Overview of Site Visit Process
Ryan White HIV/AIDS Program
Part C, D, and F-Dental
Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Bureau
Division of Community HIV/AIDS Programs
Admin
Webinar Goal
To increase the knowledge of Consultants and Project Officers on
how to effectively assess and report on the HRSA/HAB/DCHAP’s
Ryan White HIV/AIDS Program Part C, D, and F-Dental grantees
provision of comprehensive, high quality healthcare for people living
with HIV/AIDS, compliance with legislative and programmatic
requirements, and the National HIV/AIDS Strategy.
Webinar Objectives
By the end of the webinar, participants will:
• Become familiar with all applicable Federal statutes and regulations
relative to the administration of grants.
• Increase knowledge of how to properly use the Site Visit Assessment
Tool.
• Compare and contrast the Ryan White HIV/AIDS Program Parts
A,B,C,D, and F, and Minority AIDS Initiative.
• Describe the reasons for conducting a site visit and how to prepare
for pre and post site visit activities.
• Identify “What’s New?” with the 2013 Site Visit Assessment Tool.
• Increase knowledge of the site visit process.
• Apply tools to write a concise and comprehensive report.
Webinar Outline
• Overview of HRSA/HAB
• Authorities that Govern Site Visits
• Ryan White HIV/AIDS Program Parts A,B,C,D, and F,
and MAI
• Monitoring Site Visits
• Site Visit Roles and Responsibilities
• Team Member Professional Standards
• Site Visit Assessment Tool
• Site Visit Reporting Criteria
• Tips for Writing a Concise and Comprehensive Report
Health Resources and Services
Administration (HRSA)
Vision
Healthy Communities, Healthy People
Mission
To improve health and achieve health equity through
access to quality services, a skilled health workforce,
and innovative programs.
HIV/AIDS Bureau
Vision
Optimal HIV/AIDS care and treatment for all.
Mission
Provide leadership and resources to assure access to
and retention in high quality, integrated care and
treatment services for vulnerable people living with
HIV/AIDS and their families.
Authority
The site visit process is governed by:
•
•
•
•
•
Ryan White HIV/AIDS Legislation
Title XXVI of the Public Health Service Act
HAB Policy Notice
National HIV/AIDS Strategy
Funding Opportunity Announcement
Ryan White HIV/AIDS Legislation
Congress enacted the Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act in 1990 to improve the quality and availability
of care for low-income, uninsured, and underinsured individuals and
families affected by HIV disease. The CARE Act was amended and
reauthorized in 1996, 2000, and 2006; in 2009 it was reauthorized as
the Ryan White HIV/ AIDS Treatment Extension Act of 2009 (Public
Law 111–87).
Ryan White HIV/AIDS Program
Administered by the U.S. Department of Health and Human Services
(HHS), Health Resources and Services Administration (HRSA),
HIV/AIDS Bureau (HAB), the Ryan White HIV/AIDS Program works
with cities, states, and local community based organizations to
provide services to over 559,000 people each year who do not have
sufficient health care coverage or financial resources to cope with HIV
disease. The majority of Ryan White HIV/AIDS Program funds
support primary medical care and essential support services. A
smaller but equally critical portion is used to fund technical
assistance, clinical training, and research on innovative models of
care.
Title XXVI of the Public Health Service Act- examines the authority
of the government at various jurisdictional levels to improve the health
of the general population within societal limits and norms.
HAB Policy Notices- provides updates from HAB regarding
clarification of legislation and policies.
Funding Opportunity Announcement (FOA)- explains the
availability of a Federal grant funding opportunity and application
process and is released through Grants.gov.
National HIV/AIDS Strategy Goals
Increasing access to
Reducing new HIV
care and improving
infections
health outcomes for
PLWHA
Reducing HIV-related
disparities and health
inequities
Achieving a more
coordinated national
response to the HIV
epidemic
Ryan White HIV/AIDS Program
Parts A,B,C,D, and F, and the Minority AIDS
Initiative
Ryan White HIV/AIDS Program
Part A
• Metropolitan Areas affected by HIV/AIDS
Part B
• States and US Territories
• AIDS Drug Assistance Program (ADAP)
Part C
• Early Intervention Services and Capacity
Development
Part D
• Women, Infants, Children and Youth (Part D)
Part F
• Dental, Education/Training, Planning, Capacity
Development and Demonstrations, Minority AIDS
Initiative
Ryan White HIV/AIDS Program
Administration
Part A
• Division of Metropolitan HIV/AIDS Programs
Part B
• Division of State HIV/AIDS Programs
Part C, D and F
Dental
• Division of Community HIV/AIDS Programs
Ryan White HIV/AIDS Program
Part A
• Emergency assistance to Eligible Metropolitan Areas
(EMAs) and Transitional Grant Areas (TGAs) that are
most severely impacted by the HIV/AIDS epidemic
• Award made to Chief Elected Official
• Funding allocations determined by Planning Council
• Part A funds distribution:
• 2/3 by formula – based on the number of living cases of HIV
(non AIDS) and AIDS
• 1/3 supplemental – competitive grant process
Ryan White HIV/AIDS Program
Part B
• Base Grant - Provides grants to all 50 States, the District of
Columbia, Puerto Rico, Guam, U.S. Virgin Islands, 6 Pacific
jurisdictions to pay for care for people living with HIV/AIDS
• For jurisdictions with >1 percent of nation’s HIV/AIDS cases,
match required $1 state: $2 federal
• Funds distributed by formula based on HIV/AIDS cases
• Award made to Chief Elected Official
• AIDS Drug Assistance Program (ADAP) pays for:
• Medications to treat HIV disease
• Insurance continuation for eligible clients
• Services that enhance access, adherence, and monitoring of
drug treatment
Part C EIS Overview
• Purpose: To provide comprehensive continuum of
outpatient HIV primary care in a service area.
