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Effective February 2020

AIDS CT Housing Standards of Care

The Quality Assurance Review (QARP) Manual

Effective February 2020

Domain 1: Facilitated Access to Housing and Services AIDS CT QUALITY ASSURANCE REVIEW

Domain 1

Measures

SCORE

(a) Housing

Resource

Utilization

Program Occupancy Rate during the year.

Input(s): Pre-Review Policy Review

Occupancy

fell below 60

percent for a

period of > 2

consecutive

months

Occupancy

did not fall

below 60%

for a period

of > 2

consecutive

months

Occupancy

did not fall

below 70%

for a period

of > 2

consecutive

months

Occupancy

did not fall

below 80%

for a period

of > 2

consecutive

months

Occupancy

did not fall

below 90%

for a period

of > 2

consecutive

months

Occupancy

did not fall

below 100%

for a period

of > 2

consecutive

months

(b) Application

Process

• Application process and eligibility criteria are clear.

• Application process is fully accessible to persons

with disabilities.

• Individuals receive a formal notice of approval or

denial.

• Individuals are notified that they can grieve a denial

and are told how to do so.

• Applicants come from a variety of sources including

hard-to-reach persons.

Input(s): Client Application Section, Pre-Review Policy Review,

Intake Chart (Progress Note& Admission Letter)

No elements

Present

One element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present

Selection

Research on

client selection

• The program has clearly stated eligibility criteria for

admission into the program that are in compliance

with funders requirements.

• The program uses consistent intake process.

• Client selection is first come - first served or based

on identified waitlist priorities.

• Name, date and referral source are documented in

intake forms.

• HIV status is verified with handwritten doctor

signature and license number (scanned or faxed

copies acceptable)

Input(s): Client Application Section, Pre-Review Policy Review,

Intake Chart

No elements

Present

One element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present

(d) Client

Eligibility

Housing and services are for individuals or heads of

household who fall below 80% of the Federal Poverty

Level (FPL) and have an HIV or AIDS diagnosis

Inputs: Intake Charts: Disability and Homelessness Verification

Form

Verification

of homeless

and

disability

status not

present

Verification

of homeless

and

disability

status

present in

≥20% of files

Verification

of homeless

and

disability

status

present in

≥40% of files

Verification

of homeless

and

disability

status

present in

≥60% of files

Verification

of homeless

and

disability

status

present in

≥80% of files

Verification

of homeless

and

disability

status

present in

100% of files

Effective February 2020

Domain 2: Client Rights, Input and Leadership AIDS CT QUALITY ASSU

RANCE REVIEW

Domain 2

Measures

Score

(a)

Client Lease

Client’s lease or housing agreement conforms to fair

housing law.

Input(s): Active and Intake Charts: Copy of Lease

Not

present

Lease

present in

≥20% of

files

Lease

present in

≥40% of files

Lease

present in

≥60% of files

Lease

present in

≥80% of files

Lease

present in

100% of files

(b)

Client Guide

There is signed verification of receipt of resident manual

and HUD VAWA policy as of March 1 2020

Input(s): Active and Intake Charts

Statement

Signed

statement

in at least

20% of

Client files

Signed

statement in

at least 40%

of Client files

Signed

statement in

at least 60%

of Client files

Signed

statement in

at least 80%

of Client files

Receipt in at

100% of

Client files

(c)

Client Input

• Client have regular opportunities to provide input into

program operations and rules, and to voice

complaints.

• Rules are communicated clearly, consistently enforced,

and are distributed to Clients at intake.

• There are clearly defined grievance procedures that

are communicated to Clients that include review,

disposition and decision completed within 30 days of

the receipt of the grievance with an additional 15 days,

if approved by the agency director, provided the Client

is notified.

• Resident satisfaction surveys are completed annually

and program responds to the information provided.

• Clients are proactively notified of their rights including

how to obtain legal services.

Input(s):Pre-Review Policy Review/ Client and Staff Interviews

elements

Present

One

element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present

(d)

Client Rights

• Client files and charts are securely maintained to

ensure protection of confidential information.

• Staff advocate with landlords and/or property

managers regarding Clients’ rights.

