UNIVERSALSTANDARDS

STANDARD / MEASURE
1. Accessto Services
a. Servicesmustbeprovidedirrespectiveofage,physical or mental challenges,creed,criminalhistory, historyofsubstanceuse,immigrationstatus,marital status,nationalorigin, race,sexualorientation,genderidentityandexpression,socioeconomic status,orcurrent/pasthealthconditions. /
  • Policiesandprocedures
  • Consumer grievances

b. Sub-recipients mustmaketranslatoror interpreterservicesavailableforthoseconsumerswhoneedthem. /
  • Policiesandprocedures
  • Programliteratureinapplicablelanguage

c. Services mustbeprovidedinaccordancewiththe Americanswith DisabilityAct guidelines. Formore information,refer to:ADA Guidelines. /
  • Policiesandprocedures

d. Sub-recipients must have written instructionsforconsumersonhowtoaccesstheSub-recipientsafterbusinesshours. /
  • Policiesandprocedures
  • Informationalflyers,handouts

2. HIV Continuum ofCare
a. Sub-recipients mustestablishformalcollaborativeagreementswith HIV and other serviceorganizations. /
  • MemorandaofAgreementorMemorandaofUnderstanding

b. Sub-recipients mustinformconsumersofthevariousHIV services and resourcesavailablethroughoutthe Transitional Grant Areas, (TGA) /
  • Informationalflyers,handouts,resourcemanuals,literature
  • Documentation in consumerrecords of resourcesgiven

c.Sub-recipients must have aresource referralandtracking systemwithidentifiedHIVandotherserviceSub-recipients. /
  • Referral tracking systemforeach servicecategory

3. Staff Requirements
a. Sub-recipients must havewrittenpersonnelpoliciesandprocedures. /
  • Policiesandprocedures

b. Sub-recipients must offer to staffandcontractedserviceSub-recipientstheirjobdescriptionsthataddressminimumqualifications,corecompetencies,and jobresponsibilities. /
  • Position descriptions

c. Sub-recipients must ensurethatservices are providedin an inclusively, linguistically, culturally-competent,compassionate,non-judgmental, age appropriate andcomprehensiblemanner. /
  • Training/in-servicecertificates/sign-insheets
  • Staffinterview
  • Consumer satisfactionsurvey
  • Consumer grievances

STANDARD / MEASURE
d.Sub-recipients mustensurethat staffandcontractedserviceSub-recipientsdeliveringdirectservices toconsumersmusthaveknowledgeofthe:
  • HIV/AIDSdiseaseprocess
  • EffectsofHIV/AIDS-relatedillnessesandco-morbiditieson consumers
  • Psychosocialeffectsof HIV/AIDSonconsumersandtheirfamilies/significantothers Provide PrEP Education and Resources
  • Currentstrategiesforthe managementofHIV/AIDS
  • HIV-relatedresourcesand services inHartford TGA
For moreinformation,referto:DHHSGuidelines. /
  • Documentationofthisknowledgevia formaleducation,trainings, or othermethods.Typesofdocumentationmayinclude,but isnot limitedto, medicaldegree,license/certification,trainingcertificates, transcripts.
  • Staffinterview

e. Sub-recipients mustensurethatprofessionalstaffandcontractedserviceSub-recipients follow, atminimum,establishedcodesofconductfor theirdiscipline.For paraprofessionalstaff,Sub-recipients mustensurethatanagencycodeofconduct isestablishedandthatstafffollow the code. /
  • CodesofConduct
  • Trainings/in-servicecertificates/sign-in-sheets
  • Staffinterview

f.Sub-recipients mustensurethatstaffandcontractedserviceSub-recipientsreceiveongoing supervisionthat is relevantandappropriate totheirprofessionalneeds. /
  • Supervisory/case conferencemeeting logs
  • Documentationofsupervisoryconsumerrecordreviews

g.Sub-recipients mustensurethatstaffandcontractedserviceSub-recipientsconductbusiness ina mannerthatensurestheconfidentialityofconsumersandfollowsestablishedprotocolsoutlined in theHealthInsurancePortabilityand AccountabilityAct (HIPAA)andthe Connecticut PublicHealthCode. /
  • Policiesandprocedures
  • Trainings/in-servicecertificates/sign-insheets
  • Staffsignatureson agency’sConfidentiality/HIPAAstatements
  • Staffinterview

