Ryan White Part A

RYAN WHITE PART A

ANNUAL PROVIDER WORKPLAN

FY 2014

March 1, 2014 – February 28, 2015

AGENCY INFORMATION

Agency Name:
Administrative Address:
Program(s) Address(es):
(List all sites where Part A services are provided)
Phone:
Fax:
Web Site:
Agency Hours of Service:
Executive Director:
Part A Funded Services:
Name and Title: / Phone and Fax: / Email address:
Program Contact
Fiscal Contact
Data Contact
If your agency submitted documents in Section I (A) and none have been updated since the last workplan submission, confirm that there are no changes and skip to Section (B). / No Changes

Does your agency currently have a Strategic Plan, Vision Document, or Current Annual Plan in place?

If ‘Yes’please submita copy of thedocument. / Yes No
2. Does your agency have a Part A Program Specific Strategic Plan/Vision Document/Current Annual Plan in place?
If ‘Yes’ please submit a copy of the document. / Yes No
3. Does your agency have an organizational chart for your entire agency?
If ‘Yes’ please submita copy of the organizational chart. / Yes No
4. Does your agency have an organizational chart for each specific program/ department funded by Part A?
If ‘Yes’ please submita copy of the Part A program/department org chart. / Yes No
1. Describeany service delivery successes/challenges at your agency in the last fiscal year.(For example, successes: collaboration, expansion of services. Challenges: staff turnover, staff training, retaining clients in care, evaluation/quality improvement, addressing clients’ mental health/substance abuse issues, client outreach/recruitment, cultural and linguistic competence, collaborating with other agencies, lack of/decreased funding, etc.)Please make reference to any successes and challenges from past quarterly reports narratives and monthly calls.

2. What impact have these successes and challenges had on your service delivery?

3. How has your agency addressed these service delivery challenges?
C – REPORTING SUCCESSES AND CHALLENGES
1. Based on your funded program(s) final compliance summary for fiscal year 2013, please describe any successes or challenges your program(s) faced at meeting 100% programmatic and fiscal reporting compliance.
2. If your program(s) met compliance at 100%, please provide any feedback on how the monthly compliance summaries helped your program(s) at meeting BPHC’s reporting deadlines.
3. If compliance was not met at 100%, please provide a description of the challenges for each specific reporting requirement: invoice, narrative, data and outcomes for each of your programs, and how your agency plans to address those challenges during fiscal year 2014.
1. Does your agency have a Board of Directors? (See the attachments section for the Board of Directors Demographics Table.)
If ‘Yes’, please submit:
a)Copies of the last 4 meetings’ minutes; and
b)Completed Board of Director Members Demographics table
c)Copy of current Certificate of Liability / Yes No
2. Does your agency or program have an active and functioning Consumer Advisory Board (CAB)?
If ‘No’, skip to question 10. If ‘Yes’, answer questions 3-9. / Yes No
3. How often does the CAB meet?
4. What is the structure of the CAB (i.e. who facilitates meetings, are there subgroups or workgroups)?
5. Does a staff member of the agency attend meetings? If so, what is their role in meetings? / Yes No
6. How many HIV + consumers are active participants of the CAB?
7. What is the race and ethnic breakdown of the CAB? Please provide numbers.
White / Black or African American / Asian
American Indian / Native American/Pacific Islander / Hispanic or Latino/a
African / Cape Verdean / Haitian
Brazilian / Portuguese / Other: ______
8. What is the gender breakdown of the CAB? Please provide numbers.
Male / Female / Transgender
9. Describe how the CAB’s recommendations affect the delivery of service.
10. If there is no functioning CAB, are steps being taken to develop one? If yes, what are those steps? / Yes No
11. How do you solicit information from consumers and/or the community being served?

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Briefly describe the goals of each funded program, how clients are referred to the program, and how they are connected to the larger continuum of HIVcare.

Program(s) / Goals of the program / How are clients referred to the program / How are they connected to the larger continuum of HIV care
1
2
3
4

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Complete the client demographics table below for corresponding funded program indicated in the Program Model/Description section. The Totals in each column must equal the same number with the exception of Other Racial or Ethnic Groups which may be less than or equal to the other totals.