• Staff understands the expectation regarding Client

rights and has signed confidentiality pledges annually.

• All partners involved in the program understand the

expectations regarding Client rights and

confidentiality.

• Protected information is shared only with Client

consent.

Input(s):Pre-Review Policy Review/ Client and Staff Interviews/ Active

Chart Review

elements

Present

One

element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present

Effective February 2020

Domain 3: Housing Quality & Safety AIDS CT QUALITY ASSURANCE REVIEW

Domain 3

Measures

0 1 2 3 4 5 Score

(a)

Health and

Safety

• The program complies with the federal Department of

Labor Occupational Safety and Health Administration

(OSHA) “Enforcement Procedures for the Occupational

Exposure to Blood-borne Pathogen Standards”, as set forth

in 29 CFR 1910. 1030.

• The program facilities, in compliance with all state and

local health, fire and building codes including offices, fire,

alarm, if applicable elevator has been inspected and

Qualified Food Operator certificate available, if applicable.

• The program has protocols for educating staff and Clients

about health issues, including but not limited to,

Tuberculosis, Hepatitis B and C.

• Community based services and transportation are easily

accessible.

• There is adequate space for service delivery, community-

building, meetings and property management activities.

Input(s):Pre-Review Policy Review/ Staff Interview/ Chart reviews

elements

Present

One

element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present

(b)

Assessment of

Housing

Staff meet with Clients in their apartments or living space at

least every six months and review maintenance, health, safety

and quality.

Initial inspection will satisfy lead-free housing requirement if

children 6 or younger present and if the housing unit was built

before 1978.

Input(s): Active Charts: Progress Notes/ Apartment Inspection Form

Not

present

Present in

at least

20% of

Client files

Present in

at least

40% of

Client files

Present in

at least

60% of

Client files

Present in at

least 80% of

Client files

Present in

100% of

Client files

(c)

Emergencies

and Critical

Incidents

Incidents that are deemed critical by the agency policy are

verbally reported to management within 3 hours of incident

discovery followed by a written report within 1 business day,

with formal management review within 30 to 60 days after

the verbal report. Housing condition emergencies are

addressed within 24 hours of discovery.

Input(s):Pre-Review Policy Review/ Staff Interview/ Active Chart Review

Not

present

at least

20% of

Client files

where

applicable

at least

40% of

Client files

where

applicable

at least

60% of

Client files

where

applicable

at least 80%

of Client files

where

applicable

in 100% of

Client files

where

applicable

(d)

Child Abuse and

neglect

Suspected child abuse/neglect is reported by the provider or

collaborating provider via an oral report to DCF as soon as

practical but no longer than 12 hours after suspected abuse

with a written follow-up report to DCF no longer than 48

hours after the oral report and incident is reviewed by

management.

Input(s): Pre-Review Policy Review: Employee Handbook

Not

present

at least

20% of

Client files

where

applicable

at least

40% of

Client files

where

applicable

at least

60% of

Client files

where

applicable

at least 80%

of Client files

where

applicable

in 100% of

Client files

where

applicable

Effective February 2020

Domain 4: Support Services Design and Delivery: Client-Focused/Client-Centered Services & Client Engagement AIDS CT ASSURANCE REVIEW

Domain 4

Measures

Score

(a)

Client Education

and

Engagement

Percent of Clients who agree or strongly agree with

"Staff helped me obtain information I needed so

that I could take charge of managing my illness" on

consumer survey.

Input(s): Agency Client Satisfaction Survey

0 – 49%

50-59%

60-69%

70-79%

80-89%

90-100%

(b)

Acuity

Assessment

The client’s most recent assessment is completed,

contains all information necessary to plan and

provide services.

Input(s): Active Chart Reviews: Acuity Index

0 to 19 %

are complete

20-39% are

complete

40-59% are

complete

60-79% are

complete

80-99% are

complete

All are

complete

(c)

Service Plan

Service plan goals are based on the results of the

Acuity Index (or other person-centered goals, if

desired by client).