• Required Services:
•
•
•
•
HIV counseling, testing, and referral
Medical evaluation and clinical care
Other primary care services
Referrals to other health services
• Medical Model of Care:
• Assess
• Treat
• Refer
Part D WICY Overview
Purpose: To provide family-centered primary medical care to
women, infants, children, and youth (WICY) living with
HIV/AIDS when payments for such services are unavailable
from other sources.
Ryan White HIV/AIDS Program
Part F / Dental
Dental
Reimbursement
Program
• Expands access to oral health care for
PLWHA while training additional dental
and dental hygiene providers
Community Based • Provides oral health services to PLWHA
via cooperative projects with communityDental Partnership
Program
based providers of oral health services
Minority AIDS Initiative (MAI)
• Goal: To help reduce the disproportionate impact of
HIV/AIDS and address disparities by:
• Increasing the number of persons from racial and ethnic
minority populations receiving HIV care, and
• Increasing the number of persons from racial and ethnic
minority populations who stay in care.
• MAI funds awarded are noted under the grant specific
terms section of the Notice of Award (NoA) which
establishes the final funding for the budget period.
Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law
111-87,October 30,2009), §2693
Monitoring
Site Visits
DCHAP Site Visits
Types of Site Visits
Description
Comprehensive
•Conducted to review a Program’s
ability to meet the legislative and
programmatic requirements of the
Ryan White HIV/AIDS Program
•Newly awarded and established
grantees who have not had a site visit
within the last five years are a priority
Diagnostic
•Conducted to identify and clarify any
programmatic deficiencies for grantees
who are exhibiting challenges within
one or more of the three core areas:
clinical, fiscal or administrative
Technical Assistance
•Conducted to offer appropriate
support to enhance a grantee’s
capacity to provide high quality, cost
competitive health care and services
Ryan White HIV/AIDS Program
Compliance Monitoring
Monitoring Calls
HRSA/HAB
conducts ongoing
review and
monitoring of
grantees
Review of RW Programmatic
Reports
Review of Fiscal Reports
Comprehensive Site Visits
Diagnostic Site Visits
Why Do We Conduct Site Visits?
1. Support DCHAP’s mission to provide grantee oversight
in the delivery of comprehensive high quality HIV
primary and oral health care.
2. Verify the grantee’s program is in compliance with the
Ryan White Legislative & Programmatic requirements.
3. Ensure highest quality HIV clinical care and
compliance with HHS Guidelines.
4. Ensure administrative and fiscal integrity.
5. Identify technical assistance needs to address any
program deficiencies.
What Can “Trigger” a Site Visit?
-
Need for an initial site visit
for newly awarded grantee
or comprehensive site visit
for established grantee
- Low score on recent
competitive application or
lack of progress reflected
within non-competing
report
- Habitual and problematic
staff turnover for grantee
- Lack of communication
with Project Officer
- Continually failing to meet work
plan objectives
- A sense on the part of the
Project Officer/Branch Chief
that “something’s just not right”
with the grantee’s program
- Media attention
- Known financial problems
- Problematic spend-down
patterns and/or multiple years
with unobligated balances
- Draw down restrictions
Goal of Site Visit Timeline
Minimum of 10 Weeks Prior to Scheduled Site Visit
Consultants are identified and site visit materials are emailed to Consultants
Minimum of 8 Weeks Prior to Scheduled Site Visit
Project Officer Confirms Date and Time of Pre-Site Visit Conference Call with Consultants and Grantee
Minimum of 4 Weeks Prior to Scheduled Site Visit
Pre-Site Visit Conference Call Held with the Project Officer, Consultants, and Grantee
Goal of Site Visit Timeline
continued
Within 1 Week of Completion of Site Visit
Site Visit Report Submitted by Consultants to Team Leader
Within 2 Weeks of Completion of Site Visit
Site Visit Report Submitted by Team Leader to Project Officer
Within 4 Weeks of Completion of Site Visit
Site Visit Report Approved by Project Officer, Branch Chief, Clinical Reviewer, and Deputy Director of DCHAP
By 4 Weeks Following Completion of Site Visit
Project Officer Releases Completed Site Visit Report to Grantee
Pre-Site Visit Prep
1. Pre-Site Visit Preparation
•
Copy of most recent applicable Funding Opportunity Announcement (FOA)
• Most recent Competing Application and Non-Competing Progress Report
• Most recent Ryan White Services Report (RSR)
• Three most recent Federal Financial Reports
• Current line item budget and justification
• Copies of any previous Site Visit Reports (as applicable)
• Most recent A-133 Audit
2. Team Pre-Site Visit Conference Call
• Team Leader, Consultant Team Members and Project Officer.
3. Pre-Site Visit Conference Call with the Grantee
How Does Grantee Prepare for the Site Visit?
1. Extensive instructions from their Project Officer
2. Materials provided to grantee:
• Site Visit Assessment Tool
• Pre-Site Visit Conference Call Agenda
• List of “Materials to be Available” for review on-site
• Sample Site Visit Agenda
• “Site Visit Evaluation Form”
3. Site Visit Agenda jointly developed with Team
Leader
Site Visit
Roles and Responsibilities
Pre-Site Visit Activities
Role of Project Officer
• Internally initiates
the site visit within
HAB
• Establishes the site
visit date, Pre-Site
Visit Conference
Call(s), and
prepares packet
• Communicates
with the Team the
purpose of the site
visit
Pre-Site Visit Activities
Role of Team Leader
Confirms travel arrangements,
Makes him/herself available by
arrival and departure times with
phone or email to the other
Consultants
Consultants and Grantee’s staff
Team Leader
Facilitates Pre-Site Visit
Responsible for working with
Conference Call
PO, Grantee, and Consultants
to finalize the Site Visit Agenda
Pre-Site Visit Activities
Role of Team Leader
Pre-Site Visit Conference Call
• Facilitates the Pre-Site Visit Conference Call (reiterate purpose, introduce Team, and ensure that a
review of the site visit process is presented to the
grantee).
• Ensures the grantee will arrange for a confidential
Consumer Panel interview (preferably during a lunch).
• Ensures the grantee’s necessary staff and
subcontractors (if applicable) are available for
interviews during the site visit.
Pre-Site Visit Activities
Role of Team Members
 Responsible for making personal travel arrangements
with contractor.
 Reads the Pre-Site Visit Informational Packet.
 Responsible for participating on the Pre-Site Visit
Conference Call.
 Makes him/herself directly available by phone or
email to the other Consultants and to the grantee’s
staff.
On-Site Activities
Role of Project Officer
• Opens the entrance conference by clarifying the purpose
for the site visit; roles of the Team; and introduces the
Team.
• Provides information on questions related to: HRSA/HAB
policy; Program Guidance and Expectations; HAB/Division
of Grants Management Operations (DGMO) approved
budgets; and HRSA/HAB updates.
• Available to Consultants as they obtain information.
On-Site Activities
Role of Project Officer (cont)
• Holds “check-in” meetings with Team Leader and Consultants
throughout the visit.
• Provides clarification on questions that arise.
• Actively participates in Pre-Exit and Exit Conferences
(provides closing remarks and “next steps”).
On-Site Activities
Role of Team Leader
Serves as “lead reviewer,” getting directions to sites and
facilities, etc.
Serves as a mediator in discussions or when disagreements
arise. The “lead reviewer” is responsible for ensuring that the
Site Visit Team completes a review that meets the spoken and
written instructions of the Project Officer.
Facilitates meetings and handles on-site team logistics (e.g.
rental car, when applicable).
On-Site Activities
Role of Team Leader (cont)
“Checks in” with the Project Officer and Team Members on a regular
basis to ensure that the site visit is progressing as expected or to
make needed adjustments to the agenda.
Usually serves as the facilitator of the Consumer Panel meeting.
Ensures the preparedness of the entire Team for the Pre-Exit and/or
Exit Conference.
Provides feedback as necessary to Team Members.
On-Site Activities
Role of Team Members
 Participates in the following meetings: Entrance
Conference, Consumer Panel, Pre-Exit and/or Exit
Conference.
 Efficiently conducts review of materials and staff
interviews.
 “Checks-in” with the Project Officer and Team
Leader on a regular basis.
 Is fully prepared to make their remarks at the PreExit and/or Exit Conference.
Post-Site Visit Activities
Role of Team Members
• Submit written report to Team Leader within
one week of completion of site visit.
