Lead Agency Site Visit Form: ______VDH Contract Number # ______

Lead Agency Site Visit Form: ______VDH Contract Number # ______

Review Date
Agency Name
Agency Representatives / Name / Title
1.
2.
3.
4.
5.

Services Provided in Region

Opt/Ambulatory Health Services / #____Direct / #____ Third Party / Substance Abuse / #____Direct / #____ Third Party
Pharmaceutical 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 / Lead Agency Responsibility / Documentation / Comments /
I. Consortium Activities
Consortium activities to include planning, periodic program evaluation, and service delivery, through agreements with other entities for the provision of outpatient health and support services as permitted under Ryan White legislation. / Documentation through program records and client files that:
·  All Services provided with Part B funds are allowable under Ryan White legislation and HRSA policies
·  Services provided meet Ryan White service category definitions. / Is there documentation of program and financial records that include:
Types of services provided? / Yes No NA
Use of funds only for allowable services? / Yes No NA
Assurances and agreements between consortium and providers? / Yes No NA
HIV relatedness of expenditures? / Yes No NA
Are there formal MOUs with Key points of access? / Yes No NA
Consortium to submit to VDH signed assurances in order to receive funding from VDH under the Ryan White Part B program assurances to affirm the following:
·  Within the geographic area in which the consortium operates, populations and subpopulations of individuals and families with HIV/AIDS have been identified, particularly those experiencing disparities in access and services and/or residing in historically underserved communities.
·  The regional/geographic service plan matches the state comprehensive plan.
·  The consortium will be the single coordinating entity that will integrate the delivery of services among the populations and subpopulations identified. / Signed assurances from the consortium that affirm:
·  Identification of populations and subpopulations of individuals and families with HIV/AIDS identified, particularly those experiencing disparities in access and services and residing in historically underserved communities
·  Regional/geographic service plan matches the statewide comprehensive plan and addresses the special care and service needs of the specified populations and subpopulations
·  Consortium act as a single coordinating entity that will integrate the delivery of services. / Has the lead agency provided VDH with a copy of signed assurances? / Yes No NA
What percentage of consortium membership are consumers? / ____%
What activities have been undertaken to increase consumer participation if current membership is less than 15% consumers?
Has the consortium provided written assurances to VDH? / Yes No NA
Does the consortium’s service plan match the statewide comprehensive plan? / Yes No NA
Does the consortium’s service plan address the needs of the various subpopulations of the region? / Yes No NA
Does the consortium’s service plan include strategies to integrate the service delivery plans associated with each subpopulation in the region? / Yes No NA
Consortium to conduct a needs assessment every two years of service needs within the geographic area to be served, and ensure participation by individuals living with HIV/AIDS in the needs assessment process. / Documentation that consortium has:
·  Conducted a needs assessment to determine the service needs of the populations and subpopulations of individuals with HIV/AIDS and their families within the geographic area to be served.
·  Ensured the participation of individuals with HIV/AIDS in the needs assessment process.
Disseminate the findings of the needs assessment to stakeholders. / Is a copy of the current needs assessment (completed within the last five years) available for review? / Yes No NA
How is the region responding to needs identified in the regional needs assessment?
Has the Lead Agency released the needs assessment findings to key stakeholders? / Yes No NA
Consortium to have a service plan for the geographic region served that is based upon evaluation of service needs and is designed to meet local needs.
Consortium to demonstrate adequate planning to meet the special needs of families with HIV/AIDS, including family-centered and youth-centered care, and to provide assurances regarding content of the service plan, and address disparities in access to services and historically underserved communities.
VDH receives assurances from the consortium that there is thorough coordination and expansion of existing programs before new programs are created. / A service plan description that provides documentation and assurances that the service plan addresses the following:
·  Specific service needs being addressed through the coordination and expansion of existing program.
·  The geographic service areas in metropolitan areas that correspond, to the extent practicable, to boundaries of local health and support service delivery systems.
·  Rural case management services that are linked to available community support services and specialized HIV medical services.
·  Participation of individuals living with HIV/AIDS in needs assessment and service planning.
·  Adequate planning to meet the special needs of families with HIV/AIDS, including family- and youth-centered HIV care services.
Disparities in access and services and historically underserved communities. / Develop regional/geographic service plans for the consortium region that matches the standard:
Is there documented proof of involvement of the required representatives in the development of the service plan? / Yes No NA
Is there a comprehensive services plan in the region? / Yes No NA
Is there regional cost data for services? / Yes No NA
Is there documented proof of cost effectiveness of each service provided? / Yes No NA
Is there evidence of negotiation of rates paid for services by subcontractors? / Yes No NA