Input(s): Active and Intake Chart Reviews: Acuity Index and

Service Plan

No service

plan goals

are present

or goals not

based on the

acuity index

or person-

centered

goals

Service plan

goals based

acuity index

or person-

centered

goals in

≥20% of

plans

Service plan

goals based

acuity index

or person-

centered

goals in

≥40% of

plans

Service plan

goals based

acuity index

or person-

centered

goals in

≥60% of

plans

Service plan

goals based

acuity index

or person-

centered

goals in

≥80% of

plans

Service plan

goals based

acuity index

or person-

centered

goals in

100% of

plans

(d)

Service

Provision

• Case manager contacts Clients at least 2 times per

month (including at least one face-to-face) or for

Clients with less intensive needs an alternate plan

of contact approved by supervisor is

implemented.

• Case managers are flexible in their response to

Client meeting times/locations and services

provided.

• Clients who refuse services are regularly engaged

using different methods in an attempt to increase

likelihood of service participation.

Inputs: Active Charts: Progress Notes/Client and Staff Interviews

Not present

at least 20%

of Client files

at least 40%

of Client files

in at least

60% of Client

files

at least 80%

of Client files

in 100% of

Client files

Effective February 2020

Domain5:SupportServicesDesignandDelivery:ServicesthatPromoteRecovery,WellnessandCommunityIntegrationAIDSCTQUALITYASSURANCEREVIEW

Domain5 Measures



0 1 2 3 4 5 Score

(a)

Connectionto

Benefitsand

Income

PercentofClientsincreasedtheirincomefromall

sourcesduringtheyear.(Ifzeroincome,toreceive

points,thereisdocumentationprovidedshowing

duediligencewiththeagency.)



Input(s):Pre‐ReviewDateReview,HMISAPRs 

0‐49% 50‐59% 60‐69% 70‐79% 80‐89% 90‐100%

(b)

Connectionto

Healthcare

 Clientsareconnectedtomedicallyappropriate

levelsofmedicalcareincluding,butnotlimited

to,PrimaryCare/InfectiousDiseaseCare.

 Programisabletodemonstratepracticesfor

consistenttrackingofclients’viralloadandCD4

countsandusesthisinformationonanindividual

andaggregatelevel



Input(s):ActiveCharts:ProgressNotes,ServicePlan,Acuity

Index

Notpresent Atleast20%

ofclientfiles

Atleast40%

ofclientfiles

Atleast60%

ofclientfiles

Atleast80%

ofclientfiles

In100%of

clientfiles



(c)

Evaluating

Service

Progress

Progressnotesreflectactivitiestakentomeet

serviceplangoals.



Input(s):ProgressNotes,ServicePlan,AcuityIndex

Notpresent

ordonot

reflect

actionstaken

tomeet

goalsplan

goalsin<20

percentof

files

Progress

notesreflect

activities

takento

meetservice

plangoalsin

atleast20%

ofClientfiles

Progress

notesreflect

activities

takento

meetservice

plangoalsin

atleast40%

ofClientfiles

Progress

notesreflect

activities

takento

meetservice

plangoalsin

atleast60%

ofClientfiles

Progress

notesreflect

activities

takento

meetservice

plangoalsin

atleast80%

ofClientfiles

Progress

notesreflect

activities

takento

meetservice

plangoalsin

allClientfiles



(d)

Service

Coordination

andConnection

toResources

 CasemanagersassistClientsinidentifyingand

accessingcommunityprovidersandresources.

 Servicesarewell‐coordinatedwithother

providersandreferralsaredocumentedand

tracked.



Input(s):ActiveCharts:ProgressNotes,ServicePlan,Acuity

Index



Notpresent atleast20%

ofClientfiles

atleast40%

ofClientfiles

atleast60%

ofClientfiles

atleast80%

ofClientfiles

in100%of

Clientfiles



Effective February 2020

Domain6:FocusonHousingStabilityAIDSCTQUALITYASSURANCEREVIEW

Domain6 Measures



0 1 2 3 4 5 Score

(a)

Housing

Stability

 PercentofClientswhoexitedtonon‐

homelessness.



Inputs:HMISAPR,Pre‐Review

0

–

59% 60‐69% 70‐79% 80‐89% 90‐99% 100%



(b)

Discharge

Practices

 Programhasacomprehensivedischargepolicy.

 DischargedClientsgiveninformationregarding

dischargegrievanceprocedure.

 Dischargegrievancereviews,dispositionsand

decisionsarecompletedwithin30daysofthe

receiptofthegrievancewithanadditional15

days,ifapprovedbytheagencydirector,

providedtheformerClientisnotified.

 Clientsareno

tremovedfromhousin

gwithout

legalevictionproceedings,ifatenantholdsthe

lease.

 Fortenantsofprogramwithagreements,this

dischargeisinaccordancewithprogrammatic

dischargepolicy.

 Foralldischarges,appropriatecommunication

existswithproviders,landlord,andothersas

appropriate.

Input(s):DischargedCharts:ProgressNotes,ServicePlan,Acuity

Index,DischargeSummary



Noelements

Present

Oneelement

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present



(c)

Continuityof

Support

 Thedischargesummaryincludesidentificationof

providerscontinuingservices,reasonfor

discharge,locationofnewresidence,assessment

ofongoingneeds,andabilitytomaintainhousing

whenpossible.

 Clientdischargeplanningoccursatleast3

monthsinadvanceofdischargedatewhen

possible

 Thereisatleas

t1attempt

edcontactpermonth

for3monthsafterindividualisdischarged

Input(s):DischargedCharts:ProgressNotes,ServicePlan,Acuity

Index,DischargeSummary



Notpresent atleast20%

ofClientfiles

atleast40%

ofClientfiles

atleast60%

ofClientfiles

atleast80%

ofClientfiles

in100%of

Clientfiles

ORno

discharges

occurred

withinthe

review

timeframe



Effective February 2020

Domain7:BuildingInternalQualityAssurancePractices,KeyStaffingandCoordinationAIDSCTQUALITYASSURANCEREVIEW

Domain7 Measures



0 1 2 3 4 5 Score

(a)

Documentation

Quality

 Acuityindexsignedanddatedbycasemanagerandsupervisor.

 Dischargesummariessignedanddatedbycasemanagerand

supervisor.

 ServiceplanssignedanddatedbyClient,casemanagerand

supervisor.

 Progressnotesenteredwithin1weekofservices.

 Progressnotesincludedateofservice,ty

eofcontact,dateof

note,andpersonenteringnote.

Input(s):Discharged&ActiveCharts:ProgressNotes,ServicePlan,AcuityIndex,

DischargeSummary



Not

present

atleast

20%of

Client

files

atleast

40%of

Client

files

atleast

60%of

Clientfiles

atleast80%

ofClientfiles

in100%of

Clientfiles



(b)

Standardsfor

Planningand

Documenting

Services

 Serviceplangoalsaremeasurable.

 Clientinputisapartofserviceplandesign.

 Thereisacollaborativerelationshipwhichexistsand is

documentedbetweencasemanagersandotherprovidersand

landlord.

Input(s):ActiveCharts:ProgressNotes,ServicePlan;Staff&ClientInterviews

Not

present

atleast

20%of

Client

files

atleast

40%of

Client

files

atleast

60%of

Clientfiles

atleast80%

ofClientfiles

in100%of

Clientfiles



(c)

Timelinessof

Service

Provision

 Acuityindexcompletedwithin30daysofentryandrepeatedat

leastevery6months.

 TheserviceplanbasedontheAcuityIndex(orotherperson‐

centeredgoals,ifdesiredbyclient)developedwithin60daysof

admission.

 Serviceplansupdated/amendedatleasteve

rysixmont

hsbased

uponthemostrecentAcuityIndexand/orotherperson‐centered

goals.

 Progresstowardmeetingserviceplangoalsisdocumentedat

least2timespermonthunlessanalternateplanisdocumented.

Input(s):ActiveCharts:ProgressNotes,ServicePlanandAcuityIndex

Not

present

atleast

20%of

Client

files

atleast

40%of

Client

files

atleast

60%of

Clientfiles

atleast80%

ofClientfiles

in100%of

Clientfiles



(d)

Staffing

 Staffmeetsthecurrentcaseloadrequirements.

