Universal Standards
Universal Standards print version
Texas Department of State Health Services, HIV Care Services Group – HIV/STD Program | Texas DSHS
The Universal Standards listed below apply to all service categories funded under the Ryan White Part B Program for direct care service providers. These Universal Standards are taken directly from the HRSA Standards listed in the Part B HIV/AIDS Bureau (HAB) National Monitoring Standards (NMS) and expanded to include DSHS program requirements for all Ryan White Part B and State Service sub-recipients.
HRSA/DSHS STANDARD: Structured and ongoing efforts to obtain input from clients in the design and delivery of services | |
1 |
Maintain documentation of at least one of the following efforts to obtain client input regarding the design and delivery of services:
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HRSA/DSHS STANDARD: Provision of services regardless of an individual’s ability to pay for the service | |
2 | Sub-recipients billing and collection policies and procedures do not:
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HRSA/DSHS STANDARD: Provision of services regardless of the current or past health condition of the individual to be served | |
3 | Documentation of eligibility and clinical policies to ensure that they do not: (1) permit denial of services due to preexisting conditions; (2) permit denial of services due to non HIV-related conditions (primary care); or (3) provide any other barrier to care due to a person’s past or present health condition. |
HRSA/DSHS STANDARD: Provision of services regardless of English proficiency or other barriers to communication | |
4 | Provide culturally and linguistically appropriate goals and policies that ensure management accountability that language assistance is provided to individuals who have limited English proficiency or other communication needs at no cost to them in order to facilitate timely access to all health care and services. |
5 | Provide documentation of easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area to inform all individuals of the availability of language assistance services. |
HRSA/DSHS STANDARD: Provision of services in a setting accessible to low-income individuals with HIV | |
6 | A facility that is handicapped accessible, accessible by public transportation. |
7 | Policies and procedures that provide, by referral or vouchers, transportation if facility is not accessible to public transportation. |
8 | No policies that may act as a barrier to care for low-income individuals. |
HRSA/DSHS STANDARD: Efforts to inform low-income individuals of the availability of HIV-related services and how to access them | |
9 | Availability of informational materials about sub-recipient’s services and eligibility requirements such as: newsletters; brochures; posters; community bulletins; or any other types of promotional materials. |
HRSA/DSHS STANDARD: Use of Telehealth, Telemedicine, and Teledentistry | |
10 | Policies and procedures for Telehealth, Telemedicine, and Teledentistry, as applicable, must be in place for virtual platforms. Policies should align with all applicable State and Federal laws, as well as the DSHS Guidance for Telemedicine. |
IMPOSITION AND ASSESSMENT OF CLIENT CHARGES | |
HRSA/DSHS STANDARD: Publicly available schedule of charges | |
11 | Establish, document, and have available for review: (Pilot Measure 2024-2025)
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12 | Documentation that a schedule of charges is publicly available. (Pilot Measure 2024-2025) |
13 | Policies and procedures in place to inform clients of their responsibility to track their expenditures to ensure that they are not charged beyond the annual cap on charges based upon their federal poverty level (FPL). (Pilot Measure 2024-2025) |
HRSA/DSHS Standard: No charges are imposed on clients with individual incomes less than or equal to 100 percent of the FPL | |
14 | Policies and procedures document that: (Pilot Measure 2024-2025)
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HRSA/DSHS Standard: Charges imposed for RWHAP services on clients with individual annual gross incomes greater than 100 percent of the FPL are determined by the schedule of charges | |
15 | Policies and procedures limit annual aggregate charges in a calendar year for RWHAP services based on the percent of the client’s annual individual gross income, as follows: (Pilot Measure 2024-2025)
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16 | Imposition of charges policy includes: (Pilot Measure 2024-2025)
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ELIGIBILITY DETERMINATION | |
HRSA/DSHS STANDARD: Eligibility determination and reassessment of clients to determine eligibility as specified by the jurisdiction (in this case State) or ADAP | |
17 | Document that the process and timelines for establishing initial client eligibility, assessment, and recertification takes place at a minimum of every six months. |
18 | Document that all staff involved in eligibility determination have participated in required training. |
HRSA/DSHS STANDARD: Ensure military veterans with Department of Veterans Affairs (VA) benefits are deemed eligible for Ryan White services | |
19 | Documentation that eligibility determination policies and procedures do not consider VA health benefits as the veteran’s primary insurance and deny access to Ryan White services citing “payor of last resort.” |
