be a prerequisite to the provision of services or supplies. Reviewer Code Met Not Met Sub-Recipient/ Service Site Score Implementation Strategy Comments F Grantee policies and procedures indicate if the project service sites may request and/or accept donations. F Site A: ___ Site B: ___ Site C: ___ Onsite documentation and observation demonstrates that clients are not pressured to make donations and that donations are not a prerequisite to the provision of services or supplies. Observation may include signage, financial counseling scripts, or other evidence. 8.4 Additional Comments: 8.5: Project Personnel Title X grantees must have approved personnel policies and procedures. Section 8.5.1: Personnel Policies Grantees and sub-recipients are obligated to establish and maintain personnel policies that comply with applicable Federal and State requirements, including Title VI of the Civil Rights Act, Section 504 of the Rehabilitation Act of 1973, Title I of the Americans with Disabilities Act, and the annual appropriations language. Reviewer Code Met Not Met Sub-Recipient/ Service Site Implementation Strategy Comments A Grantee has written policies and procedures in that provide evidence that there is no discrimination in personnel administration at its organizations and within its sub-recipient network. These policies should include, but are not to be limited to, staff recruitment, selection, performance evaluation, promotion, termination, compensation, benefits, and grievance procedures. A There is evidence that the grantee monitors sub-recipients to ensure compliance with this requirement.
A Site A: ___ Site B: ___ Site C: ___ A patient bill of rights or documentation which outlines client’s rights and responsibilities. 9.2 Link to QFP: Cultural Competency and Client Dignity A core premise of Recommendations for Providing Quality Family Planning Services is that quality services are client-centered, which includes providing services in a respectful and culturally competent manner. Reviewer Code Evidence of Quality Indicator in Place? Quality Indicator Comments A Yes No The grantee needs assessments or other documentation (including those of the sub-recipients) describe populations that may be in need of culturally competent care. A Yes No The grantee has written policies and procedures that require their sites and sub-recipients to receive training in culturally competent care. This should include how to meet the needs of the following key populations: LGBTQ, adolescents, individuals with limited English-proficiency, and the disabled. A Yes No Documentation (e.g., training records) that demonstrates staff have received training in providing culturally competent care to populations identified in the needs assessment. A Yes No Observation of the clinic environment demonstrates that it is welcoming (i.e., Privacy, cleanliness of exam rooms, ease of access to service, fair and equitable charges for services including waiver of fees for “good cause,” language assistance). A Yes No Client surveys document that clients perceive providers and other clinic staff to be respectful. A Yes No + Additional quality indicators, best practices, or highly innovative approaches If Yes, describe: 9.2 Quality Assessment Score: Exceptional (All 5 Quality Indicators Evident + Best Practices In Place) Good (3 – 5 Quality Indicators Evident) Fair (1 – 2 Quality Indicators Evident) 0 Quality Indicators Evident 9.2 Additional Comments: 9.3: Non-Discriminatory Services
C Yes No A review of clinic/pharmacy records demonstrates no of any contraceptive method that is routinely offered occurred during the past 6 months. C Yes No Documentation that clinical staff has participated in training on QFP (e.g., training available from the Title X National Training Centers). A Yes No A review of the service site’s FPAR data demonstrates that the proportion of males receiving family planning services is close to or above the national average. C Yes No A review of medical records confirms that adolescents have been counseled about abstinence, the use of condoms and other contraceptive methods, including LARCs. A / C Yes No + Additional quality indicators, best practices, or highly innovative approaches If Yes, describe: 9.8 Quality Assessment Score: Exceptional (All 5 Quality Indicators Evident + Best Practices In Place) Good (3 – 5 Quality Indicators Evident) Fair (1 – 2 Quality Indicators Evident) 0 Quality Indicators Evident 9.8 Additional Comments: 9.9: Durational Residency Requirements Services must be provided without the imposition of any durational residency requirement or requirement that the client be referred by a physician (42 CFR 59.5(b)(5)). Reviewer Code Met Not Met Sub-Recipient/ Service Site Score Implementation Strategy Comments A The grantee has a written policy stating that sub-recipient and service must provide services without the imposition of any durational residence requirement or a requirement that the client be referred by a physician. A Site A: ___ Site B: ___ Site C: ___ Written clinic policies explicitly address this requirement. 9.9 Additional Comments: