UNIVERSALSTANDARDS

STANDARD / MEASURE
1. Accessto Services
a. Servicesmustbeprovidedirrespectiveofage,physical or mental challenges,creed,criminalhistory, historyofsubstanceuse,immigrationstatus,marital status,nationalorigin, race,sexualorientation,genderidentityandexpression,socioeconomic status,orcurrent/pasthealthconditions. /
  • Policiesandprocedures
  • Consumer grievances

b. Sub-recipients mustmaketranslatoror interpreterservicesavailableforthoseconsumerswhoneedthem. /
  • Policiesandprocedures
  • Programliteratureinapplicablelanguage

c. Services mustbeprovidedinaccordancewiththe Americanswith DisabilityAct guidelines. Formore information,refer to:ADA Guidelines. /
  • Policiesandprocedures

d. Sub-recipients must have written instructionsforconsumersonhowtoaccesstheSub-recipientsafterbusinesshours. /
  • Policiesandprocedures
  • Informationalflyers,handouts

2. HIV Continuum ofCare
a. Sub-recipients mustestablishformalcollaborativeagreementswith HIV and other serviceorganizations. /
  • MemorandaofAgreementorMemorandaofUnderstanding

b. Sub-recipients mustinformconsumersofthevariousHIV services and resourcesavailablethroughoutthe Transitional Grant Areas, (TGA) /
  • Informationalflyers,handouts,resourcemanuals,literature
  • Documentation in consumerrecords of resourcesgiven

c.Sub-recipients must have aresource referralandtracking systemwithidentifiedHIVandotherserviceSub-recipients. /
  • Referral tracking systemforeach servicecategory

3. Staff Requirements
a. Sub-recipients must havewrittenpersonnelpoliciesandprocedures. /
  • Policiesandprocedures

b. Sub-recipients must offer to staffandcontractedserviceSub-recipientstheirjobdescriptionsthataddressminimumqualifications,corecompetencies,and jobresponsibilities. /
  • Position descriptions

c. Sub-recipients must ensurethatservices are providedin an inclusively, linguistically, culturally-competent,compassionate,non-judgmental, age appropriate andcomprehensiblemanner. /
  • Training/in-servicecertificates/sign-insheets
  • Staffinterview
  • Consumer satisfactionsurvey
  • Consumer grievances

STANDARD / MEASURE
d.Sub-recipients mustensurethat staffandcontractedserviceSub-recipientsdeliveringdirectservices toconsumersmusthaveknowledgeofthe:
  • HIV/AIDSdiseaseprocess
  • EffectsofHIV/AIDS-relatedillnessesandco-morbiditieson consumers
  • Psychosocialeffectsof HIV/AIDSonconsumersandtheirfamilies/significantothers Provide PrEP Education and Resources
  • Currentstrategiesforthe managementofHIV/AIDS
  • HIV-relatedresourcesand services inHartford TGA
For moreinformation,referto:DHHSGuidelines. /
  • Documentationofthisknowledgevia formaleducation,trainings, or othermethods.Typesofdocumentationmayinclude,but isnot limitedto, medicaldegree,license/certification,trainingcertificates, transcripts.
  • Staffinterview

e. Sub-recipients mustensurethatprofessionalstaffandcontractedserviceSub-recipients follow, atminimum,establishedcodesofconductfor theirdiscipline.For paraprofessionalstaff,Sub-recipients mustensurethatanagencycodeofconduct isestablishedandthatstafffollow the code. /
  • CodesofConduct
  • Trainings/in-servicecertificates/sign-in-sheets
  • Staffinterview

f.Sub-recipients mustensurethatstaffandcontractedserviceSub-recipientsreceiveongoing supervisionthat is relevantandappropriate totheirprofessionalneeds. /
  • Supervisory/case conferencemeeting logs
  • Documentationofsupervisoryconsumerrecordreviews

g.Sub-recipients mustensurethatstaffandcontractedserviceSub-recipientsconductbusiness ina mannerthatensurestheconfidentialityofconsumersandfollowsestablishedprotocolsoutlined in theHealthInsurancePortabilityand AccountabilityAct (HIPAA)andthe Connecticut PublicHealthCode. /
  • Policiesandprocedures
  • Trainings/in-servicecertificates/sign-insheets
  • Staffsignatureson agency’sConfidentiality/HIPAAstatements
  • Staffinterview

4. Safetyand EmergencyProcedures
a. Sub-recipients must ensurethatservices are providedinfacilities thatare clean,comfortable, handicap accessibility andfreefrom hazards. /
  • Site visitobservation

b.Sub-recipients must havepolicies andproceduresforthefollowing
  • Physical Plant Safety
  • EmergencyProceduresthatincludefire,severeweather,andintruder/weaponthreat
  • Medical/Health CareCrisis
  • InfectionControlandTransmissionRisk
/
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

STANDARD / MEASURE
  • RiskAssessment
  • Accident/ IncidentReporting
Sub-recipients mustensurethatstaffandcontractedserviceSub-recipients are trainedandfollowing thesafetyandemergencyprocedures.
c. Sub-recipients mustfollowrecommendedOccupationalSafetyand HealthAdministration(OSHA) and Connecticut OccupationalSafetyandHealth Administration (CTOSHA)regulations. /
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

d. Sub-recipients mustfollowthe AssociationforProfessional in InfectionandEpidemiologyGuidelines(APIC) and/or Societyfor HealthCareEpidemiologyof America (SHEA) guidelinesincaringforimmune-compromisedindividuals. /
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

5. ConsumerEligibilityand RecertificationRequirements
a. Sub-recipients mustensurethatRyanWhitefundsareusedas a payeroflastresort. /
  • Policiesandprocedures
  • Documentation in consumerrecords of accessingresourcesfrom otherpayers

b. Sub-recipients must verifyproofof HIV status, income,residency,andinsurancein accordancewiththeDHHSRyanWhite ProgramGuidance#14-01. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofestablishedeligibilityand recertificationwithin specified timeframes

c.ProofofHIV statusmust beestablishedwithin 30businessdaysofintake. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofestablishedHIVstatus withinspecifiedtimeframe

d.If aconsumerisnotenrolled in aninsuranceplan,Sub-recipientsmustassist theconsumerwithbenefitscounselingandenrollmentintoanappropriateinsuranceplan. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofbenefitscounseling/enrollment

6. Intake
a. Sub-recipients must screenconsumersintoappropriateRyanWhite servicecategories asdetermined bypresentingneeds. /
  • Documentation in consumerrecords ofscreeningforappropriateRyanWhiteservices

b. Sub-recipients must completeanintakewithconsumerswithin 5businessdays of initialcontact. /
  • Documentation in consumerrecords of timelyintake withinspecified timeframes

STANDARD / MEASURE
c. Theintakeformmustinclude, atminimum,alltherequireddataelementsincluded in themostrecent RSR Manual. Themost recentversionofthis manualcanbefoundattheHRSA/HABTarget Center. /
  • Intakeform, with all therequireddataelements
  • Documentation in consumerrecords ofcompletedintakes

7. Consents and RelatedConsumerDocumentation
a. Sub-recipients mustobtainanddocumentconsumer’sinformedconsentfor provision ofRyanWhiteservices. /
  • Consent to Serve form

b. Sub-recipients mustensurethatconsumerrecordsaremaintained ina securelocation. /
  • Policiesandprocedures
  • Staffinterview
  • Site visitobservation

c.Sub-recipients must havepolicies andprocedurestoensurethatconsumers’medicalrecordsandotherpersonalhealthinformation are:
  • Securelyfaxed,emailed, or phoned
  • Safelytransported duringthe courseofconductingbusiness
  • Securelystored electronicallywith limitedaccess
  • Sharedwiththirdparties in accordancewithHIPAA
/
  • Policiesandprocedures
  • Staffinterview
  • Sitevisitobservation

d.Sub-recipients musthave a writtenstatementoutliningconsumerrightsthat,atminimum,includes:
  • Nature ofservicesoffered.
  • Conditionsfor service
  • Theabilityto terminate service at anytime.
  • Transferanddischargeprocedures
  • Consumerprogressreview
  • Access to consumerrecords
/
  • Consumer RightsandResponsibilitiesform

e.Sub-recipients musthave a writtenstatementoutliningconsumerresponsibilities that,atminimum,includes:
  • Scheduling,rescheduling, andcancellingappointments
  • Drugand alcohol useon premises
  • Weapons onpremises
  • Acts ofabusetowards staff,propertyorservices
/
  • Consumer RightsandResponsibilitiesform

f.Sub-recipients musthaveanobjective process toaddressand trackconsumers’grievances. /
  • Policiesandprocedures
  • Documentationofresolution ofgrievance