HRSA/DSHS STANDARD: Payor of Last Resort: Ensure that RWHAP Part B and State Services funds distributed by DSHS are used as PoLR for eligible services and eligible clients | |
20 | Agencies have written policies or protocols for ensuring RWHAP Part B and State Services funds are used as PoLR for eligible services and eligible clients. |
HRSA/DSHS STANDARD: Vigorous Pursuit of Third-Party Payers | |
21 | Sub-recipients have policies in place and maintain documentation that agency educated client on available health insurance options in area. |
22 | Sub-recipients have policies in place and maintain documentation that all clients who are FPL-eligible to enroll in a marketplace plan were offered enrollment assistance or a referral for health insurance options. |
ANTI-KICKBACK STATUTE | |
HRSA/DSHS STANDARD: Demonstrated structured and ongoing efforts to avoid fraud, waste, and abuse (mismanagement) in any federally funded program | |
23 | Employee Code of Ethics including:
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STANDARD: 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 | |
24 | Any documentation required by the Compliance Plan or employee conduct standards that prohibits employees from receiving payments in kind or cash from suppliers and contractors of goods or services. |
QUALITY MANAGEMENT | |
HRSA/DSHS STANDARD: Implementation of a Clinical Quality Management (CQM) Program | |
25 | Documentation that the subrecipient is actively participating in the regional Clinical Quality Management (CQM) Program, including an agency-level CQM plan or inclusion in a regional CQM plan with the following elements: (Pilot Measure 2024-2025)
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OTHER SERVICE REQUIREMENTS | |
HRSA/DSHS STANDARD: Referral relationships with key points of entry: Requirement that Part B service providers maintain appropriate referral relationships with entities that constitute key points of entry | |
26 | Documentation that written referral relationships exist between Part B service providers and key points of entry. |
PROHIBITION ON CERTAIN ACTIVITIES | |
HRSA/DSHS STANDARD: Purchase of Vehicles without Approval: No use of Ryan White funds by recipients or sub-recipients for the purchase of vehicles without written approval of HRSA Grants Management Officer (GMO) | |
27 | No use of Ryan White funds by recipients or sub-recipients for the purchase of vehicles without written approval of HRSA Grants Management Officer (GMO). |
28 | Where vehicles were purchased, review of files for written permission from GMO. |
HRSA/DSHS STANDARD: Lobbying Activities: Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel | |
29 | Prohibition on the use of Ryan White funds for influencing or attempting to influence members of Congress and other Federal personnel. |
30 | Include in personnel manual and employee orientation information on regulations that forbid lobbying with federal funds. |
HRSA/DSHS STANDARD: Direct Cash Payments: No use of Ryan White program funds to make direct payments of cash to service recipients | |
31 | Review of Service Standards and other policies and procedures for service categories involving payments made on behalf of individuals to ensure that no direct payments are made to individuals (e.g., emergency financial assistance, transportation, health insurance premiums, medical or medication copays and deductibles, food and nutrition). |
HRSA/DSHS STANDARD: Employment and Employment-Readiness Services: Prohibition on the use of Ryan White program funds to support employment, vocational, or employment-readiness services | |
32 | Prohibition on the use of Ryan White program funds to support employment, vocational, or employment-readiness services. |
HRSA/DSHS STANDARD: Maintenance of Privately Owned Vehicle: No use of Ryan White funds for direct maintenance expenses (tires, repairs, etc.) of a privately owned vehicle or any other costs associated with a vehicle, such as lease or loan payments, insurance, or license and registration fees | |
33 | Documentation that Ryan White funds are not being used for direct maintenance expenses or any other costs associated with privately owned vehicles, such as lease or loan payments, insurance, or license and registration fees – except for vehicles operated by organizations for program purposes. |
HRSA/DSHS STANDARD: Syringe Services: No use of Ryan White funds shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drugs | |
34 | Documentation that Ryan White funds are not being used for programs related to sterile needles or syringe exchange for injection drug use. |
HRSA/DSHS STANDARD: Additional Prohibitions | |
35 | Documentation that no Part B funds are used to purchase or improve land, or purchase, construct, or permanently improve (other than minor remodeling) any building or other facility. (Pilot Measure 2023-2024) |
SECTION 2: STATEWIDE PROGRAMMATIC STANDARDS | |
GENERAL HIV POLICIES AND PROCEDURES | |
Grievance Policies | |
36 | Agency has a policy or procedure for handling client grievances. |
Delivery of Client Services | |
37 | Agency has written procedures to deal with clients who may be disruptive or uncooperative. |
38 | Agency has written procedures to deal with clients who are violent or exhibit threatening behavior. |