Consortium to conduct periodic evaluation of its success in responding to identified needs and the cost-effectiveness of mechanisms used to deliver comprehensive care.
Each consortium is required to report to VDH the results of its evaluation and make available upon request the data and methodology information needed for VDH to conduct an independent evaluation. / Documentation of guidance provided to the consortium by VDH regarding evaluation requirements:
·  Documentation that the consortium is conducting periodic evaluation of both consortium success in responding to identified needs and cost-effectiveness of mechanisms used to deliver comprehensive care, such as timetables and methodology for evaluations of success in meeting needs and cost. / Develop plans to evaluate service success and the cost-effectiveness of mechanisms used to deliver comprehensive care:
Has the consortium conducted evaluations in accordance with guidelines and timetables determined by VDH? / Yes No NA
Are the evaluation results available to VDH on request, for review and for use in conducting an independent evaluation? / Yes No NA
Is there a system to evaluate the success of services? / Yes No NA
II. Human Resources/Anti-Kick Back Statues
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 provider 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. / Does the Lead Agency have the following documents:
Corporate Compliance Plan (required by CMS if providing Medicare- or Medicaid- reimbursable services) / Yes No NA
Personnel Policies / Yes No NA
Code of Ethics or Standards of Conduct / Yes No NA
Bylaws and Board policies. / Yes No NA
Procedure for documenting and documentation of any employee or Board Member violation of the Code of Ethics or Standards of Conduct. / Yes No NA
Procedure for documenting and documentation of any complaint of violation of the Code of Ethics or Standards of Conduct and its resolution. / Yes No NA
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 required by the Compliance Plan or employee conduct standards that prohibit employees from receiving payments in kind or cash from suppliers and contractors of goods or services. / Does the lead agency and its subcontractors 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
Employee time and effort to be documented, with charges for the salaries and wages of hourly employees. / Review of documentation of employee time and effort, through:
·  Review of payroll records for specified employees
·  Documentation of allocation of payroll between funding sources if applicable / 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
III. Fiscal/Programmatic Monitoring Activities
Proper stewardship of all grant funds including compliance with programmatic requirements. / Policies, procedures, and contracts that require:
·  Timely submission of detailed fiscal reports by funding source, with expenses allocated by service category
·  Timely submission of programmatic reports
·  Documentation of method used to track unobligated balances and carryover funds
·  A documented reallocation process
·  Report of total number of funded providers / Meet the following contractual programmatic and fiscal requirements, including:
Do financial reports contain expenditures by service category and use of Ryan White funds as specified by the VDH? / Yes No NA
Is there a policy and procedural manual, such as a Consortium Policy Manual, that meet federal and Ryan White program requirements? / Yes No NA
Does the Lead Agency have a copy of each subcontractor’s programmatic reports? / Yes No NA
Any provider or individual receiving federal funding is 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. / Does the Lead Agency have documentation of monitoring all service subcontractors for compliance with federal and programmatic requirements? / Yes No NA
Does the Lead Agency have an appropriate system to monitor subcontractors’ expenditures? Please describe the system in the last column. / Yes No NA
Does any subcontractor charge fee for service? / Yes No NA
If yes, how do they comply with federal requirements?
Are all regional policies in compliance with state and federal policy? / Yes No NA
Monitoring activities expected to include annual site visits of all subcontractors. / Review of the following program monitoring documents and actions:
·  Policies and procedures
·  Tools, protocols, or methodologies
·  Reports
·  Corrective site action plans
Progress on meeting goals of corrective action plans / Are there established policies and procedures to ensure compliance by subcontractors with federal and programmatic requirements (such as site visits)? / 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 / Are requests for payment correct and an accurate reflection of year to date expenditures? / Yes No NA
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
Corrective actions taken when provider 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. / Have the subcontractors prepared and submitted a timely and detailed response to monitoring findings and timely progress reports on implementation of corrective action plan? / Yes No NA
IV. Assurances
Lead Agency must maintain documentation stating that subcontractors are knowledgeable of and agree not to bill for unallowable cost and services. / Signed contracts, subcontractor assurances, and/or certifications that define and specifically forbid the use of Ryan White funds for unallowable expenses.
VDH review of contractor’s budgets and expenditures to ensure that they do not include any unallowable costs. / Does the Lead Agency maintain a file with signed subcontractor agreement, assurances, and/or certifications that specify unallowable costs? / Yes No NA
Does the Lead Agency ensure that budgets/expenditures do not include unallowable costs? / Yes No NA
Has the Lead Agency provided budgets and financial expense reports to VDH with sufficient detail to document that they do not include unallowable costs? / Yes No NA
Utilize the unallowable table to ensure that assurances include all Ryan White unallowable use of funds. See supplemental form.
V. Income from funds
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