Program 1
% Clients / Program 2
% Clients / Program 3
% Clients / Program 4
% Clients
Total Clients to be Served:
(Enter total unduplicated client number)
Gender:
Male
Female
Transgender
Total:
Ethncity:
Hispanic/Latino/a
Not Hispanic/Latino/a
Total:
Race:
White
Black or African American
Asian
Native Hawaiian/Pacific Islander
American Indian/Alaskan Native
Total:
Ethnic Groups:
African
Cape Verdean
Haitian
Brazilian
Portuguese
Total:
Primary Language:
English
Spanish
Haitian Creole
French
Portuguese
Crioulo (Cape Verdean)
Asian Languages (Specify)
American Sign Language
Other (Specify)
Total:
Mode of Transmission:
Men who have sex with men (MSM)
Injection drug users (IDU)
MSM and IDU
Heterosexual contact
Perinatal Transmission
Hemophilia/Coagulation disorder
Through blood/blood products
Unknown/Undetermined
Total:

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Based on your target populations as identified under Mode of Transmission, Race/Ethnicity, and Gender in the previous client demographics, complete the key population matrix for each subpopulation and how your program(s)address(es) specific needs, barriers, and challenges to HIV care.

Key/subpopulations / Client recruitment methods & entry point(s) / Service needs, barriers, & challenges / Client retention methods and strategies

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Complete the Expected Units Table only for theprograms your agency is funded to provide. Describe key activities for each subservice type/service unit proposed and which Part A funded staff positions are responsible for providing those subservices to clients. Refer to the Service Code Information section of your FY 2014 Provider Manual starting on page 49 for more detailed information about specific service categories.

AIDS Assistance Drug Program
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Prescription / 4181
Food Bank/Home Delivered Meals/Medical Nutrition Therapy
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Home Delivered Food, Prof. / 4221
Home Delivered Food, Vol. / 4222
Meals, Congregate / 4223
Assessment, Nutritional / 4224
Visit, General Nutritional Counseling / 4225
Food Bank Package / 4226
Nutritional Supplement / 4227
Housing
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Visit, Initial / 4261
Visit, Follow-up / 4262
Phone, Follow-up / 4263
Placement, Temporary / 4265
Placement, Permanent / 4266
Rental Assistance / 4271
Utility Assistance / 4271
Housing Discharge / 4052
Medical Case Management
MAI Funded? Yes No
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Initial Intake, Started / 4080
Assessment, Completed / 4081
Visit, General / 4082
Visit, Home-Based / 4282
Phone, Follow-up / 4083
Reassessment/Follow-Up Service Care Plan Completed / 4084
Supported Referral / 4612
Medical Transportation (based on one-way rides)
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Public / 4441
Taxi/Transportation Company / 4442
Van/Funded Agency Vehicle / 4443
Volunteer / 4444
Oral Health Care
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Initial Intake, Started / 4161
Treatment Committed / 4162
Treatment Claim / 4163
Phone, Follow-up / 4164
Psychosocial Support (Peer Support, Mental Health, Substance Abuse-Outpatient)
MAI Funded? Yes No
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Peer Support Session, Group / 4361
Peer Support Session, Individual / 4365
Peer Networking, Group / 4368
Mental Health Session, Individual / 4371
Mental Health Session, Group / 4372
Mental Health Session, Family / 4373
Substance Abuse-Outpatient, Hour, Individual / 4421
Substance Abuse-Outpatient, Hour, Group / 4422
Substance Abuse (Residential)
Subservice / Service Code / # Service Units / Activity Description & Responsible Staff
Bed Day - RRS / 4703
Bed Day - TSS / 4704

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Complete the Interagency Coordination and Referrals table. List agencies and/or programs and linkages for each of your funded programs.

Agency Name / Type of Partner (Referral to/from/both)& Specific Linkage to a funded service / Description of services offered and utilized by your staff and clients / Do you have a signed MOA on file with this agency? If yes, also provide a copy as an attachment.

How do you ensure clients are receiving or are engaged in primary medical care?

Does the agency have resources and referral information available to clients? Describe.