• Provide any clarification or edits as
requested.
Post-Site Visit Activities
Role of Team Leader
• Compiles and submits final Site Visit Report
within two weeks of completion of site visit.
• Contacts Team Members for edits requested
by Project Officer.
Post-Site Visit Activities
Role of Project Officer
• Reviews and provides feedback to Team
Leader on Site Visit Report.
• Assures the completion and release of the
Site Visit Report to the grantee within four
weeks of the conclusion of the site visit.
• Monitors completion of grantee’s Corrective
Action Plan and provides technical assistance
when necessary.
Contractor and Project Officers Roles
The Contractor is responsible for issuing all
reimbursement for consultants’ out of pocket
expenses and honorariums for site
visits. Honorariums are issued by the
contractor upon final approval of the Site Visit
Report by the Project Officer. All
communication concerning consultant
reimbursement should be sent to the
Contractor.
Team Member
Professional Standards
Confidentiality
CONFIDENTIALITY:
As a Consultant, you must fully understand the confidential nature of the site
visit discussions related thereto and agree:
(1) to return all copies of review-related materials;
(2) to erase all electronic review-related materials;
(3) not to discuss these materials or the site visit review proceedings with any
individual except the staff of Health Resources and Services Administration
(HRSA) and Grants Management Officials; and
(4) to refer all inquiries made concerning any aspect of the review
proceedings to the HRSA Project Officer in charge of the review.
Team Member Professional Standards
• Maintain utmost degree of professionalism at all times.
• Strike a balance in decorum. Avoid opposite extremes
- being condescending or being overly-friendly.
• Avoid expressing personal opinions on the policies
and procedures of DHHS, HRSA, or HAB. Avoid
personal biases (“That’s not how WE do it at OUR
clinic.”)
Team Member Professional Standards
• Refrain from conducting personal business on Federal
time.
• Avoid even the slightest PERCEPTION of a “Conflict
of Interest.”
• Never market personal consulting services or products
(e.g. books you have authored, etc.).
Team Member Professional Standards
• Refrain from accepting significant gifts, meals,
drinks, etc. from grantees. Items of nominal value
(e.g. t-shirt, pens, button, coffee mug, etc.) are
permissible.
• If the Consumer Panel is during lunch (optimal), the
Team Members are expected to contribute their
portion of the cost of the meal.
Team Member Professional Standards
• Be respectful of the time and availability of the grantee’s
staff, consumers, Board Members, and subcontractors.
• Be thorough in your review with as little disruption of the
grantee’s workplace as possible.
• Be respectful of your fellow Team Members’ time and
efforts.
• Be fully prepared for Pre-Exit and Exit Conferences.
• Be respectful of the grantee’s organizational culture!
• Frame your closing remarks to be sensitive to the culture of
the grantee.
Site Visit Assessment Tool
Site Visit Assessment Tool
What’s New?
Name – Site Visit Assessment Tool
Core Site Visit Requirements At A Glance
Introduction page
Mission, Vision, and respective websites
Reason – to familiarize the Consultant with our
services and brand
Site Visit Assessment Tool
What’s Old?
What’s New?
Site Visit Categories
•4 – Administrative
•5 – Fiscal
•8 – Clinical
Site Visit Requirements
We have identified a separate authority and
resource for each requirement for a total of:
•4 – Administrative
•4 – Fiscal
•4 – Clinical
MIS – included as a separate category at the end
of each module
MIS – we have integrated MIS into all
requirements
Improvement options
All improvement options were removed.
Reason – to place focus on legislative authorities
and essential elements versus citing grantees for
trivial issues. This approach will lead to a more
streamlined report and concise corrective action
plan.
Site Visit Assessment Tool
What’s Old?
Fiscal – reference tools
What’s New?
A separate document that will accompany the
Site Visit Assessment Tool with reference
material.
Resources added below each requirement.
Reason – to assist Consultants in identifying
materials for review
No sub-categories
Sub-categories added under each requirement
Reason – for relative ease in reviewing the tool
by grouping similar subject matter
Findings – potential for numerous findings
Consultants will identify findings based on 12
requirements. Each finding will not be
addressed individually within the report.
Reason – provide a more tailored approach to
the exit conference, report, and corrective
action plan. Project Officer can provide more
targeted TA based on respective requirement.
Core Site Visit Requirements At A Glance
Section I: Administrative
1
2
3
4
Sections 2601-2692 of title XXVI of
the PHS Act; 42 USC §300ff-11,
§300ff-111; 45 CFR 74; 45 CFR 92;
2 CFR 215; HHS Grants Policy
Statement (2007); HAB Policy Notice
11-02
Administrative Structure
and Management
Grantee maintains a fully staffed management and clinical
team as appropriate for the size and needs of the program.
