h. Provider must demonstrate willingness to provide services to individuals regardless of gender, sexual orientation, religion, race, or ability to pay. Policy statement posted at agency, including in intake materials, if any, and on file at agency as examined by grantee Policy statement visibly posted at agency Policy and procedures 2. HIV Continuum of Care a. Providers must establish formal collaborative agreements with HIV and other service organizations. Memoranda of Agreement or Memoranda of Understanding b. Providers must inform consumers of the various HIV services and resources available throughout the state. Informational flyers, handouts, resource manuals, literature Documentation in consumer records of resources given c. Providers must have a resource referral and tracking system with identified HIV and other service providers. Referral tracking system for each service category 3. Staff Requirements a. Providers must have written personnel policies and procedures. Policies and procedures b. Providers must offer to staff and contracted service providers their job descriptions that address minimum qualifications, core competencies, and job responsibilities. Position descriptions c. Providers must ensure that services are provided in a culturally-competent, compassionate, non- judgmental, and comprehensible manner. Training/in-service certificates/sign-in sheets Staff interview Consumer satisfaction survey Consumer grievances
STANDARD MEASURE Risk Assessment Accident / Incident Reporting Provider must ensure that staff and contracted service providers are trained and following the safety and emergency procedures. c. Providers must follow recommended Occupational Safety and Health Administration (OSHA). Policies and procedures Site visit observation Training certificates and/or sign-in sheets Staff interview d. Providers must follow the Association for Professional in Infection and Epidemiology Guidelines (APIC) and/or Society for HealthCare Epidemiology of America (SHEA) guidelines in caring for immune-compromised individuals. Policies and procedures Site visit observation Training certificates and/or sign-in sheets Staff interview 5. Consumer Eligibility and Recertification Requirements a. Providers must ensure that Ryan funds are used as a payer of last resort. Policies and procedures Documentation in consumer records of accessing resources from other payers b. Providers must verify proof of HIV status, income, residency, and insurance in accordance with the Charlotte TGA Eligibility requirements. Policies and procedures Documentation in consumer records of established eligibility and recertification within specified timeframes c. Proof of HIV status must be established within 30 business days of intake. Policies and procedures Documentation in consumer records of established HIV status within specified timeframe d. Provider must screen clients on an ongoing basis for eligibility and enrollment in insurance programs such as Medicaid, Medicare, private/commercial insurance, or other third-party payer program. Policies and procedures Documentation in consumer records of benefits counseling/enrollment Clients must be reassessed every 6 months to determine continued eligibility for Ryan White services Policies and procedures Documentation in consumer records 6. Intake a. Providers must screen consumers into appropriate Ryan service categories as determined by presenting needs. Documentation in consumer records of screening for appropriate Ryan White services party
STANDARD MEASURE Providers must have releases of information that, at minimum, includes information regarding: To what/whom information will be released, including name of organization or person (emergency contact), address, etc. What specific information will be released Time-limits for releases to not exceed 1 year Printed name and signature of consumer/legal guardian Signature of a witness Releases of information are not valid once a consumer is discharged from services. Release of Information form Documentation in consumer records of signed and updated releases of information before disclosures are made Within 30 business days of completing intake, providers must review with consumer and obtain signed documentation of the following consents and related documentation: Consent to Serve form Confidentiality Procedures, including HIPAA Consumer Rights and Responsibility Grievance process Documentation in consumer records of signed documentation 8. Discharge A discharge from services must occur if any of the following criteria is met: Completion of services Consumer’s death Verification of HIV positive status cannot be obtained within 30 business days of intake Verification of eligibility cannot be obtained The consumer/legal guardian has requested the case be closed Relocation of consumer outside of the provider’s geographic service area Inability to contact the consumer for more than 90 calendar days The consumer’s needs are more appropriately addressed through other providers The consumer exhibits acts of abuse towards staff, property or services Documentation in consumer records that discharge criteria was followed b. Providers must notify consumers when they are being discharged. Documentation in consumer records of consumers being notified of discharge
STANDARD MEASURE 9. Consumer Satisfaction Providers must establish evaluation methods to assess consumer satisfaction and receive feedback on services using any of the following methods: Consumer Advisory Board Consumer satisfaction survey Suggestion box or consumer input mechanism Focus groups and/or public meetings Consumer Advisory Board meeting notes/minutes Consumer satisfaction survey/results Visual verification of suggestion box or other consumer input mechanisms during site visit Notes or reports from focus groups and/or public meetings b. Providers must use results from evaluation methods to improve service delivery. Quality Improvement Plan Modification to service delivery policies and procedures based on feedback Inclusion of consumer feedback in internal training/staff communications
STANDARD MEASURE Purpose of the comprehensive client needs assessment and other pertinent information Client must include documentation that the following was discussed with the client: Eligibility and participation in other HIV/AIDS program/services Financial information Medical history and current health status Client adherence to treatment Social information Emotional/mental health status Documentation on client records Case management assessment and reassessment forms must be used for initial comprehensive assessment and reassessment of client needs Documentation on client records 6. Individualized Care Plan Client must participate in the development of care plans Documentation on client records Care plans must be completed within 15 days of the client’s referral to the case management agency Documentation on client records Provide clients a choice of service providers during the development of the individualized care plan Documentation on client records 7. Service Coordination a. The case manager must communicate with other service providers to remove barriers to client linkage to service Documentation on client records 8. Monitoring and Service Plan Revision a. The case manager must determine the extent of follow-up needed on each client to effectively address unmet needs. Documentation on consumer records b. Care plan must be re-evaluated and revised quarterly by the case manager and client to ensure provisions are adequate to the current state of HIV infection and client needs Documentation on consumer records
Referrals should be responded to within 3 business days of their initial contact with the office Documentation on client records Active must reflect a face-to-face visit conducted on a semi-annual basis Documentation on client records Identified client needs must be addressed within 7 working days Documentation on client records Clients will have access to a case manager during normal business hours Documentation on client records Clients must be offered the opportunity to have a home visit on an annual basis Documentation on client records Clients must be notified in writing within 30 days of a change in case manager Documentation on client records Messages must be returned by case management staff within 24 business hours Documentation on client records Case managers must maintain up-to-date documentation on all activities with, or on behalf of clients Documentation on client records Case managers must ensure that a copy of a client’s entire record is sent to the receiving agency within 10 working days of a client’s request to change case management providers Documentation on client records
STANDARD MEASURE c. The provider must make appropriate referrals to other transportation resources if consumers do not meet the criteria for medical transportation. Documentation in consumer records of referrals 2. Service Delivery (for van services) a. Drivers must have, at minimum, a valid Class D license. The provider must verify the driving records of all drivers once a year. Copy of current Class D License Documentation of annual review of records b. All vehicles used in medical transportation must have appropriate, updated registration and insurances. Copy of vehicle registration and insurance c. All vehicles used in medical transportation must have regular maintenance and inspections according to the vehicle’s maintenance schedule. Policies and procedures for routine service and inspection Documentation of vehicle maintenance history d. All vehicles used in medical transportation must have standard safety equipment in compliance with federal and state laws. Policies and procedures on driver and passenger safety e. The provider must ensure that medical transportation services are available to those with disabilities who may require assistive devices. Site visit observation that confirms presence of assistive equipment Documentation that proper maintenance of transport mechanisms are available and documented f. The provider must curb to curb transportation services to consumers with disabilities. Policies and procedures Notification to consumer of limitation of drivers on file g. The provider must ensure that medical transportation services are available for consumers with outside of normal business hours. Policies and procedures for accommodating consumers between 5 p.m. and 7 a.m.