Non-Discrimination Policy | |
39 | Agency has comprehensive non-discrimination policies, which prohibit discrimination on the basis of race, color, national origin, religion, sex, sexual orientation, age, disability, gender-identity, and any other non-discrimination provision in specific statutes under which application for federal or state assistance is being made. |
Confidentiality Regarding Patient Information | |
40 | All staff, management, and volunteers have completed a signed confidentiality agreement annually affirming the individual's responsibility for keeping client information and data confidential. |
41 | All staff, management, and volunteers have successfully completed confidentiality and security training. |
Breach of Confidentiality | |
42 | Agency has detailed policies outlining how to address negligent or purposeful release of confidential client information in accordance with the Texas Health and Safety Code and HIPAA regulations. |
Child Abuse Reporting | |
43 | Agencies will have detailed policies outlining how to address suspected child abuse in accordance with Texas law and DSHS policy. |
44 | Agencies have documented evidence of training provided to all staff on reporting child abuse. |
Incarcerated Persons in Community Facilities | |
45 | Agency has policies in place ensuring RWHAP and State Services funding is not utilized in paying for medical care or medications when incarcerated persons in community facilities are receiving services in local service provider locations. |
Conflict of Interest | |
46 | Agency has written conflict of interest policies and procedures. |
47 | All employees and board members of the agency have completed and signed an annual Conflict of Interest Disclosure Form, which contains, at a minimum, the content in the sample provided by DSHS. |
Personnel Policies and Procedures | |
48 | Personnel and human resources policies are available that address new staff orientation, ongoing training plan and development, employee performance evaluations, and employee/staff grievances. |
Required Training | |
49 | 49 Agency maintains documentation of staff trainings, conferences, and meetings to ensure program compliance. |
50 | Providers shall complete cultural competency training to include cultural awareness of youth and the aging population or relevant local priority populations based on epidemiological data and service priorities. |
Take Charge Texas (TCT) | |
TCT Security Policy | |
51 | Policies are in place at all agency locations that are funded in the state of Texas with RWHAP Part B and State Services funds that ensure TCT information is protected and maintained to ensure client confidentiality. (Pilot Measure 2023-2024) |
TCT Data Managers Core Competencies | |
52 | Agency has local policies and procedures in place relating to TCT and the data collected through TCT. (Pilot Measure 2023-2024) |
CORE SERVICES ADDITIONAL POLICIES AND PROCEDURES | |
Outpatient/Ambulatory Health Services | |
53 |
Ensure that client medical records document services provided, the dates and frequency of services provided, that services are for the treatment of HIV. Texas Administrative Code: |
54 |
Include clinician notes in client records that are signed by the licensed provider of services. Texas Administrative Code: |
55 |
Maintain professional certifications and licensure documents and make them available to the Recipient on request. Texas Administrative Codes: TITLE 22 EXAMINING BOARDS TITLE 22 EXAMINING BOARDS |
56 |
Standing Delegation Orders are available to staff and are reviewed annually, dated and signed. Texas Administrative Code: |
57 |
Follow Texas Medical Board guidelines for client notification and posting of guidance to file complaints for in-person care and telemedicine (English and Spanish). (Pilot Measure 2023-2024) 22 Texas Administrative Code §178.3 |
58 | Service providers shall employ clinical staff who are experienced regarding their area of clinical practice as well as knowledgeable in the area of HIV/AIDS clinical practice. Personnel records/resumes/applications for employment will reflect requisite experience/education. |
59 | All staff without experience with HIV/AIDS shall be supervised by an employee with at least one (1) year of experience. Reviewers will look for evidence of: (1) a policy that states the supervision requirements; (2) language in contracts/MOUs stating that this will occur; or (3) a verification process of staff and staff supervisors in personnel files. |
60 | When the subrecipient is utilizing OAHS funding to only pay for specialty visits or preventive care and screening that the primary clinic does not cover: (1) limitations of the use of funds is documented in the contract between the subrecipient and the Administrative Agency; and (2) the established guidelines are written into agency policies regarding the use of OAHS funds. (Pilot Measure 2023-2024) |
Local AIDS Pharmaceutical Assistance Program (LPAP) | |
61 | Agency has an LPAP policy that meets HRSA/HAB requirements. |
62 |
Only authorized personnel dispense/provide prescription medication. Texas Administrative Code: |
63 |
Medications and supplies are secured in a locked area and stored appropriately. Texas Administrative Code: |
64 | Agency has a system for drug therapy management, if applicable. |