 Casemanagersattended10hoursormoreofcasemanagement

trainingduringtheyear,3hoursofwhichmustbeHIVmedical

trainings.

 Coveragehoursclearlydefinedandinclude24houron‐call

supervision.

 Casemanagerandprogramsupervisorjobdescriptionsand

qualificationsarestandardizedandcont

ainclearlydefinedroles

andres

ponsibilities.

 Thereisaclearandongoingevaluationofemployee

performance.

Input(s):Pre‐ReviewPolicyReview&EmployeeHandbook

Not

present

One

element

Present

Two

elements

present

Three

elements

present

Four

elements

present

Five

elements

present



Effective February 2020

Scoring AIDS CT QUALITY ASSURANCE REVIEW

Domain

Available

Points

High Quality

Meets Quality

Stronger Focus

on Quality

Needed

1: Facilitated Access to Housing and Services 20 18.5-20 16.5-18 0-16

2: Client Rights, Input and Leadership 20 18.5-20 16.5-18 0-16

3: Housing Quality & Safety 20 18.5-20 16.5-18 0-16

4: Support Services Design and Delivery: Client-Focused/Client-Centered Services & Client Engagement 20 18.5-20 16.5-18 0-16

5: Support Services Design and Delivery: Services that Promote Recovery, Wellness and Community

Integration

20 18.5-20 16.5-18 0-16

6: Focus on Housing Stability 15 13.5-15 11.5-13 0-11

7: Building Internal Quality Assurance Practices, Key Staffing and Coordination 20 18.5-20 16.5-18 0-16

1. Total Score Grade

High Quality

Meets Quality

Needs Stronger

Focus

122.5 - 135

108.5 - 122

108 and below

2. AIDS CT Quality Review Implications: Consequences: Who will be audited again? (proposed, pending funders concurrence)

Exemption for 2 years

Exemption for 1 year

with Corrective Action

Plan for specific domain

Reviewed next year &

required Corrective

Action Plan within 2

months

High Quality with no

domain needing stronger

focus

Meets Quality with no

more than one domain

needing stronger focus.

Needs Stronger

Focus

and Meets Quality

where more than

one domain needing

stronger focus

0.0

Effective February 2020

ACT Quality Assurance Review Manual

Adapted from Connecticut Supportive Housing Quality Assurance Review Manual

1/28/2014

Effective February 2020

PRE-REVIEW PROCESS

Quality Assurance Review Process

Pre-Review Worksheet

Review Contacts & Location

Please provide the address where reviewers should report on the day of the site review: Please include any special

parking considerations.

Contact for Review/Feedback:

Phone: Email:

If applicable, additional or alternate contacts for Review/Feedback:

Name: Phone: Email:

A. The provider should submit the following information to ACT at least 4 weeks before the on-site review:

 Program Information- from the client perspective

 Application Form- if not using the universal CAN (D.1B)

 Grievance Procedure for:

o Entry into program (D.2C)

o While in program (this could be your Incident Report form) (D.2C)

o Discharge from program (D.6B)

 Program’s Comprehensive Discharge Policy

 Group Materials:

o A list of training topic for clients and staff on required health issues—including the number attending

and percent of group (D.3A)

 Customer surveys (Summarized reports dated for prior year)

o Number of responses to each question and percent of the current group (D.4A)

o Percent with appropriate response to question “staff helped me obtain information I needed so that I

could take charge of managing my illness.” (D.4A)

 Current caseload /provider summarized (D.7D)

 Data Reports—highlight or extract the information needed to calculate the outcomes – occupancy rate, Length of

Stay (LOS), income and an explanation provided if necessary. For sites with multiple components (scattered site,

congregate) do calculations separately and then combined. (D.1A)

 Policies on Abuse and Neglect (i.e. Child abuse, elder abuse, domestic violence) Child Abuse and Neglect- Process

and Procedures and Form used (D.3D)

 Critical Incidents- Process and Procedures and Form used (D.3C)

Did you program have any Critical Incidents during this review period? Yes No

 Current 24-hour coverage schedule/After business hour emergency contact (D.7D)

 Standard job descriptions of case manager and supervisors (D.7D)

 Program occupancy goal and actual occupancy for each month (D.1A)