The organization has established appropriate oversight and
authority over all aspects of the program.
Data Reporting
Grantee has systems which accurately collect and organize
data for program reporting and which support management
decision making.
Section 2664 (a), Section 2671 (c),
and Section 2691 (b) of title XXVI of
the PHS Act; 42 USC §300ff-64,
§300ff-71, and §300ff-101; FOA
Grantee makes efforts to establish and maintain
collaborative relationships with medical and support
providers.
Section 2651 (e) and Section 2671
(c) of title XXVI of the PHS Act; 42
USC §300ff-51 and §300ff-71; HAB
Policy Notice 12-01
System Coordination
Accessibility,
Confidentiality, and Cultural
Competency
Grantee has policies and procedures that address
HIV/AIDS related confidentiality and program processes
that include limiting access to passwords, electronic files,
medical records, faxes and release of client information.
Grantee adheres to accessibility and National Standards
on Culturally and Linguistically Appropriate Services
(CLAS).
Section 2652 (a) (2) and Section
2661 (a) of title XXVI of the PHS Act;
PL104-191 HIPPAA; CLAS
Standards
Core Site Visit Requirements At A Glance
continued
Section II: Clinical
5
6
7
8
HIV Counseling, Testing,
Referral, and Patient
Enrollment
Grantee maintains formal linkages to HIV Counseling,
Testing, Referral, and partner counseling either on site or
from other sources that are available and accessible to the
targeted population(s).
Section 2651 (e) (1) (A) and (B),
Section 2661 (a) and (b), and Section
2662 (a) and (b) of title XXVI of the
PHS Act
HIV Medical Care
Grantee provides a comprehensive continuum of outpatient
HIV primary care services within a targeted area that
attempts to link persons with HIV disease as early in the
course of infection as possible and retain them in medical
care. Program must reflect a medical model of care that
remains abreast of clinical advances in which providers
can assess, treat, and refer patients.
Section 2651 (c) (3), (e) (D) and (E) of
title XXVI of the PHS Act
Other Services to Support
HIV Clinical Outcomes
Grantee ensures access, either directly or via referral, to
oral health care, adherence counseling, outpatient mental
health care and substance abuse treatment, nutritional
services, and specialty medical care. Formal
arrangements such as contracts or memoranda of
agreements are established with appropriate providers as
applicable.
Section 2651 (c) (3), (d) of title XXVI of
the PHS Act.
Clinical Quality
Management Program
Grantee has established a clinical quality management
(CQM) program that assesses the extent to which HIV
health services are consistent with performance standards
as defined by HHS benchmarks and quality indicators.
Grantee’s CQM program includes an evaluation
component that measures performance and continuously
plans, implements, evaluates, and incorporates strategies
to improve delivery of care.
Section 2664 (a) (3), (g) (5) and
Section 2671 (f) (2) of title XXVI of the
PHS Act
Core Site Visit Requirements At A Glance
continued
Section III: Fiscal
Ryan White Budget and
Use of Funds
Grant Funds are budgeted and expended for approved
activities in alignment with applicable Federal legislation
and program requirements.
Section 2664 (g), Section 2651 and
Section 2671 of title XXVI of the PHS
Act; 2 CFR Parts 215, 220, 225, and
230; 45 CFR Part 92; and OMB
Circular A-133
10
Fiscal Management and
Oversight
Grantee maintains accounting and internal control systems
appropriate to the size and complexity of the organization
reflecting Generally Accepted Accounting Principles
(GAAP) and separates functions appropriate to
organizational size to safeguard assets, maintain financial
stability, and account for the appropriate expenditure of
Ryan White funds.
Section 2664 (g) of title XXVI of the
PHS Act; 2 CFR Parts 215, 220, 225,
and 230; 45 CFR Part 92; and OMB
Circular A-133
11
Third Party
Reimbursement: Billing,
Collections, and Program
Income Reporting
Grantee has systems in place to identify and maximize
collections and reimbursement for its costs in providing
health services, including written billing, credit and
collection policies and procedures, and how such revenue
is invested in the Ryan White funded program.
Section 2652 (b) and Section 2664 of
title XXVI of the PHS Act; 2 CFR 215
and 45 CFR 92
12
Sliding Fee Discounts and
Annual Cap on Charges
Grantee has a system in place to determine eligibility for
patient discounts and maintains legislative Sliding Fee
Scale and Annual Cap on Charges to ensure no one is
denied services based on an inability to pay.