Does your agency have written policies or procedures for Part A funded services on the following? / Agency has written policy or procedure: / If ‘Yes’,
a new/updated copy of the policy/procedure is submitted with this report: / If ‘Yes’ and already submitted in FY13 and there are no changes, confirm by checking:
1-Client eligibility for funded services (see policy/procedure checklist) / Yes No / Yes / No Changes
2- Procedure for collecting service eligibility verification documentation (i.e., HIV, Income, Insurance, EMA Residency) / Yes No / Yes / No Changes
3- Client grievance procedure / Yes No / Yes / No Changes
4- Client confidentiality / Yes No / Yes / No Changes
5- Client consent to release medical information or use of services / Yes No / Yes / No Changes
6- Client’s right to receive comprehensive progress review of care, as per the Standards of Care for HIV/AIDS Services (see policy/procedure checklist) / Yes No / Yes / No Changes
7- Client discharge (voluntary/involuntary) and transition from funded services, as per the Standards of Care for HIV/AIDS Services / Yes No / Yes / No Changes
8- Process for tracking active and inactive clients / Yes No / Yes / No Changes
9- Grantee’s right to audit client files at site visit (see Policies and Procedures section of the FY 2014 Provider Manual – Page 80) / Yes No / Yes / No Changes
10- Client assessment for eligible/appropriate benefits and programs (e.g. Medicaid) / Yes No / Yes / No Changes
11- Access to services for clients with limited English skills / Yes No / Yes / No Changes

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Were there any new staff members hired after March 1, 2013?
Yes No
1. How soon is orientation provided?
Within 1 mo.
Within 3 mo.
Within 6 mo. / What orientation do staff members receive upon appointment?Describe the agency orientation program.
2. Are there training requirements for funded staff members?
Yes No / Describe requirements.
3. How soon after hire is staff training provided?
Within 1 mo.
Within 3 mo.
Within 6 mo. / How are staff members trained on specific program requirements?Describe training.
4. Do staff members receive administrative supervision?
Yes No / Describe who provides the supervision and what supervision is done (i.e., chart review, staff case consultations, etc.).
5. How frequent is administrative supervision?
Weekly Bi-weekly Monthly Other
6. Dostaff members receive clinical supervision?Note: All peer support staff (paid, stipend, and volunteer) must receive at least one hour of clinical supervision per month.
Yes No / Describe who provides the supervision and what supervision is done (i.e., chart review, staff case consultations, etc.).
7. How frequent is clinical supervision?
Weekly Bi-weekly Monthly Other

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1. Is there aPolicy or Practicethat demonstrates recruitment, retention and promotion of a diverse staff reflecting cultural (racial/ethnic, but also group culture i.e. IDU) and linguistic diversity of the community? Yes No
Is there a written policy on file?
Yes
If yes, submit a copy of this document.
Attached? Yes / If there is no written policy, is there a practice? If so, does it include:
Hiring practices / Are job listings available in various languages
Where job listings are posted / Staff development
Please describe the practice.

1. Quality Management Plan

Agency has written Plan. / If ‘Yes’,
is a copy of the plan being submitted with this report?

Does your agency currently have a quality management plan in place?

/ Yes No / Yes

Does your agency currently have a strategic plan for HIV Quality Management and Improvement?

/ Yes No / Yes

2. Evaluation

1. Which of these methods is your agency using to evaluate Ryan White services? Select all that apply. / For which service(s)? / How often is this service evaluated? / How do the findings affect service planning/delivery?
Provide examples.
Agency-specific outcomes reports
Client satisfaction surveys
Quantitative data
Needs Assessment
Other
Other

2. Which of these methods is your agency using to evaluate the cultural and linguistic needs of its population? Select all that apply.