4. Safetyand EmergencyProcedures
a. Sub-recipients must ensurethatservices are providedinfacilities thatare clean,comfortable, handicap accessibility andfreefrom hazards. /
  • Site visitobservation

b.Sub-recipients must havepolicies andproceduresforthefollowing
  • Physical Plant Safety
  • EmergencyProceduresthatincludefire,severeweather,andintruder/weaponthreat
  • Medical/Health CareCrisis
  • InfectionControlandTransmissionRisk
/
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

STANDARD / MEASURE
  • RiskAssessment
  • Accident/ IncidentReporting
Sub-recipients mustensurethatstaffandcontractedserviceSub-recipients are trainedandfollowing thesafetyandemergencyprocedures.
c. Sub-recipients mustfollowrecommendedOccupationalSafetyand HealthAdministration(OSHA) and Connecticut OccupationalSafetyandHealth Administration (CTOSHA)regulations. /
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

d. Sub-recipients mustfollowthe AssociationforProfessional in InfectionandEpidemiologyGuidelines(APIC) and/or Societyfor HealthCareEpidemiologyof America (SHEA) guidelinesincaringforimmune-compromisedindividuals. /
  • Policiesandprocedures
  • Site visitobservation
  • Trainingcertificatesand/orsign-in sheets
  • Staffinterview

5. ConsumerEligibilityand RecertificationRequirements
a. Sub-recipients mustensurethatRyanWhitefundsareusedas a payeroflastresort. /
  • Policiesandprocedures
  • Documentation in consumerrecords of accessingresourcesfrom otherpayers

b. Sub-recipients must verifyproofof HIV status, income,residency,andinsurancein accordancewiththeDHHSRyanWhite ProgramGuidance#14-01. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofestablishedeligibilityand recertificationwithin specified timeframes

c.ProofofHIV statusmust beestablishedwithin 30businessdaysofintake. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofestablishedHIVstatus withinspecifiedtimeframe

d.If aconsumerisnotenrolled in aninsuranceplan,Sub-recipientsmustassist theconsumerwithbenefitscounselingandenrollmentintoanappropriateinsuranceplan. /
  • Policiesandprocedures
  • Documentation in consumerrecords ofbenefitscounseling/enrollment

6. Intake
a. Sub-recipients must screenconsumersintoappropriateRyanWhite servicecategories asdetermined bypresentingneeds. /
  • Documentation in consumerrecords ofscreeningforappropriateRyanWhiteservices

b. Sub-recipients must completeanintakewithconsumerswithin 5businessdays of initialcontact. /
  • Documentation in consumerrecords of timelyintake withinspecified timeframes

STANDARD / MEASURE
c. Theintakeformmustinclude, atminimum,alltherequireddataelementsincluded in themostrecent RSR Manual. Themost recentversionofthis manualcanbefoundattheHRSA/HABTarget Center. /
  • Intakeform, with all therequireddataelements
  • Documentation in consumerrecords ofcompletedintakes

7. Consents and RelatedConsumerDocumentation
a. Sub-recipients mustobtainanddocumentconsumer’sinformedconsentfor provision ofRyanWhiteservices. /
  • Consent to Serve form

b. Sub-recipients mustensurethatconsumerrecordsaremaintained ina securelocation. /
  • Policiesandprocedures
  • Staffinterview
  • Site visitobservation

c.Sub-recipients must havepolicies andprocedurestoensurethatconsumers’medicalrecordsandotherpersonalhealthinformation are:
  • Securelyfaxed,emailed, or phoned
  • Safelytransported duringthe courseofconductingbusiness
  • Securelystored electronicallywith limitedaccess
  • Sharedwiththirdparties in accordancewithHIPAA
/
  • Policiesandprocedures
  • Staffinterview
  • Sitevisitobservation

