Direct Contractor Site Visit Form: ______VDH Contract Number # ______
Review DateAgency Name
Agency Representatives / Name / Title
1.
2.
3.
4.
5.
Services Provided by Contractor
Opt/Ambulatory Health Services / ____Direct / ____ Third Party / Substance Abuse / ____Direct / ____ Third PartyPharmaceutical Assistance / ____Direct / ____ Third Party / Medical Transportation Services / ____Direct / ____ Third Party
Oral Health Care / ____Direct / ____ Third Party / Health Insurance Premium/Cost Sharing / ____Direct / ____ Third Party
Mental Health Services / ____Direct / ____ Third Party / Medical Case Management / ____Direct / ____ Third Party
Standard / Performance Measure / Agency Responsibility / Documentation / Comments /
I. Contractor Accountability
Structured and ongoing efforts to obtain input from clients in the design and delivery of services. / Documentation of Consumer Advisory Board and public meetings – minutes and/ or documentation of existence and appropriateness of a suggestion box or other client input mechanism and/or documentation of content, use, and confidentiality of a client satisfaction survey or focus groups conducted at least annually. / Is there a Consumer Advisory Board (CAB) or group and documentation of activities conducted? / Yes No NA
Are there regularly implemented client satisfaction survey tools, focus groups, and/or public meetings with analysis and use of results? / Yes No NA
Does the contractor have
assurances and agreements or MOUs with providers? / Yes No NA
Is there a visible suggestion box or client input mechanism that allows clients to provide immediate feedback on services? / Yes No NA
Provision of services regardless of an individual’s ability to pay for the service. / Contractor billing and collection policies and procedures do not:
· Deny services for non-payment;
· Require full payment prior to service or include any other procedure that denies services for non-payment. / Are there billing, collection, co-pay, and sliding fee policies that act as a barrier to providing services regardless of the client’s ability to pay? / Yes No NA
Is there a refusal of services policy/procedure or documentation of people refused services with reasons for refusal; including complaints from clients, review and decision reached? / Yes No NA
Demonstrated structured and ongoing efforts to avoid fraud, waste and abuse (mismanagement) in any federally funded program. / Employee Code of Ethics including:
· Conflict of Interest;
· Prohibition on use of contractor 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. / Are the following documented:
· Corporate Compliance Plan (required if providing Medicare- or Medicaid- reimbursable services); / Yes No NA
· Personnel Policies; / Yes No NA
· Code of Ethics or Standards of Conduct (including confidentiality agreements); / Yes No NA
· Bylaws and Board policies; / Yes No NA
· File documentations of any employee or Board Member violation of the Code of Ethics or Standards of Conduct; / Yes No NA
· Documentation of any complaint of violation of the Code of Ethics or Standards of Conduct and its resolution. / Yes No NA
Are job descriptions of all persons paid by grant funds available? / Yes No NA
Do time and effort sheets show percentage of time and funding source for employees? / Yes No NA
Number of forms reviewed. / # ____ forms for # ____ employees
Complete Time and Effort Section
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. / Documentation of guidance provided to the consortium by VDH regarding evaluation requirements including documentation that prohibit employees from receiving payments in kind or cash from suppliers and contractors of goods or services. / Does the contractor have policies and procedures to discourage soliciting cash or in-kind payments for:
· Awarding contracts, referring clients, purchasing goods or services and/ or submitting fraudulent billings and large signing bonuses? / Yes No NA
II. Monitoring Activities
Any contractor or individual receiving Federal funding required to monitor for compliance with federal requirements and programmatic expectations. / Development and consistent implementation of policies and procedures that establish uniform administrative requirements governing the monitoring of awards. / Meet contracted programmatic and fiscal requirements, including:
· Do financial reports contain expenditures by service category and use of Ryan White funds as specified by VDH? / Yes No NA
· Is there fiscal and program policies and procedures manuals that meet federal and Ryan White program requirements? / Yes No NA
Performance of fiscal monitoring activities to ensure that Ryan White funding being used for approved purposes. / Review of the following fiscal monitoring documents and actions:
· Fiscal monitoring policy and procedures;
· Fiscal monitoring tool or protocol;
· Fiscal monitoring reports;
· Fiscal monitoring corrective action plans;
· Compliance with goals of corrective action plans; / Has the contractor established policies and procedures to ensure compliance with federal and programmatic requirements? / Yes No NA
Corrective actions taken when contractor outcomes do not meet program objectives and VDH expectations, which may include:
• Improved oversight
• Redistribution of funds
• A "corrective action" letter / Review corrective action plans.