65 | Policy for timeliness of services—prescriptions should be available and approved for LPAP assistance within 2 business days, per LPAP service standard. |
66 | MOUs ensuring cost efficient methods are in place. |
67 | MOUs ensure dispensing fees are established and implemented. |
68 |
Pharmacy technicians and other personnel authorized to dispense medications are under the supervision of a licensed pharmacist. Texas Administrative Code: |
69 |
Active pharmacy license is onsite and is renewed every two years. Texas Administrative Code: |
70 |
Documentation on file that pharmacy owner, if not a Texas licensed pharmacist, is consulting with a pharmacist in charge (PIC) or with another licensed pharmacist. Texas Administrative Code: |
Oral Health Care | |
71 | Oral health services are provided by general dental practitioners, dental specialists, dental hygienists, and auxiliaries and meet current dental care guidelines. |
72 | Oral health professionals providing the services have appropriate and valid licensure and certification, based on State and local laws. |
73 | Services fall within specified service caps, expressed by dollar amount, type of procedure, limitations on the procedures, or a combination of any of the above, as determined by the State and local communities. |
Early Intervention Services | |
74 | Documentation that Part B funds are used for HV testing only where existing federal, state, and local funds are not adequate, and RW funds will supplement, and not supplant, existing funds for testing. |
75 | Documentation that individuals who test positive are referred for and linked to health care and supportive services. |
76 | Documentation that health education and literacy training is provided that enables clients to navigate the HIV system. |
77 | Documentation that EIS is provided at, or in coordination with, documented key points of entry. |
78 | Documentation that EIS services are coordinated with HIV prevention efforts and programs. |
Health Insurance Premium and Cost-sharing Assistance | |
79 | Agency has policy that outlines caps on assistance/payment limits and adheres to DSHS Policy 270.001 (Calculation of Estimated Expenditures on Covered Clinical Services). |
80 | Agency has policy that details the expectation for client contribution and tracks these contributions under client charges. |
81 | Agency has policy that requires referral relationships with organizations or individuals who can provide expert assistance to clients on their health insurance coverage options and available cost reductions. |
82 | Agency has policies and procedures detailing process to make premium and out-of-pocket payments or IRS payments. |
83 | Where funds are used for copays of eyewear, agency must maintain documentation of the physician's statement that the eye condition is related to HIV. (Pilot Measure 2023-2024) |
Home Health Care | |
84 |
Maintain on file and provide to the Recipient upon request, copies of the licenses of home health care workers. Texas Administrative Code: |
85 | Agency policy on operation and procedures to contact agency after hours for urgent or emergency care is current and evident. |
Home and Community-based Health Services | |
86 | Services are being provided only in an HIV-positive client’s home, or a day treatment or other partial hospitalization services program as licensed by the State. (Pilot Measure 2023-2024) |
87 |
Maintain, and make available to Recipient, copies of appropriate licenses and certifications for professionals providing services. Texas Administrative Code: |
88 |
License or certification is posted in a conspicuous place at the agency's main office. Texas Administrative Code: |
89 | Documented policy on operation and procedures to contact agency after hours for urgent or emergency care. |
90 |
All agency professional staff, contractors, and consultants who provide direct-care services, and who require licensure, shall be properly licensed by the State of Texas, or documented to be pursuing Texas licensure while performing tasks that are legal within the provisions of the Texas Medical Practice Act (or in the case of a nurse, the Nursing Practice Act), including satisfactory arrangements for malpractice insurance with evidence of such in the personnel file. Texas Administrative Code: |
91 | Provider will document provision of in-service education to staff regarding current treatment methodologies and promising practices. |
Hospice Services | |
92 |
Obtain and have available for inspection appropriate and valid licensure to provide hospice care. Texas Administrative Code: |
93 | Maintain and provide the Recipient access to program files and client records. |
94 | Documentation that staff attended continuing education on HIV/AIDS and end-of-life issues. |
95 |
Documentation that supervisory provider or registered nurse provided supervision to staff. Texas Administrative Code: |
96 | Agency has a policy regarding reasons for refusal of referral. |
97 | Agency has a policy for patient discharge. |
Mental Health Services | |
98 | Obtain and have on file and available for Recipient review appropriate and valid licensure and certification of mental health professionals, including supervision of licensed staff. |
99 | MOUs are available for referral needs. |
100 | Policies/procedures in place for emergency/crisis intervention plan. (Pilot Measure 2023-2024) |