d.Sub-recipients musthave a writtenstatementoutliningconsumerrightsthat,atminimum,includes:
  • Nature ofservicesoffered.
  • Conditionsfor service
  • Theabilityto terminate service at anytime.
  • Transferanddischargeprocedures
  • Consumerprogressreview
  • Access to consumerrecords
/
  • Consumer RightsandResponsibilitiesform

e.Sub-recipients musthave a writtenstatementoutliningconsumerresponsibilities that,atminimum,includes:
  • Scheduling,rescheduling, andcancellingappointments
  • Drugand alcohol useon premises
  • Weapons onpremises
  • Acts ofabusetowards staff,propertyorservices
/
  • Consumer RightsandResponsibilitiesform

f.Sub-recipients musthaveanobjective process toaddressand trackconsumers’grievances. /
  • Policiesandprocedures
  • Documentationofresolution ofgrievance

STANDARD / MEASURE
g.Sub-recipients musthave releasesofinformationthat,atminimum,includesinformationregarding:
  • Towhat/whominformationwill be released,includingnameoforganization or person(emergencycontact), address,etc.
  • Whatspecificinformationwill be released
  • Time-limitsfor releases to notexceed 18 months
  • Printednameandsignatureofconsumer/legalguardian
  • Signatureof awitness
Releasesofinformation arenot validonceaconsumer is dischargedfromservices. /
  • ReleaseofInformationform
  • Documentation in consumerrecords ofsignedandupdatedreleasesofinformationbeforethird partydisclosuresaremade

h.Within5businessdays ofcompletingintake,Sub-recipients must reviewwith consumer andobtainsigneddocumentationofthefollowing consentsand relateddocumentation:
  • Consent to Serveform
  • ConfidentialityProcedures,including HIPAA
  • Consumer RightsandResponsibility
  • Grievance process
/
  • Documentation in consumerrecords ofsigneddocumentation

8. Progress Notes
a. A progress note must be done on a client at least monthly /
  • Documentationin consumerrecords ofongoingassessmentofneedsandappropriatereferrals

  1. Documentationof progress notes in consumerrecords at least monthly
/
  • Documentationin consumerrecords ofongoing contactwith other serviceSub-recipients

  1. Documentationin consumerrecords ofprogress toward meeting the goals in the care plan
/
  • Documentationin consumerservice plans thatneeds areclosedout whentheyaremet/deferred

  1. Documentationin consumerrecords after each progress notes showing Sub-recipients full name/title; date; time; credentials within 3 days after interaction with client
/
  • Documentationin consumerservice plans thatneeds areclosedout whentheyaremet/deferred

  1. Documentationin consumer record of efforts to contact client
  2. Documentationin consumerrecords showing no black spaces between progress notes
/
  • Documentationin consumerrecords ofongoing contactwith other serviceSub-recipients

9. Discharge
a.Adischargefromservices must occurifanyofthefollowing criteria ismet:
  • Completionofservices
  • Consumer’sdeath
  • VerificationofHIVpositive status cannotbeobtainedwithin30businessdaysofintake
  • Verificationofeligibilitycannotbeobtained
  • Theconsumer/legalguardian has requestedthecasebe closed
  • Relocationofconsumer outsideof theSub-recipient’sgeographicservice area
  • Inabilityto contacttheconsumerfor morethan90 calendardays
  • Theconsumer’sneedsaremoreappropriatelyaddressedthroughotherSub-recipients
  • Theconsumerexhibitsact ofabusetowardsstaff,propertyor services
/
  • Documentation in consumerrecords thatdischargecriteriawasfollowed

b. Sub-recipients mustnotifyconsumers whentheyarebeing discharged. /
  • Documentation in consumerrecords ofconsumersbeingnotifiedof discharge