Review resolution of issues identified in corrective action plan.
Policies that describe actions to be taken when issues are not resolved in a timely manner. / Is there documented evidence that federal funds have been used for allowable services and spent in accordance with Federal requirements and Ryan White expectations? / Yes No NA
Are requests for payment correct and an accurate reflection of year to date expenditures? / Yes No NA / Note the months of invoices reviewed.
Are expenditures for each line item reasonable and show progress to expenditure of total annual allocation? / Yes No NA
Do line items on request for payment match approved budget line items? / Yes No NA
III. Assurances
VDH shall provide to Part B contractors definitions of allowable cost. / Signed contracts, contractor signed assurances, and/or certificates that define and specifically forbid the use of Ryan White funds for unallowable expenses.
· VDH review of contractor’s budgets and expenditures to ensure they do not include any unallowable costs. / Has the contractor submitted to VDH a record of signed assurances of the unallowable costs for the current contract year? / Yes No NA
How does the contractor ensure that budgets do not include unallowable cost?
Utilize the unallowable table to ensure that assurances include all Ryan White unallowable use of funds. See supplemental form.
IV. Program Income from Fees for Services
Use of Part B and third party funds to maximize program income from third party sources and ensure that Ryan White is the payer of last resort. Third party funding sources include:
• Medicaid
• State Children’s Health Insurance Programs (SCHIP)
• Medicare (including the Part D prescription drug benefit)
• Veteran’s Administration, and
• Private insurance (including medical, drug, dental and vision benefits) / Information in client files that includes proof of screening for insurance coverage:
· Documentation of policies and consistent implementation of efforts to enroll all eligible uninsured clients into Medicare, Medicaid, private health insurance or other programs;
· Documentation of procedures for coordination of benefits by VDH. / Are there policies and staff training on the requirement that Ryan White be the payor of last resort? / Yes No NA
Is there documentation that each client is screened for insurance coverage and eligibility for third party programs, and helped to apply for such coverage, with documentation of this in the client file? / Yes No NA
Ensure billing and collection from third party payers, including Medicare and Medicaid, so that payer of last resort requirement is met. / Inclusion in subcontractor agreements of language that requires billing and collection of third party funds.
Review of the Contractors systems and procedures:
· Billing and collection policies and procedures;
· Electronic or manual system to bill third party payors;
· Accounts receivable system for tracking charges and payments for third party payers. / Establish and consistently implement in medical offices and pharmacies:
· Billing and collection policies and procedures;
· Billing and collection processes and/or electronic system;
· Documentation of accounts receivable. / Review and comment on the billing and collection policy and procedure.
Contractor participation in Medicaid and certification to receive Medicaid payments required, unless waived by the Secretary of Health and Human Services / Review of each contractor’s individual or group Medicaid numbers:
· If contractor is not currently certified to receive Medicaid payments, documentation of efforts under way to obtain documentation and expected timing / Is there documentation of the contractor’s Medicaid status and certification to receive Medicaid payments? / Yes No NA
For contractors who don’t meet the requirement is there a waiver available or request for a waiver? / Yes No NA
V. Auditing Requirements
Recipients and sub-recipients of Ryan White funds that are institutions of higher education or other non-profit organizations (including hospitals) are subject to the audit requirements contained in the Single Audit Act Amendments of 1996 (31 USC 7501–7507) and revised OMB Circular A-133, with A-133 audits required for contractors receiving more than $500,000 per year in federal grants.