 Employee evaluation procedure (D.7D)

 Program facilities: copy of documentation regarding state and local health, fire and building, fire alarm, elevator

inspection and Qualified Food Operator certificates (if—and—all that apply to your program.) (D.3A)

Effective February 2020

Data (only de-identified data should be submitted)

• List of program vacancies for prior year (D1A)

• A copy of the results of the most recent consumer survey for the program (D.2C, D.4A)

• A copy of the most recent HUD APR for the program Length of stay for each Client served (including discharges)

during the prior year (D.1A)

• Current caseload numbers for each case manager (D.7D)

• Training hours and courses completed in the prior year for each case manager (D.7D)

• Percent of Clients who have an identified primary healthcare provider (D.5B)

B. Programmatic Data

Program Being Reviewed:

Funding Source: Housing Type (i.e. PSH, Congregate, Rapid):

No During this review Period did your program have any critical Incidents? Yes

If so please briefly describe incident(s):

Total Clients served in last 12 months:

Number of new Clients in the last 12 months: Number of discharges in last 12 months:

Applications received in the last 12 months: Number of rejected applications:

Program Capacity:

(D.5A)

*Program vacancy rate for each month (capacity/vacancies)

Most recent HMIS APR report:

Percent of Clients who increased income from all sources over the past year:

Percent of Clients who remained in permanent housing or exited to permanent housing:

(D.6A)

Month 1 2 3 4 5 6 7 8 9 10 11 12

Capacity

Vacancies

Rate

0.00%

Effective February 2020

This table is an optional tool for providers to use to provide data for the Independent Reviewer

Client ID

Date of

Admission

Date

Housed

Increased

Earned Income?

(Y/N)

Increased

Other

Income

(Non-

earned

Income)

(Y/N)

Date of

Discharge

or N/A if

client is

still in

program

Non-

Cash/mainstream

benefits(Y/N)

Health

Insurance

(Y/N)

If applicable,

did client exit

to permanent

housing

(Y/N or

indicate if

tenant is

deceased)

Current Case Manager

Effective February 2020

C. Application Form and Materials Review

1. Is the application process and eligibility criteria clear? (D.1B)  Yes No

2. Is the application process fully accessible to persons with disabilities? (D.1B)  Yes No

3. Do application materials indicate or suggest that service participation is a requirement?  Yes No

4. Do application materials include an assessment of housing readiness or any indication that housing readiness is a

requirement?  Yes No

5. Are there additional admission requirements beyond housing/homeless status, disability and below poverty level?

Yes No

6. Copies of all staff annual confidential pledge? (D.2D)  Yes No

7. Policy on blood borne pathogens and Hepatitis B vaccination (D.3A)  Yes No

Grievance Process Information

1. Is there a standard grievance process that includes reviews, dispositions and decisions within 30 days of the receipt of

the grievance with an additional 15 days, if approved by the agency director, provided the Client is notified. (D.2C)

 Yes No

2. Is the process for submitting a grievance clear? (D.2C)  Yes No

3. Are Clients notified that they have a right to obtain legal services including how to access such services? (D.2C)

 Yes No

Client Group Materials, Notifications of Meetings, Agendas, Minutes, etc.

1. Is there an identified consumer group? (D. 2C) Yes No

2. Does the consumer group meet regularly? (D.2C)  Yes No

3. Do staff support and provide assistance to the consumer group? (D.2C)  Yes No

4. Do consumer group meetings include opportunities to provide input into program operations, rules and to voice

complaints? (D.2C)  Yes No

Current Coverage Schedule

1. Is the current coverage schedule clearly defined and does it include on call supervision 24 hrs/day 7 days/week?

(D.7D)  Yes No

Employee Evaluation Procedure and Form

1. Are employees evaluated using a uniform process and criteria and on a defined schedule? (D.7D)  Yes No

Standard Job Descriptions for Case Managers and Supervisors

1. Are job descriptions for case manager and supervisors standard, including qualifications and do they include clearly

defined roles & responsibilities? (D.7D)  Yes No

Effective February 2020

Current Caseload Numbers for Each Case Manager

1. Do staff meet or exceed the current caseload requirements? (D.7D)  Yes No

Training hours completed in the prior year for each case manager

1. Have all staff has at least 10 hours of training in the prior year?

 Yes No

(Prorate for new staff or staff on leave) (D.7D)