101 | If mental health services are provided in-house, agency has a policy for regular supervision of all licensed staff. |
102 | If mental health services are provided in-house, agency has a policy for regular supervision of all licensed staff. |
103 | Agency/provider has a discharge policy and procedure. |
Medical Nutrition Therapy | |
104 |
Maintain and make available copies of the dietitian’s license and registration. Texas Administrative Code: |
105 | Staff has the knowledge, skills, and experience appropriate to providing food or nutritional counseling/education services. Personnel records/resumes/applications for employment will reflect requisite education, skills, and experience. |
106 | Licensed Registered Dietitians will maintain current professional education (CPE) units/hours, including HIV nutrition and other related medical topics approved by the Commission of Dietetic Registration. Documentation in personnel records of professional education. |
107 | Agency has a policy and procedure for determining frequency of contact with the licensed Registered Dietitian based on the level of care needed. |
108 | Agency has a policy and procedure on obtaining, tracking inventory, storing, and administering supplemental nutrition products, if applicable. |
109 | Agency has a policy and procedure on discharging a patient from medical nutrition therapy and the process for discharge/referral. |
Medical Case Management, including Treatment Adherence | |
110 | Maintain documentation showing that MCM services are provided by trained professionals who are either medically credentialed or trained health care staff and operate as part of the clinical care team. |
111 | Policies and procedures are in place for conducting MCM services, including data collection procedures and forms, data reporting. |
112 | Staff Qualifications: Minimum qualifications for Medical Case Management supervisors: degreed or licensed in the fields of health, social services, mental health, or a related area (preferably Masters’ level). Additionally, case manager supervisors must have 3 years experience providing case management services, or other similar experience in a health or social services related field (preferably with 1 year of supervisory or clinical experience). |
113 | Required MCM trainings are documented in personnel files. |
114 | The agency shall have policies/procedures for: Initial Comprehensive Assessment. |
115 | The agency shall have policies/procedures for: MCM Case Management Acuity Level and Client contact. |
116 | The agency shall have policies/procedures for: Care Planning. |
117 | The agency shall have policies/procedures for: Viral Suppression/Treatment Adherence. |
118 | The agency shall have policies/procedures for: Referral and Follow-up. |
119 | The agency shall have policies/procedures for: Case Closure/Graduation. |
120 | The agency shall have policies/procedures for: Case Conferencing. |
121 | The agency shall have policies/procedures for: Caseload Management. |
122 | The agency shall have policies/procedures for: Case Transfer (internal/external). |
123 | The agency shall have policies/procedures for: Probationary Period (new hire). |
124 | The agency shall have policies/procedures for: Staff Supervision. |
125 | The agency shall have policies/procedures for: Staff Training, including agency specific training. |
Substance Abuse Outpatient Care | |
126 | Maintain and provide provider licensure or certifications as required by the State of Texas. |
127 | If applicable, facilities providing substance use treatment services will be licensed by the Texas Department of State Health Services (DSHS) or be registered as a faith-based exempt program. |
128 | If applicable, agency will have documentation on site that license is current for the physical location of the treatment facility. |
129 | Documentation of supervision during client interaction with Counselors In Training (CIT) or Interns as required by the Texas Department of State Health Services (DSHS). |
130 | Documentation of professional liability for all staff and agency. |
131 | Provider agency must develop and implement policies and procedures for handling crisis situations and psychiatric emergencies, which include, but are not limited to, the following:
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132 | Agency will have a policy and procedure for clients to follow if they need after-hours assistance. |
133 | There will be written policies and procedures for staff to follow in psychiatric or medical emergencies. |
134 | Policies and procedures define emergency situations, and the responsibilities of key staff are identified. |
SUPPORT SERVICES POLICIES AND PROCEDURES | |
Non-Medical Case Management | |
135 | Maintain client records that include the required elements as detailed by the Recipient. |
136 | Provide assurances that any transitional case management for incarcerated persons meets contract requirements. |
137 | Policies and procedures are in place for conducting NMCM services. |
138 | Non-medical case managers will complete annual trainings per DSHS. |
Child Care Services | |
139 | Maintain documentation of child care services provided. |
140 | Maintain documentation of child care services provided. |
141 | Informal child care arrangements are in compliance with Recipient requirements. |
