900.002 Completing the Contractor Risk Assessment Tool

Procedure Number	900.002
Effective Date	December 31, 1996
Revision Date	May 12, 2006
Subject Matter Expert	Field Operations Consultants
Approval Authority	Branch Managers
Signed by	Felipe Rocha, M.S.S.W., L.M.S.W. and Sharon K. Melville, M.D., M.P.H.

1.0 Purpose

A Contractor Risk Assessment Tool (RAT) will be completed for each HIV/STD contractor following each program compliance review (formal site review, technical assistance, desktop review, or follow-up visit) in conjunction with the development of the review report. The resulting rating is an assessment of the contractor to provide guidance in determining when future site visits are to be conducted. The RAT rating becomes effective (retroactively) on the last day of the review. The RAT rating may be changed after the lead monitor receives the contractor’s response to the report and is found to have met the criteria for a higher rating.
 

2.0 How to Obtain a RAT

The RAT can be downloaded from the Program Evaluations Tools page.

 

3.0 Completing the RAT Cover Page

The RAT cover page contains comprehensive contract information completed for each contract reviewed during the site visit.

File Name: Use the contractor acronym followed by the scope of work, and then indicate the year and month of the review. For example, if a site review for the Lubbock Health Department’s Prevention Program were conducted in May 2008, the RAT document would be named “LHD PREVF RAT May 2008.” After completing the RAT, the Word file is copied to the appropriate directory as determined by the scope of work. In the example above, the file would then be placed in the S://drive under S:\RAT\PREV/2008.

• S:\RAT\SERVICES\Review Year\contractor SOW RAT date of review.doc

• S:\RAT\SERVICES\Review Year\contractor SOW RAT date of review.doc*

• S:\RAT\HOPWA\Review Year\contractor SOW RAT date of review.doc

• S:\RAT\STD\Review Year\contractor SOW RAT date of review.doc

*Ryan White and State Services

Contractor – Enter the complete legal name of the contractor assessed. No acronyms may be used. This information is located in their application for funding or if an existing contractor, in the contract file.

Contractor Address – Enter the city of the contractor's administrative offices. This information is located in their application for funding or if an existing contractor, in the contract file.

Region – Enter the public health region in which the contractor is located. This information is located in their application for funding or if an existing contractor, in the contract file.

Monitors – Enter the names of the monitors who conducted the review and indicate the lead monitor with an asterisk. The lead monitor will serve as the contact person regarding the information included in the review report and RAT.

DSHS Document # – Enter the DSHS document number for each current and/or pending contract(s) identified. If a pending document does not have a number assigned, enter “pending.” This information is in the contract file.

Contract Amount – Enter the total amount of each contract identified. This information is in the contract file.

Agency Director/Title – Enter name of agency’s director and title specific to the scope of work assessed.

Phone – Enter the telephone number for the agency’s director.

Email – Enter the email address for the agency’s director.

Program Contact/Title – Enter the information for the agency’s contact person specific to the scope of work assessed.

Phone – Enter the telephone number for the identified contact person.

Email – Enter the email address for the identified contact person.

MLP# Assigned – Reserved for tracking purposed for the Contract Management Unit.

Due Date – Reserved for tracking purposes for the Contract Management Unit.

Risk Rating – Enter in the Risk Rating following the completion of the Risk Assessment Tool.

Sanction Level – Enter in the sanction level recommended following the completion of the Risk Assessment Tool, if applicable.

RAT Risk Rating Effective Date – Enter the last day the most recent review.

Review Type – Indicate whether this review was a Formal, Technical Assistance, Desktop or Follow-Up Review.
 

4.0 Completing the Risk Assessment Tool, Specific to the Scope of Work

The Risk Assessment Tool, Specific to the Scope of Work, is the second and third page of the RAT. This section is to be completed for each contract reviewed. This information should be completed based upon the most recent program review, the resulting review report, and other documentation found within this office.

RAT Completed By – Enter your name.

Date – Enter the date of the completed assessment.
 

4.1 Standards

1. The contractor submitted a corrective action plan by the due date if required by the previous site visit report.
   Responses to site visit reports are located in the branch monitoring files.
   Mark YES, NO, or N/A

2. The contractor submits program reports and data by the due date.
   A report is considered submitted on time if it is received on the third working day after a due date. Data submission information can be obtained through the Program Improvement Group (PIG). Reports and data submission includes quarterly reports, semi-annual reports, prevention data, service dates, and STD data entry.
   Mark YES, NO, or N/A

3. The contractor’s program reports and data are complete and accurate.
   Program reports (quarterly and semi-annual reports) are maintained in the branch contract files and copies were routed to the Field Operations consultant and/or Regional Coordinator.
   Mark YES, NO, or N/A

4. The contractor meets objectives as agreed upon in their contract with DSHS.
   Progress towards achieving program objectives is tracked in quarterly and semi-annual reports submitted by the program and through data systems maintained by the Program Improvement Group (PIG).
   Mark YES, NO, or N/A