2. Have at least 3 of the 10 trainings hours been HIV medical trainings?

 Yes No

Effective February 2020

ON-SITE REVIEW PROCESS

The on-site review consists of four parts:

1. A review of rej

ected applications in the prior year (if any)

2. A review of five or 10 percent (whichever is greater) of active Client charts

3. A review of all intake charts (up to 5) in the prior year. If there were more than 5 intakes, randomly select 5.

3. A chart review of all Clients discharged in the prior year

4. Staff interviews (both program manager and case managers)

5. Observations

6. Focus Group

Agency/Program:________________________ Reviewer:__________________________ D

ate:_____________

Rejected Applications

Client Codes

Element

Y/N/NA

Name, date and, disability referral source

documented (D.1C)

Formal notice of denial sent (D.1B)

Applicant notified of right to grieve decision

(D.2C)

Applicant given instructions on how to

grieve decision (D.2C)

INTAKE

Client Codes

Element

Y/N/NA

Name, date, disability and referral source

documented (D.1C)

Formal notice of approval sent (D.1B)

A copy of the Client lease given to the Clients;

lease or housing agreement conform to fair

housing laws (D.2A)

Service plan based on the assessment

developed within 60 days of admission (D.7C)

Acuity Index developed within 30 days of entry

and repeated at least every 6 months (D.7C).

Effective February 2020

Client Codes

Element

Y/N/NA

Verification that Client received the program

rules (D.2C)

Signed verification that Client received the

resident manual (D.2B)

Signed verification that Client received

information regarding grievances (D.1B)

Verification that Client received information

regarding Client rights (D.2C)

ASSESSMENT AND ACUITY INDEX

Client Codes

Element

Y/N/NA

Verification of homeless and disability status

present. (D.1D)

First assessment developed within 30 days of

program entry (D.7C)

New Acuity Index conducted at least every six

months. (D.7C)

The most recent assessment is completed,

contains all information necessary to plan and

provide services.

The acuity index is complete (D.7C)

The most recent acuity Index is signed and

dated by case manager and supervisor. (D.7A)

Client has an identified primary healthcare

provider (MD/APRN) (D.5B)

Program is able to demonstrate practices for

consistent tracking of clients’ viral load and

CD4 counts (D.5B) and is using data on an

individual & aggregate Level

Effective February 2020

SERVICE PLANS

Client Codes

Element

Y/N/NA

Service plan goals are based on the results of

the current acuity index (or other person-

centered goals, if desired by client) (D.7C)

Service plans signed and dated by Client, case

manager and supervisor (D.7A)

Service plan goals are measurable (D.7B)

Service plans updated/amended at least every

six months based upon the most recent Acuity

Index and/or other person-centered goals

(D.7C)

Client input is a part of service plan design

(D.7B)

PROGRESS NOTES

Client Codes

Element

Y/N/NA

Progress notes entered within one week of

services (D.7A)

Progress toward meeting service plan goals is

documented at least 2 times per month unless

an alternate plan is documented (D.7C)

Progress notes include date of service, type of

contact, date of note, and person entering

note (D.7A)

Staff meet with Clients in their apartments at

least every six months and review

maintenance, health, safety and quality (D.3B)

Case manager contacts Clients at least 2 times

per month (including at least one face-to-face)

or for Clients with less intensive needs an

alternate plan of contact approved by

supervisor is implemented (D.4D)

Progress notes reflect activities taken to meet

service plan goals (D.5C)

Case managers assist Clients in identifying and

accessing community providers and resources

(D.5D)

Effective February 2020

Client Codes

Element

Y/N/NA

Services are well-coordinated with other

providers and referrals are documented and

tracked in a defined process (D.5D)

There is no indication that service participation

is required or mandatory

(If applicable) Agencies most defined critical

incidents are verbally reported to

management within 3 hours of incident

discovery followed by a written report within 1

business day, with formal management review

within 30 to 60 days after verbal report. (D.3C)

(If applicable) Housing condition emergencies

are addressed within 24 hours of discovery.