Section 2652 (b) and Section 2664 of
title XXVI of the PHS Act; 2 CFR 215
and 45 CFR 92
9
Snapshot of a Requirement
Requirement 3: System Coordination
Authority: Section 2651 (e) and Section 2671 (c) of title XXVI of
the Public Health Service Act; 42 USC §300ff-51 and §300ff-71;
HAB Policy Notice 12-01
Resources: 1) Contracts/MOAs; 2) SOPS; and 3) EHR/EMR
Management
Does the program have collaborative relationships with other health
care providers, other community centers, other RW providers, as
well as local, state, and private organizations providing similar or
complimentary services in the community?
Yes/Met
No
Partially
Met
N/A
Not Met
Site Visit Report
Title XXVI of the PHS Act as amended by the Ryan White
HIV/AIDS Treatment Extension Act of 2009 (Ryan White
Program)
Site Visit Report
Grantee Information:
Grantee Name:
Grant Number:
Type of Visit:
Purpose of Visit:
Comprehensive ____
Diagnostic ____
Technical Assistance____
The purpose of this site visit was to assess grantee’s compliance with the
legislative and programmatic requirements of the Ryan White Part [C Early
Intervention Services (EIS)] Program. The site visit team reviewed the clinical,
fiscal, Management Information Systems (MIS), administrative and support
services of the HIV program operations.
[State Reason that prompted this particular site visit]
Date(s) of Visit:
Project Officer:
Consultant(s):
Overview of Grantee Organization: Include brief summary of organizations’ model of care, hours of
operations, services provided, client demographics, third party payors, summary of chart audit review, and
consumer panel.
Defining Use of Met / Partially Met /
Not Met
Met
•All elements of a Requirement are
met.
•No findings or recommendations
should be included within the Site
Visit Report under the specific
Requirement.
Partially Met
•Not all elements of the
Requirement are met.
•Include findings and
recommendations that were not
met within the Site Visit Report
under the specific Requirement.
Not Met
•All elements of a Requirement are
not met.
•Include findings and
recommendations within the Site
Visit Report under the specific
Requirement and reflect a “must”
in this case.
Site Visit Report
Sample of a Requirement
Section I. Administrative
3. System Coordination: Grantee makes efforts to establish and maintain collaborative relationships with medical and
support providers.
Authority: Section 2651 (e), and Section 2671 (c) of title XXVI of the Public Health Service (PHS) Act; 42 USC §300ff-51 and
§300ff-71; HAB Policy Notice 12-01
Met/ Partially Met/Not Met:
Finding(s):
Recommendations:
Tips for Writing a Concise and
Comprehensive Site Visit Report
• Limit “overview” to one page (Refer to Site Visit Report for an
example)
• Limit total pages to 10.
• If a Requirement is not met or partially met provide a short description
of finding(s) and recommendation(s).
• Only include findings related to the Requirements.
Remember to:
Communicate with the Project Officer
Follow the site visit template
Tailor the report to the findings discussed in the Exit
Conference
Produce a clear and concise report
Meet the Site Visit Report deadline of two weeks
following conclusion of the site visit.
Questions should be emailed to
David Pitman at
DPitman@hrsa.gov
FY 2013 Administrative Requirements
Part C HIV Early Intervention Services (EIS)
Part D Grants for Coordinated HIV Services and Access to
Research for Women, Infants, Children, and Youth (WICY)
Part F – Dental
Presented by:
Department of Health and Human Services
Health Resources and Services Administration
HIV/AIDS Bureau
Division of Community HIV/AIDS Programs
Purpose
The following webinar is offered in support of the Health Resources
and Services Administration’s (HRSA), HIV/AIDS Bureau (HAB),
Division of Community HIV/AIDS Programs (DCHAP), 2013 Site Visit
Assessment Tool.
Webinar Goal
• To increase HRSA/HAB/DCHAP’s Ryan White Part C, D, and F
Consultants’ and Project Officers’ knowledge of how to effectively
assess and report on the grantee’s provision of comprehensive, high
quality healthcare for people living with HIV/AIDS; compliance with
legislative and programmatic requirements; and the National
HIV/AIDS Strategy.
• To learn to effectively assess compliance and report findings based
on administrative practices required by legislation.
Webinar Objectives
By the end of the webinar, participants will be able to:
•
•
•
•
Apply knowledge of how to effectively assess compliance and report findings
based on administrative practices required by law
List the four Requirements of the Administrative Module
Determine if an agency has fully met, partially met, or not met components of
each requirement.
Identify the sources to review to ensure that the grantee meets the stated
requirement.