STANDARD / MEASURE
10. Consumer Satisfaction
a.Sub-recipients mustestablishevaluationmethodstoassess consumersatisfactionandreceivefeedbackon services usinganyof thefollowingmethods:
  • Consumer AdvisoryBoard
  • Consumer satisfactionsurvey
  • Suggestionboxor otherconsumerinputmechanism
  • Focus groupsand/orpublicmeetings
/
  • Consumer AdvisoryBoardmeetingnotes/minutes
  • Consumer satisfactionsurvey/results
  • Visual verificationofsuggestion boxor otherconsumerinputmechanismsduringsitevisit
  • Notes or reportsfromfocusgroups and/or publicmeetings

b. Sub-recipients mustuse resultsfromevaluationmethodsto improveservicedelivery. /
  • QualityImprovementPlan
  • Modificationto servicedeliverypoliciesandproceduresbasedonfeedback
  • Inclusionofconsumerfeedback ininternaltraining/staffcommunications

MENTAL HEALTH SERVICES

ServiceDefinition

Mental Health Services is the provision of psychological/psychiatric treatment, and counseling services to include individual and group counseling, for individuals with a diagnosis of mental illness. Services must be provided in homeless shelters, clinics, community settings and in rural areas to the fullest extent possible by a state licensed and/or certified mental health professional such as a psychiatrist, psychologist, registered nurse, social worker, counselor, or clinical nurse specialist.

STANDARD / MEASURE
1. StaffRequirements
  1. Sub-recipients must ensure that staff and contracted service Sub-recipients are mental health professionals and are currently licensed to provide such services.
/
  • A copyofmostrecentlicense

2. Assessment
a.Aface-to-faceassessmentmustbe completedwithin 5 businessdaysofintake. /
  • Documentationinconsumerrecords ofcompletedassessmentformor progressnote withinspecifiedtimeframe

b.Theassessmentmustinclude,atminimum,areviewofthefollowingareas:
  • Presentingproblems
  • Medical historyandmedication list
  • Mental healthandpsychiatric history
  • Substanceuseandtreatmenthistory
  • Laboratory assessment, as clinically indicated
  • Familyhistory
  • Historyoftrauma
  • Psychologicalfunctioning
  • Leisureandrecreationalactivities
  • Social support
  • Coordination of Care internal/external resources
  • Name and contact information of HIV Primary Care Sub-recipients and Case Manager
/
  • Assessmentformorprogress note

STANDARD / MEASURE
c.A psychiatricevaluation, asneeded,mustbecompletedwithin 30businessdays of theassessment. /
  • Documentationin consumerrecords of a completedpsychiatricevaluation

3. Treatment Plan
a. A treatmentplanisdevelopedcollaboratively withthe consumerwithin30businessdaysofintake. /
  • Documentationin consumerrecords ofcompletedtreatmentplanwithinspecified timeframe

b.Thetreatmentplanmustinclude:
  • Clinical mental healthdiagnosis; Diagnostic and Statistical Manual of Mental Disorders to clarify illness and disorder
  • A descriptionoftheneed(s)
  • Action steps/interventionstoaddresstheneed(s)
  • Mental health inpatient or Partial Hospitalization, ED due to MH HX:
  • Thetreatmentmodality
  • Timeframestoaddresstheneed(s),includingrecommendednumberofsessions and measureable goals
  • Dated signaturesoftheconsumerandmentalhealthtreatmentSub-recipients
  • Discharge: After care plan must be included in discharge summary
/
  • CompletedandsignedTreatmentPlanform

c. Themental healthsupervisor must reviewand signthe treatmentplans within 5 days of completion /
  • Documentationin consumerrecords oftreatmentplanwithrelevantsignatures

4. Continuityof Care
a. Themental healthtreatmentSub-recipients mustassesson anongoing basis theneedfor othermentalhealth programsthatmaybettermeetconsumer’sclinicalneedsandprovideappropriatereferrals.Thesereferrals mayincludedayprograms,inpatientpsychiatricunits,communitymentalhealthprograms,etc. /
  • Documentationin consumerrecords ofongoingassessmentofneedsandappropriatereferrals

b. Themental healthtreatmentSub-recipients mustmaintainongoing contactandfollow-up withconsumer’smedicalcasemanager,medicalSub-recipients,and/orotherpsychosocial Sub-recipients. /
  • Documentationin consumerrecords ofongoing contactwith other serviceSub-recipients

c. Themental healthtreatmentSub-recipients mustreviewandupdate thetreatmentplanonanas neededbasis /
  • Documentationin consumerservice plans thatneeds areclosedout whentheyaremet/deferred