STANDARD / MEASURE
g.Sub-recipients musthave releasesofinformationthat,atminimum,includesinformationregarding:
  • Towhat/whominformationwill be released,includingnameoforganization or person(emergencycontact), address,etc.
  • Whatspecificinformationwill be released
  • Time-limitsfor releases to notexceed 18 months
  • Printednameandsignatureofconsumer/legalguardian
  • Signatureof awitness
Releasesofinformation arenot validonceaconsumer is dischargedfromservices. /
  • ReleaseofInformationform
  • Documentation in consumerrecords ofsignedandupdatedreleasesofinformationbeforethird partydisclosuresaremade

h.Within5businessdays ofcompletingintake,Sub-recipients must reviewwith consumer andobtainsigneddocumentationofthefollowing consentsand relateddocumentation:
  • Consent to Serveform
  • ConfidentialityProcedures,including HIPAA
  • Consumer RightsandResponsibility
  • Grievance process
/
  • Documentation in consumerrecords ofsigneddocumentation

8. Progress Notes
a. A progress note must be done on a client at least monthly /
  • Documentationin consumerrecords ofongoingassessmentofneedsandappropriatereferrals

  1. Documentationof progress notes in consumerrecords at least monthly
/
  • Documentationin consumerrecords ofongoing contactwith other serviceSub-recipients

  1. Documentationin consumerrecords ofprogress toward meeting the goals in the care plan
/
  • Documentationin consumerservice plans thatneeds areclosedout whentheyaremet/deferred

  1. Documentationin consumerrecords after each progress notes showing Sub-recipients full name/title; date; time; credentials within 3 days after interaction with client
/
  • Documentationin consumerservice plans thatneeds areclosedout whentheyaremet/deferred

  1. Documentationin consumer record of efforts to contact client
  2. Documentationin consumerrecords showing no black spaces between progress notes
/
  • Documentationin consumerrecords ofongoing contactwith other serviceSub-recipients

9. Discharge
a.Adischargefromservices must occurifanyofthefollowing criteria ismet:
  • Completionofservices
  • Consumer’sdeath
  • VerificationofHIVpositive status cannotbeobtainedwithin30businessdaysofintake
  • Verificationofeligibilitycannotbeobtained
  • Theconsumer/legalguardian has requestedthecasebe closed
  • Relocationofconsumer outsideof theSub-recipient’sgeographicservice area
  • Inabilityto contacttheconsumerfor morethan90 calendardays
  • Theconsumer’sneedsaremoreappropriatelyaddressedthroughotherSub-recipients
  • Theconsumerexhibitsact ofabusetowardsstaff,propertyor services
/
  • Documentation in consumerrecords thatdischargecriteriawasfollowed

b. Sub-recipients mustnotifyconsumers whentheyarebeing discharged. /
  • Documentation in consumerrecords ofconsumersbeingnotifiedof discharge

STANDARD / MEASURE
10. Consumer Satisfaction
a.Sub-recipients mustestablishevaluationmethodstoassess consumersatisfactionandreceivefeedbackon services usinganyof thefollowingmethods:
  • Consumer AdvisoryBoard
  • Consumer satisfactionsurvey
  • Suggestionboxor otherconsumerinputmechanism
  • Focus groupsand/orpublicmeetings
/
  • Consumer AdvisoryBoardmeetingnotes/minutes
  • Consumer satisfactionsurvey/results
  • Visual verificationofsuggestion boxor otherconsumerinputmechanismsduringsitevisit
  • Notes or reportsfromfocusgroups and/or publicmeetings

b. Sub-recipients mustuse resultsfromevaluationmethodsto improveservicedelivery. /
  • QualityImprovementPlan
  • Modificationto servicedeliverypoliciesandproceduresbasedonfeedback
  • Inclusionofconsumerfeedback ininternaltraining/staffcommunications