142 | Agency has a policy and procedure to address liability issues addressed through liability release forms designed to protect the client, provider, and the RW program. |
Emergency Financial Assistance | |
143 | Agency has a policy for documenting client eligibility, types of EFA provided, dates of EFA, and method of providing EFA. |
144 | Policies include medication purchase limitations. |
145 | Agencies providing EFA medications must develop policies and procedures to pursue all feasible alternative revenues systems (e.g., pharmaceutical company patient assistance programs) before requesting reimbursement through EFA. |
Food Bank/Home-Delivered Meals | |
146 | Maintain documentation of: • Services provided by type. • Amount and use of funds for purchase of non-food items. • Compliance with all federal, state, and local laws regarding the provision of food bank, home-delivered meals and food voucher programs, including any required licensure or certifications. • Assurance that RW funds were used only for allowable purposes and RW was the payor of last resort. • Records of local health department food handling/food safety inspection are maintained on file. |
147 | Food pantry program will meet regulations on Food Service Sanitation as set forth by Texas Department of State Health Services, Regulatory Licensing Unit, and local city or county health regulating agencies. |
148 | Current license(s) will be on display at site. |
149 | Records of local health department food handling/food safety inspections are maintained on file. |
150 | Agency will be licensed for non-profit salvage by the Texas Department of State Health Services Regulatory Licensing Unit and local city or county health regulating agencies. |
151 | Food Pantry must display "And Justice for All" posters that inform people how to report discrimination. |
152 | There must be a method to regularly obtain client input about food preference and satisfaction. Such input shall be used to make program changes. |
153 | Director of meal program must complete and pass Service Safety certification every three (3) years. |
154 | An application form is completed for each volunteer. |
155 | Each staff and volunteer position has written job descriptions. |
156 | Staff/Volunteer Education - Personnel files reflect completion of applicable trainings and orientation. |
Health Education/Risk Reduction | |
157 | Maintain records of services provided. |
158 | Documentation that supervisors reviewed 10 percent of each HE/RR staff client records each month. |
Housing Services | |
159 | Maintain documentation of services provided. |
160 | Ensure staff providing housing services are case managers or other professionals who possess knowledge of local, state, and federal housing programs and how to access those programs. |
161 | Policies and procedures are written ensuring individualized written housing plans are consistent with Housing Policy. |
162 | Agency established payment methodology to issue direct payment to housing vendor or voucher system. Agency will establish payment methodology to include either direct payment to a housing vendor or a voucher system with no direct payments to clients. Payment process will include documentation of lease/mortgage, utility bill, fees (late fees, legal), utility bill, IRS Form W-9. |
163 | Documentation of required initial training by staff as outlined for Housing Services completed within three (3) months of hire is located in personnel files. All professional housing providers must complete the following within three (3) months of hire: effective communication; Texas HIV Medication Program; HIV Case Management; HIV and Behavioral Risk; Substance Use and HIV; Mental Health and HIV; local, state, and federal housing program rules and regulations; and how to access housing programs. |
164 | Client eligibility for services, actual services provided by type of service, number of clients served, and level of services will be collected. |
Linguistic Services | |
165 | Policy outlining documentation procedures for the provision of linguistic services. |
166 | Maintain documentation showing that interpreters and translators employed with RW funds have appropriate training and hold relevant State and local certification. |
Other Professional Services | |
167 | Document services provided, including specific types of services. |
168 | Provide assurance that funds are being used only for services directly necessitated by an individual’s HIV status. |
169 | All licensed agency professional staff, contractors, and consultants who provide legal services shall be currently licensed by the State Bar of Texas. |
170 | Law students, law school graduates, and other legal professionals will be supervised by a qualified licensed attorney. |
171 | Agency-paid legal staff and contractors must complete two (2) hours of HIV-specific training annually. |
172 | Agency maintains system for dissemination of HIV/AIDS information relevant to the legal assistance needs of PLWH to staff and volunteers. |
Medical Transportation Services | |
173 | Maintain program files. |
174 | Maintain documentation that the provider is meeting stated contract requirements with regard to methods of providing transportation. |
175 | Collection and maintenance of data documenting that funds are used only for transportation designed to help eligible individuals remain in medical care by enabling them to access medical and support services. |