5. Reassessment
a. Themental healthserviceSub-recipients mustcomplete a reassessment,atminimum,everysixmonths /
  • Documentationin consumerrecords of a reassessment atspecified timeframes

6. Progress Notes
a. A progress note must be done on a consumer at least monthly /
  • Documentationof progress notes in consumerrecords at least monthly

b. The mental health staff will document the progress on meeting the goals addressed in the Care Plan in the client’s record /
  • Documentationin consumerrecords ofprogress toward meeting the goals in the care plan

c. The mental health staff making the progress note entry must use his/her full legal name and title. The entry must also be dated and time, title and credentials within three (3) days after an interaction with the consumer /
  • Documentationin consumerrecords after each progress notes showing Sub-recipients full name/title; date; time; credentials within 3 days after interaction with consumer

d.The mental health staff will document efforts to contact the consumer as needed (e.g., to update consumer information, reassess service care plan, assess completion of referral, etc.) /
  • Documentationin consumer record of efforts to contact client

e. The mental health staff should not leave blank spaces within the progress notes /
  • Documentationin consumerrecords showing no black spaces between progress notes

STANDARD / MEASURE
7. Discharge
a. Themental healthtreatmentSub-recipients mustconsultwithsupervisor to decidethata consumer is to bedischarged /
  • Documentationin consumerrecords ofsupervisoryconsultation

b. If discharge is due to a no show the Sub-recipients must prior to the discharge make a referral to the TGA’s Early Intervention Services for possible reengagement to servicesworks better with MCM /
  • Documentation in consumer records of EIS release of information

c. After adecisionhasbeenmadetodischargeconsumer,thementalhealthtreatmentSub-recipientsmust complete a discharge summarywithin 10businessdays /
  • Documentationin consumerrecords ofdischargesummarywithinspecifiedtimeframes

d. Themental healthtreatmentSub-recipients must ensurethatthedischarge summaryincludes:
  • Summaryofneeds atadmission
  • Summaryofservicesprovided
  • Goals completedduringtreatment
  • Reasonfor discharge
  • Consumer-centered discharge plan
  • Referralsprovided
  • Dated signaturesofthementalhealthtreatmentSub-recipients
/
  • CompletedandsignedDischarge Summaryform

e. Themental healthsupervisor must reviewand signthedischargesummary /
  • Documentationin consumerrecords ofdischargesummarywithrelevantsignatures

STANDARD MEASURE
8. Fee For Services ONLY
  1. Ensure that the referral (manual/CAREWare) is a completed referral and meets all the eligibility requirements
/
  • Documentation reflects completed referral.
  • Documentation of eligibility

  1. Continued Sub-recipients Education

a. The agency must encourage and allow continuing
education and professional development
opportunities to be pursed on an annual basis. At a
minimum 10 hours per year /
  • Documentationin Sub-recipientsrecords of a minimum of 10 hours of trainings per year

b. The agency is responsible for ensuring that each
staff person attends training and educational
opportunities related to HIV/AIDS and pertinent
related topics /
  • Documentationin Sub-recipientsrecords of

Performance Measure

Mental Health

85% of new clients with HIV infection (entering the mental health services for the first time) will have had at least one mental health screening in the measurement year

94% of mental health persons with an HIV diagnosis will have at least one HIV medical care visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between the first medical visit in the prior 6 month period and the last medical visit in the subsequent 6 month period

Service Unit(s):

Face to face individual and/ or group visits

CAREWare Data Reporting:

Part A service sub- recipients are responsible for documenting and keeping accurate records of Ryan White program data/client information, units of service, and client health outcome.