Webinar Outline
•
•
•
•
Administrative Structure and Management Requirement
Data Reporting Requirement
System Coordination
Accessibility, Confidentiality, and Cultural Competency
Administrative Module
Administrative Module Components
•
•
•
•
•
•
Corporate organization
and structure
Governance
Strategic and short term
planning
Personnel policies and
procedures
Clinical personnel
issues
Data collection
• Capacity
• Licenses and
certification
• Risk management and
liability protection
• Facility networking
• Collaboration
• Linkages
• Outreach and education
services
• Consumer involvement
Administrative Module
The Administrative Module addresses the following four
requirements:
•
•
•
•
Administrative Structure and Management
Data Reporting
System Coordination
Accessibility, Confidentiality and Cultural Competency
Core Site Visit Requirements At A Glance
Section I: Administrative
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2
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Sections 2601-2692 of title XXVI of
the PHS Act; 42 USC §300ff-11,
§300ff-111; 45 CFR 74; 45 CFR 92;
2 CFR 215; HHS Grants Policy
Statement (2007); HAB Policy Notice
11-02
Administrative Structure
and Management
Grantee maintains a fully staffed management and clinical
team as appropriate for the size and needs of the program.
The organization has established appropriate oversight and
authority over all aspects of the program.
Data Reporting
Grantee has systems which accurately collect and organize
data for program reporting and which support management
decision making.
Section 2664 (a), Section 2671 (c),
and Section 2691 (b) of title XXVI of
the PHS Act; 42 USC §300ff-64,
§300ff-71, and §300ff-101; FOA
Grantee makes efforts to establish and maintain
collaborative relationships with medical and support
providers.
Section 2651 (e) and Section 2671
(c) of title XXVI of the PHS Act; 42
USC §300ff-51 and §300ff-71; HAB
Policy Notice 12-01
System Coordination
Accessibility,
Confidentiality, and Cultural
Competency
Grantee has policies and procedures that address
HIV/AIDS related confidentiality and program processes
that include limiting access to passwords, electronic files,
medical records, faxes and release of client information.
Grantee adheres to accessibility and National Standards
on Culturally and Linguistically Appropriate Services
(CLAS).
Section 2652 (a) (2) and Section
2661 (a) of title XXVI of the PHS Act;
PL104-191 HIPPAA; CLAS
Standards
Requirement 1 - Administrative
Structure and Management
Grantee maintains a fully staffed management
and clinical team as appropriate for the size and
needs of the program. The organization has
established appropriate oversight and authority
over all aspects of the program.
Requirement 1 - Administrative
Structure and Management
Authority:
• Sections 2601-2692 of
title XXVI of the PHS
Act
•
42 USC §300ff-11 and
§300ff-111
•
•
•
•
45 CFR 74 and 92
2 CFR 215
HHS Grants Policy
Statement (2007)
HAB Policy Notice 1102
Source documents:
• Organizational Chart
• SOPs
• Contracts/MOAs for
core providers
• Job Descriptions
• Meeting Minutes
• Sub-recipients
agreements, if
applicable
Requirement 1 - Administrative
Structure and Management
For each question in this section: Determine if the
agency has fully met, partially met, or not met
components of each requirement.
For example, when reviewing the personnel files for
evidence of orientation and training, policy,
procedures and other requirements, ask questions to
prompt discussion with staff and will aid the review of
this requirement.
Requirement 1 - Administrative
Structure and Management
Example
Is Senior Management aware of the local health care
environment and its impact on provision of services
(e.g. state budget cuts, ADAP, ACA, managed care,
etc.). If so, is it reflected in the strategic planning
process and the latest agency Strategic Plan?
Examples of Administrative
Structure and Management
Met, Partially Met, Unmet Standards
Met
•
•
•
Grantee Senior
Management has
approved most recent
personnel manual.
Personnel files located in
a secure location
Staff position descriptions
are documented, current,
and readily available .
Partially Met
•
•
Inconsistent after hours
policy.
Job descriptions are
available but not current.
Unmet
•
•
•
•
HIPAA patient
confidentiality
violations
There are no policies
and procedures for
after hours or
emergency coverage
for medical or dental
services
Job descriptions do
not accurately reflect
the position
requirements of the
work in the Part C/D
funded program
Personnel files are
incomplete.
Requirement 2 - Data Reporting
Grantee has systems which accurately collect
and organize data for program reporting and
support management decision making.
Requirement 2 - Data Reporting
Authority:
• Section 2264 (a),
Section 2671 (c),
and Section 2691
(b) of title XXVI of
the PHS Act
• 42 USC §300ff64, §300ff-71, and
§300ff-101
• FOA Reporting
Requirements
Source documents:
• RSR Report and
RSR
Completeness
Report
• SOPs
• EMR/ EHR
• CAREWare
Requirement 2 - Data Reporting
Evaluate the capacity and system of data collection
 Are there policies in place for data reporting?
Requirement 2 - Data Reporting
Example
Does the grantee reconcile the practice management
system to the Ryan White Services Report?
Examples of Data Reporting
Met, Partially Met, Unmet Standards
Met
•
•
•
Grantee has IT policies
•
and procedures around
confidentiality and access,
and the accuracy of data
found in required reports.
