Ryan White Part B Programmatic Site Visit Monitoring Tool
1. District Information
Location Name: District: Liaison Name: Site Visit Date: GIA Amount: Report Date:
2. Part B Reports: Submitted correctly, completely, and on time Programmatic/Quality Reports Fiscal Reports Yes No N/A Yes No N/A 1st Quarter (Apr-Jun) 2nd Quarter (Jul-Sep) 3rd Quarter (Oct-Dec) 4th Quarter (Jan-Mar) Notes:
3. Consortium Requirements Ye s No N/A Grievance Policy (English & Spanish) posted in sites where clients receive services Consortium meeting calendar submitted to state HIV office Minutes of Consortium meetings submitted to state HIV office Copy of Grievance Policy in English and Spanish submitted to state HIV office Signed Consortium Agreements & Assurances submitted to state HIV office Notes:
4. Provider Contract Requirements Ye s No N/A Documentation provided to Liaison of annual site visit to site(s) where subcontracted services are provided Memoranda of Agreement/Understanding exist with community partners Copies of MOA/MOU provided to Liaison Contracts have been executed for subcontracted client services
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool Copies of contracts provided to Liaison Notes: 5. Security: Patient Information Ye s No N/A Physical setup of clinic prevents unauthorized access to files Client charts are secured under lock Electronic records are password protected Client lab work is secured under lock Notes:
6. Confidentiality Ye s No N/A Procedures to protect client confidentiality are documented and reviewed by Liaison Signed confidentiality agreements on file for all staff & reviewed by Liaison Notes:
**7. Fiscal Requirements Ye s No N/A Fee schedule established for client services Fee schedule provided to Liaison Sliding fee scale policy implemented Mechanism in place to track client charges and caps on charges Mechanism in place to bill third party payors to ensure Ryan White is the payor of last resort Mechanism in place to ensure program income is used for program expenses “Certification Regarding Employees Who Work For Programs That Receive Federal Funding” provided to Liaison for all staff funded 100% by Part B **Documentation of providers’ Medicaid certification provided for review: Notes (describe mechanisms in place):
8. Physical Site Review Ye s No N/A Clinic/Offices where clients are provided services are clean, handicap accessible, and located to minimize client transportation barriers (close to public transportation, easy to find, convenient parking, etc.) Clinic/offices are designed to provide adequate space for providing services and maintain client confidentiality Notes:
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool **9. Outpatient/Ambulatory Care Health districts must provide a list of all health care professionals providing Outpatient/Ambulatory Care services funded by Ryan White Part B. This list must include all physicians, physician’s assistants, clinical nurse specialists, nurse practitioners, and registered nurses providing services funded by Ryan White Part B. Copies of current professional licenses for each health care professional must be provided for review. Yes No N/A Is district funded by Ryan White Part B in this service category? Current list of all Part B funded health care professionals provided Current licenses reviewed for all listed health care professionals Names of any health care providers whose licenses were not reviewed or were not current:
Notes:
**10. Mental Health Health districts must provide a list of all mental health professionals providing Mental Health services funded by Ryan White Part B. This list must include psychiatrists, psychologists, and licensed clinical social workers providing mental health services funded by Ryan White Part B. Copies of current professional licenses and/or certifications for each mental health professional must be provided for review. Yes No N/A Is district funded by Ryan White Part B in this service category? Current list of all Part B funded mental health professionals provided Current licenses/certifications provided for all listed mental health professionals Names of any mental health professionals whose license was not reviewed or was not current:
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool Notes:
**11. Medical Nutrition Therapy A. Health districts must provide a list of all licensed registered dietitians providing Medical Nutrition Therapy services funded by Ryan White Part B. Copies of current professional licenses for each licensed registered dietitian professional must be provided for review. B. Health districts must provide access to client files for review to ensure that services provided and dates of services are documented in client files. Yes No N/A Is district funded by Ryan White Part B in this service category? Current list of all Part B funded licensed registered dietitians provided Current licenses/certifications provided for all listed licensed registered dietitians Names of any licensed registered dietitians whose license was not reviewed or not current:
Number of clients receiving at least one service in the previous 12 months:
Number of files reviewed for documentation of Medical Nutrition Therapy:
Number of client files with documentation of services provided:
Number of client files with dates of service documented: Notes:
**12. Emergency Financial Assistance Ye s No N/A Is district funded by Ryan White Part B in this service category? Emergency Financial Assistance funds are allocated into subcategories of utilities, housing, medications, and groceries/food.
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool Documentation of tracking of EFA expenditures within subcategories: **Health district has written policies specifying limits on amounts and frequency of assistance to a single client. Notes:
**13. Food Bank/Home Delivered Meals Ye s No N/A Is district funded by Ryan White Part B in this service category? The service provider is licensed and certified as required by applicable local, state or federal laws: Copies of any required licenses and/or certifications provided: Health district has written policy that funds are used only for purchase of allowable non-food items (personal hygiene products, household cleaning supplies, and water filtration/purification systems in communities where issues with water purity exist). Copy of policy provided: Health district includes limitations on purchase of allowable non-food items in all contracts for subcontracted Food Bank/Home Delivered Meals services. Health district has system in place to monitor expenditures to ensure compliance with requirements for non-food items. Notes:
**14. Health Education/Risk Reduction Ye s No N/A Is district funded by Ryan White Part B in this service category? Verify that clients have been educated and counseled on HIV transmission and risk reduction Verify that clients have been provided information about available medical and psychosocial support services Notes:
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool **15. Medical Transportation Ye s No N/A Is district funded by Ryan White Part B in this service category? Health district maintains documentation that tracks services provided (van, public transportation, taxi, or gas voucher) and purpose of travel: Documentation of service tracking provided for review: Health district has written guidelines specifying requirements for receiving medical transportation services: Copy of guidelines provided for review: Health district has written guidelines specifying requirements for the provision of transportation services for any subcontracted transportation providers Copy of guidelines provided for review: Notes:
**16. Psychosocial Support Services Ye s No N/A Is district funded by Ryan White Part B in this service category? Verify funds are being used only for allowable services Verify that no funds are being used for the provision of nutritional supplements Funds for pastoral care/counseling meet all requirements Pastor care/counseling is available to all clients regardless of religious affiliation Notes:
**17. Treatment Adherence Counseling Ye s No N/A Is district funded by Ryan White Part B in this service category? Services are provided by non-medical personnel Services are provided outside of the Medical Case Management and clinical setting Information on services provided is documented in clients’ files Notes:
Chart Review Summary Explanation of Ratings: Unacceptable: 0-50% of the charts reviewed had the required documentation Conditionally Acceptable: 51-75% of the charts reviewed had the required documentation Meets or Exceeds Expectations: 76-100% of the charts reviewed had the required
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool documentation Meets or Exceeds Conditionally Expectations Acceptable Unacceptable Appropriate documentation of HIV status on file Initial financial screening conducted at intake Six month recertifications completed in a timely manner Documentation of income Fee levels established for clients Screened for other payors at initial intake and recertifications Eligible patients are referred for enrollment in Medicaid, Medicare, etc. Client Rights and Responsibilities are updated annually
Technical Assistance Requests
2012-2013 Ryan White Part B Programmatic Site Visit Monitoring Tool