Review requirements for contractor audits
Review most recent audit (which may be an A-133 audit)to assure it includes:
· List of federal contractors to ensure that the Ryan White grant is included;
· Programmatic income and expense reports to assess if the Ryan White grant is included;
· Review of audit management letter if one exists;
· Review of all programmatic income and expense reports for payer of last resort verification by auditor. / Is there an annual audit (an agency audit or an A-133 audit, depending on amount of federal funds)? / Yes No NA
Is there a management letter from the auditor? / Yes No NA
Has the contractor submitted auditable reports? / Yes No NA / Year of last audit submitted to VDH______
Were there deficiencies found? / Yes No NA
Was a request for technical assistance submitted to VDH? / Yes No NA
Selection of auditor to be based on Audit Committee for Board of Directors (if nonprofit) policy and process. / Review of contractor financial policies and procedures related to audits and selection of an auditor. / Is there a financial policy that guides the selection of an auditor? / Yes No NA
VI. Quality Management
Implementation of a Clinical Quality Management (CQM) Program to:
· Assess the extent to which HIV health services provided to patients in care by this contractor are consistent with the most recent Public Health Service guidelines for the treatment of HIV/AIDS and related opportunistic infections
· Develop strategies for ensuring that services are consistent with the guidelines for improvement in the access to and quality of HIV health services
CQM program to include:
· A Quality Management Plan
· Quality expectations for contractors and services
· A method to report and track expected outcomes / Documentation that the Contractor has in place a CQM Program that includes, at a minimum:
· A QM Plan;
· Quality expectations for contractors and services;
· A method to report and track expected outcomes;
· Monitoring of contractor compliance with HHS treatment guidelines and the Part B Program’s (VDH) approved standards of care for each funded service category.
Review of CQM program to ensure that the contractors and/or contractors are carrying out necessary CQM activities and reporting CQM performance data. / Has the contractor participated in QM activities as contractually required that includes compliance with relevant service category standards of care? / Yes No NA
Is there documentation of review of QM reports from subcontractors? / Yes No NA
Is there documentation of collection and reporting of data for use in measuring performance? / Yes No NA
Is there documentation of review of QM report indicators? / Yes No NA
How has the contractor tracked and reported CQM outcomes?
VII. Miscellaneous
Does the Contractor have a Continuity of Operations Plan (COOP) that ensures continued access to essential services and care for all clients in case normal operations cannot continue? / Does the contractor have a Continuity of Operations Plan (COOP) or other written plan that ensures continued access to essential services and care for all clients in case normal operations cannot continue? / Yes No NA
Has the COOP been updated on an annual basis? / Yes No NA
Does the Contractor maintain current policies and procedures manuals?
Are Ryan White Part B services and responsibilities covered by these policies and procedures? / Is there a client confidentiality policy? / Yes No NA
Is there a client grievance policy? / Yes No NA
Is there a HIPPA policy and statement in client file? / Yes No NA
Screening of clients to determine eligibility for Ryan White services within a predetermined timeframe -
Reassessment of clients every 6 months to determine continued eligibility. / Documentation of eligibility required in client records, with copies of documents (e.g., proof of HIV status, residence, income eligibility based on the income limit established by VDH, and proof of insurance, uninsured or underinsured), using approved documentation. / How often does the contractor determine eligibility? / #______per year.
Site Visit Supplemental Forms
1. Employee Name and Title / Job Description on File / Current Resume on File / % FTE for RWPB / Does T&E Match % funded by RWPBYes No NA /
Yes No NA / ______% /
Yes No NA
T&E on File for the Following Months:
2. Employee Name and Title / Job Description on File / Current Resume on File / % FTE for RWPB / Does T&E Match % funded by RWPB
Yes No NA /
Yes No NA / ______% /
Yes No NA
T&E on File for the Following Months