PSYCHOSOCIALSUPPORT SERVICES

Service Definition

Psychosocial support is the provision of group or individual support and counseling services to assist eligible people living with HIV to address behavioral and physical health concerns

These services may include:

  • Bereavement counseling
  • Child abuse and neglect counseling
  • HIV support groups
  • Nutrition counseling provided by a non –registered dietitian
  • Pastoral care/ counseling services

Program Guidance:

  • Funds under this service category may not be used to provide nutritional supplements
  • Funded Pastoral Counseling must be available to all eligible clients regardless of their religious denominational affiliation
  • Funds may not be used for social/recreational activities or to pay for a client’s gym membership
  • Contact quality management staff for full Evidence Based Interventions list

STANDARD / MEASURE
1. ServiceDelivery
a. TheSub-recipientsmustdocumentservicesprovidedtothe consumer. /
  • Sign-in sheetsat supportgroups
  • Documentation in consumerrecords ofindividualcounseling, if applicable

b. TheSub-recipientsmustdocumenttopicsorinterventionsthatwereimplemented. Along with HAB performance measures that are tied to each topic. /
  • List ofgroupsessiontopics
  • Documentation in consumerrecords ofindividual/groupcounselingsessiontopics/interventions
  • Evident of performance measures with tracking mechanism in place

c. Onanannual basis,theSub-recipientsmustevaluatethe services and topicscovered toensuretheymeetconsumerneeds. /
  • Consumer satisfactionsurvey
  • Modificationto servicedeliverybasedonfeedback
  • Inclusionofconsumerfeedback instafftraining

d.A service plan is developed and agreed-upon by the client and provider, which outlines services goals, objectives, and interventions. /
  • Documentation is keep in consumer chart and review every 6 months

Performance Measures

Psychosocial:

85% of psychosocial persons will attend a routine HIV medical care visit within 3 months of HIV diagnosis

94% of psychosocial support persons with an HIV diagnosis will have at least one HIV medical care visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between the first medical visit in the prior 6 month period and the last medical visit in the subsequent 6 month period

Service Unit(s):

Face to face, advocacy, and telephones consult

CAREWare Data Reporting:

Part A service sub-recipients are responsible for documenting and keeping accurate records of Ryan White program data/client information, units of service, and client health outcomes.

Psychosocial Support Services Definition:

Peer Navigator:PLWHA, who run support groups, helps individuals establish medical care, assist in the enrollment for Ryan White services, attend medical appointments, assist in making behavioral health appointments, and find additional support services to ensure a person doesn’t feel alone in the medical treatment process.

Peer to Peer Participant: PLWHA who attends the groupMeeting one on one with clients who are not in care and are not assigned to a receiving medical case management and reconnect these clients into care Work with clients who are new diagnosed and assist with maneuver the continuum of care

Work with clients for up to a 3-month transition period to bridge the gap and connect clients to care

Attend psychosocial groups as a resource and to offer experience and insight on the HAB measures

STANDARDS MEASURE
  1. Peer Navigator Responsibility but not limited to

a. Sub-recipient’s roles in peer
navigation / To include major core components:
  • Peer to peer navigators are rotated
  • Steps must be tied into HAB measures
  • Clinical supervisor required
  • Comply with confidentiality status and regulations
  • Meet one on one with consumers who are not in care and not assigned to receiving medical case management and reconnect client into care
  • Meets with consumers for up to a 3 month transition period to bridge the gap and connect to care
  • Meet with consumers who are newly diagnosed and assist with maneuvering the continuum

b. Staff will meet with assigned peer
to peer navigator /
  • Create topics
  • Facilitation skills (Do’s and Don’ts)
  • Topics chosen has to relate/tie into at least one Performance Measure per group session

  1. Peer Participants

  1. Must meet Ryan White Eligibility Requirements
/
  • Income /residency verification needed
  • HIV Positive –Individuals only

  1. Ensure that the referral (manual/CAREWare) is a completed referral and meets all the eligibility requirements
/
  • Documentation reflects completed referral
  • Attend Psychosocial Group as scheduled
  • Peer to Peer participants in the next scheduled group session once documentation is provided

  1. Documentation – all Peer to Peer Participants must
/
  • Sign both CAREWare and Care Consent Forms
  • Sign in via the Peer to Peer attendance sheet at each meeting
  • Sign Release of Information