176 | Obtain HRSA and State approval prior to purchasing or leasing a vehicle(s). |
177 | Maintains voucher or token system(s). |
Outreach Services | |
178 | Document the design, implementation, priority areas and populations, and outcomes of outreach activities. |
179 | Document and provide data showing that all RFP and contract requirements are being met with regard to program design, targeting, activities, and use of funds. |
180 | Within the first (3) months of hire, 16 hours of training for new staff and volunteers shall be given, which includes, but is not limited to:
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181 | Each outreach supervisor, staff, and volunteer shall hold a valid Texas driver’s license and proof of liability insurance, if needed, to carry out work responsibilities. |
Psychosocial Support Services | |
182 | Program staff conducting nutritional counseling will be trained to perform nutritional assessments. |
183 | All non-professional staff delivering support group facilitation must be supervised by a licensed professional. |
Referral for Health Care/Supportive Services | |
184 | Maintains program files. |
185 | Maintains client records that include required elements as detailed by the State. |
186 | Maintains documentation demonstrating that services and circumstances of referral services meet contract requirements. |
Rehabilitation Services | |
187 | Maintains client records that include the required elements as detailed by the State. |
188 | Rehabilitative services must be provided in an outpatient setting. This may include ambulatory outpatient or home setting. Contracts or Memoranda of Agreement/Understanding are in place with these agencies/individual providers to provide services in an outpatient setting. |
189 | Direct supervision by a licensed/certified professional during client interaction is required if assistants or students are providing care. |
190 | Staff participating in the direct provision of services to clients must satisfactorily complete all appropriate continuing education units (CEUs) based on license requirement for each licensed/certified therapist. Courses in HIV disease and transmission should be part of continuing education. |
Respite Care | |
191 | Staff will have the skills, experience, and qualifications appropriate to providing respite care services. When the client designates a community respite care giver who is a member of his or her personal support network, this designation suffices as the qualification. |
192 | All non-professional staff must be supervised by a degreed or licensed individual in the fields of health, social services, mental health, or a related area, preferably master’s level. A person with equivalent experience may be used. |
193 | Supervisors must review a 10 percent sample of each employee's records each month for completeness, compliance with these standards, and quality and timeliness of service delivery. |
194 | Each supervisor must maintain a file on each staff member supervised and hold supervisory sessions on at least a weekly basis. The file on the staff member must include, at a minimum:
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Substance Abuse Services (residential) | |
195 | Maintain documentation of provider licensure or certifications as required by the State. This includes licensures and certifications for a provider of acupuncture services. |
196 | Documentation of staffing structure showing supervision by a physician or other qualified personnel. |
197 | Provide assurance that all services are provided in a short-term residential setting. |
198 | Maintain program files that document allowable services provided, and the quantity/frequency/modality of treatment services. |
199 | Agency maintains client records. |
200 | Agency will have documentation on site that license is current for the physical location of the treatment facility. |
201 | Documentation of supervision during patient interaction with Counselors in Training (CIT) or Interns as required by DSHS. |
202 | Each staff member will have documentation of minimum experience to include:
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203 |
All direct care staff shall maintain current Cardiopulmonary Resuscitation (CPR) and First Aid certification. Licensed health professionals and personnel in licensed medical facilities are exempt if emergency resuscitation equipment and trained response teams are available 24 hours a day. |
204 | Documentation of professional liability for all staff and agency. |
205 | Agency shall have a policy and procedure to conduct Interdisciplinary Case Conferences held for each active patient at least once every six (6) months. |
206 | Agency must develop and implement policies and procedures for handling crisis situations and psychiatric emergencies, which include, but are not limited to, the following:
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207 | Agency will have a policy and procedure for patients to follow if they need after-hours assistance. |
208 | There will be written policies and procedures for staff to follow for psychiatric or medical emergencies. |
209 | Policies and procedures define emergency situations, and the responsibilities of key staff are identified. |