/ For which service(s)? / How often is this service evaluated? / How do the findings affect service planning/delivery?
Provide examples.
Focus groups
Client satisfaction surveys
Needs Assessment
Other
Other

Indicate which if any of the following attachments are included with your submission:

Attached new or updated / Already submitted in FY13 and no changes
Strategic plans, vision documents, or mission statements (Agency-wide & Part A-specific)
Organizational chart(s) (Agency-wide & Part A-specific)
Board of Directors List and Demographics Table
Minutes from the last 4 Board Meetings
Copies of Memoranda of Agreement related to Interagency Coordination
Written policies & procedures related to Part A Services
(Refer to the Part A Policies & Procedures Master Checklist for a full list of documentation to be submitted)
Cultural & Linguistic Competency Policy Statement
Copy of Certificate of Liability
Fire Certificate

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Client Eligibility Checklist

Per the terms and conditions of Part A funding, “Client eligibility recertification is required every six months and must include verification of low income status, residency, medical necessity, and that the Ryan White HIV/AIDS Program is the payer of last resort.”Please use the following checklist to ensure that your client eligibility policy at a minimum contains the following:

HIV positive Status

Medical eligibility criteria as necessary (i.e., for services such as MNT)

Income eligibility

Proof of client’s due diligence for accessing and/or exhausting other funding streams before Part A

EMA residency eligibility

Client Progress Review Checklist

Client program review policy or procedure at a minimum must contain the following:

Process for a client Intake and Eligibility

Process for client Assessment of needs including eligible/appropriate benefits and programs (e.g. Medicaid)

Process for developing client Individual Service Plan (ISP)

Process for client Progress Review by a Supervisor

Process for six months review of client service needs and eligibility

Grievance Policy Checklist

Client grievance policy or procedure at a minimum must contain the following:

How to file a grievance

To whom the grievance should be addressed (1st designee)

An alternative addressee if the client does not choose to communicate with the 1st designee

How the grievance will be handled

Timeline for the grievance to be processed

Step-by-step process if the grievance remains unresolved

A signature section for staff to acknowledge review of the grievance procedure with client

A signature section for client to acknowledge review and receipt of grievance procedure policy

Confidentiality Policy Checklist

Confidentiality policy or procedure at a minimum must contain the following:

Staff requirement to receive confidentiality training, i.e., HIPAA

Staff acknowledgement of confidentiality policy, i.e., signed confidentiality statement

Client’s rights to meet with staff for services in a confidential setting

Client’s rights to refuse or consent to the release medical information or use of services

BPHC’s rights to review client files as necessary under HIPAA (See FY2013 Provider Manual pgs 83)

Rights for client records to be stored in a secure and confidential location

Intake/Assessment Process Checklist

1- Program has a standard intake form. / Yes No
2- Program has a standard assessment/ISP form. / Yes No
3- Intake process is completed within 30 days after initial contact with client. / Yes No
4- Program staff identify and communicate as appropriate with collateral services providers (e.g., referrals, progress notes, follow-up referrals are documented). / Yes No
5- Client record and ISP are reviewed by program supervisor. / Yes No

A copy of any intakes/assessments as appropriate (i.e., any service specific intakes/assessments) must be submitted. If agency checks ‘No’ for any of the following, a plan of action must be attached.

Access to Interpretation Services/ Appropriate Materials Checklist

Access to interpretation services/appropriate materials policy and procedures must at a minimum contain the following:

The right for clients to obtain no cost interpretation services

The right for clients with limited English skills to receive appropriate referrals

Staff requirements to be trained on the skills and ethics of interpreting terms relevant to services provision

Procedure for provider to maintain signed consent in the client’s primary language on file, if a friend or family

member over the age of 18 served as an interpreter

The right for clients to have access to linguistically appropriate signage/materials

Procedure for provider to conduct on-going assessment of program and staff’s cultural and linguistic

competence

BOARD OF DIRECTORS DEMOGRAPHICS TABLE
Attachment for SECTION I (E)

Attach a copy of your agency’s directory/listing for all members who preside over the Board of the Directors. The document at a minimum should include each board member’s full name, business title or position (if any), address, and executive role/position on the board.

Total members on the agency’s Board of Directors:

For the table below, please provide aggregate demographics for the board members represented in the figure above.

GENDER
Female
Male
Transgender
ETHNICITY
Hispanic or Latino/a
Not Hispanic or Latino/a
RACE
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian/Pacific Islander
White
Other:
Other:
Do any of the Board members identify as a person living with HIV/AIDS? If “yes” how many?
Total Board members living with HIV/AIDS:

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