5. The contractor complies with contractual requirements as reflected in site visit tools, policies, procedures.
   This information is located in the branch contract files or application for funding.
   Mark YES, NO, or N/A

6. The contractor performs required oversight activities for staff and subcontractors.
   Required oversight timelines are located in the contract language and quality assurance portion of the contractor’s application.
   Mark YES, NO, or N/A

7. The contractor has previously been monitored for this or other grants.
   This item is to differentiate between a new contractor who will need a visit within a shorter timeframe and an existing contractor that is not performing.
   Mark YES, NO, or N/A

8. The contractor is free from validated complaints within the last 24 months.
   Mark YES, NO, or N/A

9. The contractor meets the minimum standards for quality management as contractually required (for Administrative Agencies).
   The contractor is meeting contractual requirements as are outlined in the contract language for Administrative Agencies.
   Mark YES, NO, or N/A
    

4.2 Critical Standards

1. The contractor implemented its Plan of Action according to the documented DSHS program approved time line identified in the previous site visit report or subsequent correspondence. Corrective actions and improvements were substantiated during the most recent site visit.
   Responses to site visit reports and subsequent correspondences are filed in the branch monitoring files.
   Mark YES, NO, or N/A

2. The contractor has been free from DSHS and other known state or federal sanctions for the last 24 months.
   Mark YES, NO, or N/A

3. The contractor is on target in implementing the work plan.
   The contractor is implementing the work plan negotiated in its contract and is on target with the activities described in the work plan. Program reports are located in the contract files and copies are routed to the Field Operations consultant or Regional Coordinator.
   Mark YES, NO, or N/A

4. The contractor is free from validated complaints regarding an immediate and/or serious threat to the health and safety of clients since the last review.
   A list of contractors with complaints not resolved in a timely manner is available from the Field Operations Manager or the Group Manager.
   Mark YES, NO, or N/A
    

4.3 Critical Clinical Standards

1. The contractor assures that subcontractors meet the minimum standards for clinical services as contractually required.
   Use the current site visit report developed in conjunction with this RAT. Monitoring team should be in consensus and report findings for the purpose of this RAT documented.
   Mark YES, NO, or N/A.

2. The contractor assures all subcontractors meet minimum standards for case management as required.
   Mark YES, NO, or N/A

3. The contractor assures a resource for HIV related primary care is available and accessible for all eligible clients.
   Mark YES, NO, or N/A

4. The contractor assures that subcontractors who provide client care services for HIV and other sexually transmitted diseases funded under the RWII meet DSHS policies on Child Abuse Screening, Documenting and Reporting.
   Mark YES, NO, or N/A
    

5.0 Scoring

Tally the number of Yes and No answers in the STANDARDS section. Tally the number of Yes and No answers in the Critical Standards section. Tally the number of Yes and No answers in the Critical Clinical Standards section.
Assign a Risk Rating I, II, or III following the instructions for scoring.

1. Justification for Risk Rating
   Within their scope of work, each review team member will narrate a justification for the Risk Rating and explain at minimum all “No” answers.

2. Staff Member Conducting Assessment Agrees with Risk Rating
   Indicate whether you agree with this statement by marking YES or NO. If the reviewer(s) does not agree with the Risk Rating, indicate the new Risk Rating. If the Risk Rating is changed, justification for changing the Risk Rating is required, along with the staff manager’s or team leader’s signature.

3. Sanctions
   Are sanctions recommended for this contractor? Enter Yes or No. Indicate the level and type of sanctions imposed.

4. Justification for Sanctions
   Document reason(s) why sanctions are recommended for this contractor.

5. Additional Staff Comments and Concerns Regarding this Contractor
   Document any additional comments or concerns regarding this contractor. Initial and date comments. (OPTIONAL)
    

6.0 Review Process

Route this document to appropriate regional staff for review prior to submitting to Field Operations Supervisor or Manager. Once regional and central staffs agree with the Risk Rating, document the date.

Submit the final RAT to all of the Team Leaders or Group Managers represented by the site review for signature and approval.

After the Team Leaders or Managers have signed the RAT, it is returned to the lead monitor and/or FO contact person who will copy the Word file to one of the S:\RAT directories, as reflected on page one. The lead monitor and/or FO contact person will route the original RAT to the assigned contract manager who will enter the information in the CPS and the administrative technician will file the hard copy in the contractor’s monitoring file along with the program review report that it was prepared in conjunction with.

The Field Operations Consultant will inform the Team Leader of proposed types of reviews and the review schedule according to the Risk rating and sanction levels of each contract attachment. Proposed travel schedules are to be submitted to appropriate Team Leaders or Managers. The schedule need not be date specific, but should indicate what month and year each contractor will be visited.
 

7.0 Revision History

Date	Action	Section
10/8/2014	Converted format (Word to HTML)	-
7/10/2006	Revisions too substantial to list. Treated as a new policy.	All