MIS in place and
interfacing with
CAREWare, EHRs/EMRs,
the data collection
process, and cross checks
between a MIS and
submitted reports.
Grantee demonstrates
that the practice
management system data
matches the RSR report.
Partially Met
Policy and procedure
manuals are in place but
does not interface with
CAREWare, EHRs/EMRs,
the data collection
process, or cross checks
between MIS and
submitted reports.
Unmet
•
•
•
Sometimes only the
IT department knows
how to work the
system
Staff not familiar with
the IT capabilities
Grantee does not
have the
infrastructure to
support IT
Requirement 3 - System Coordination
Grantee makes efforts to establish and maintain
collaborative relationships with medical and
support providers.
Requirement 3 - System Coordination
Authority:
• Section 2651 (e) and
Section 2671 (c) of
title XXVI of the PHS
Act
• 42 USC §300ff-51
and §300ff-71
• HAB Policy Notice
12-01
Source documents:
• Contracts and/ or
MOAs
• Standard Operating
Procedures
• Electronic Health/
Medical Records
Requirement 3 - System Coordination
• Ensure that grantees have collaborative
relationships
• Evidence of MOA coordination and linkages with
CDC Funded HIV Testing and outreach services,
local Health Departments, ASOs, and Faith Based
Organizations
• Participation in the Statewide Coordinated
Statement of Need
Requirement 3 - System Coordination
For example, System Coordination should determine
if the organization has an appropriate system which
ensures care coordination and collaborative
relationships with medical and support providers.
Examples of System Coordination
Met, Partially Met, Unmet Standards
Met
•
•
•
Has a current MOA that
clearly defines the extent
of the relationship with the
organization
Detailed Policy and
Procedures highlighting
how to refer patients to
care
Active Participation with
Title V of the Social
Security Act and Maternal
and Child Health Services
agencies.
Partially Met
•
Has Policy and
Procedures highlighting
how to refer patients to
care and participates with
Title V of the Social
Security Act and Maternal
and Child Health Services
agencies but does not
have a current MOA.
Unmet
•
Dated MOA, no
established collaboration
with other RW
organizations, AETC,
FQHC, CDC Funded HIV
Testing and Outreach
Services. No Mental and
Clinical services.
•
No policies and
procedures regarding
referral of Care
•
Does not participate with
Title V of the Social
Security Act and Maternal
and Child Health Service
agencies.
Requirement 4 - Accessibility,
Confidentiality, and Cultural Competency
Authority:
•
Section 2652 (a) (2) and
Section 2661 (a) of title
XXVI of the PHS Act
•
PL104-191 HIPPAA
•
CLAS Standards
Source documents :
• Policies and
Procedures;
• Contracts/MOAs;
• Licenses
• Certifications
• Tour of Facility
Requirement 4 - Accessibility,
Confidentiality, and Cultural Competency
Reviewing Facility/Risk Management,
Cultural Competency and Confidentiality.
Requirement 4 - Accessibility,
Confidentiality, and Cultural Competency
Does the grantee have a clear confidentiality
statement signed in personnel file? In this
instance, consultants are encouraged to
review 30% of the personnel files.
Examples of Accessibility, Confidentiality,
and Cultural Competency
Met, Partially Met, Unmet Standards
Met
•
•
•
•
•
•
Grantee has documented
their staff attendance at
Cultural Competency
Trainings
Policies are in line with
American with Disabilities
Act and site has handicap
accessibility
Risk Management policies
and procedures are
documented
Clients are receiving
culturally competent care
HIPPA rules and
regulations are being
followed
Employees sign a
confidentiality statement
that is clearly in personnel
files.
Partially Met
•
No current documentation
of Cultural Competency
Trainings.
Unmet
•Inadequate policy regarding
Translation Services for
patients.
•Inadequate documentation
of cultural competency
trainings for staff.
•Policies are not in line with
American with Disabilities Act
and site does not have
handicap accessibility.
Questions should be emailed to
David Pitman at
DPitman@hrsa.gov
Next Steps
Please note that successful completion of this webinar is one
qualifying component for selection as a HRSA/DCHAP Site Visit
Consultant.
1) Within two business days, an email will be sent to all
participants that will include a Consultant Questionnaire and
a Post Test Exam.
2) Please return a signed scanned copy of the completed Post
Test Exam and Questionnaire along with a current resume/CV
to David Pitman at DPitman@hrsa.gov within two business
days of receipt of the email.
Contact Information
Karen Gooden, Co-Chair DCHAP Site Visit Workgroup
kgooden@hrsa.gov
Sandra Lloyd, Co-Chair DCHAP Site Visit Workgroup
slloyd@hrsa.gov
John Fanning, DCHAP Senior Policy Advisor
jfanning@hrsa.gov
HHS/HRSA/HAB/DCHAP
301-443-0493