(D.3C)

(If applicable) Suspected child abuse/neglect is

reported via an oral report to DCF as soon as

practical but no longer than 12 hours after

suspected abuse with a written follow-up

report to DCF no longer than 48 hours after

the oral report and incident is reviewed by

management (D.3D)

(If applicable) Clients who refuse services are

regularly engaged using different methods in

an attempt to increase likelihood of service

participation (D.4D)

(If applicable) There is a collaborative

relationship which exists and is documented

between case managers and other providers

and landlords. (D.7B).

DISCHARGE

Client Codes

Element

Y/N/NA

Discharge summaries signed and dated by case

manager and supervisor (D.7A)

The discharge summary includes identification

of providers continuing services, reason for

discharge, location of new residence,

assessment of ongoing needs and ability to

maintain housing (D.6C)

Client discharge planning occurs at least 3

months in advance of discharge date where

possible (D.6C)

Effective February 2020

Client Codes

Element

Y/N/NA

Discharged Clients given information regarding

discharge grievance procedure (D.6B)

Clients are not removed from housing without

legal eviction proceedings, if a tenant holds

the lease (D.6B)

Refusal to participate in services is not a

reason for discharge

There are at least three attempts to follow-up

with discharged Clients to determine status

regardless of reason for discharge (D.6C)

(If applicable) If eviction occurs, there is

evidence of communication between service

provider and property manager/landlord

including evidence of prevention and

connection to legal resources

(If applicable) Discharge grievance reviews,

dispositions and decisions are completed

within 30 days of the receipt of the grievance

with an additional 15 days, if approved by the

agency director, provided the former Client is

notified. (D.6B)

Observations:

For all programs:

1. Are client files stored in a secure manner to protect confidentiality? (D.2D)  Yes No

For single site programs:

2. Are service files and property management files kept in separate and secured storage?  Yes No

3. Are community based services and transportation easily accessible? (D.3A)  Yes No

4. Is there adequate space for service delivery, community-building, meetings

and property management activities? (D.3A)  Yes No

Effective February 2020

Staff Interviews: (Program manager and case managers separately)

1. Describe your role in the supportive housing program.

2. How and where do you recruit potential new Clients?

3. What is the process for placing someone on the waitlist?

4. Are there any situations where an individual who meets program requirements would not be admitted to the

program?

5. What rights do Clients have in this program?

6. How do you interact with landlords or property management to make sure that Client rights are protected?

7. How do you engage individuals and try connect them to services?

8. Where and at what times do you meet with Clients?

9. How are Clients involved in service plan design?

10. How are Clients involved in program operations including development of program rules?

11. Is there a Client group that meets regularly? If so, how are they organized and do staff assist them in running the

group?

12. What is the process involved in sharing information about Clients with other providers?

13. What are the challenges you face in providing services?

14. What technical assistance and training would you like to have?

Client Focus Group/Interview:

1. Describe your experience in this program.

2. How do case managers work with you to connect you to services that you need?

3. What rights do you have in this program?

4. Does your case manager work with your landlord or property manager to make sure your rights are protected?

5. Where and at what times does your case manger meet with you?

6. Do you feel like your case manager involves you in the development of service plans?

7. Do you ever have an opportunity to provide feedback about how this program works including the development of

program rules?

8. Do you participate in a Client group that meets regularly? If yes, what are the meetings like? If not, what would

make you more likely to participate?

9. Do you feel that your personal information is protected?

Effective February 2020

10. Do you feel pressured to participate in services?

11. Do you feel like your case manager listens to you?

12. Do you feel comfortable in your apartment?

13. Is there anything else about your experience in this program that you would like to tell us?

Effective February 2020

G. Feedback Template:

AIDS CT QUALITY ASSURANCE PROGRAM

Supportive Housing Quality Assurance Review

Agency/Provider:

Program:

Date:

Reviewers:

Observer:

Staff Interviewed:

Purpose

The AIDS CT Quality Assurance Review gives agencies information regarding how a housing program meets identified

quality standards overall with specific information categorized across seven domains. It is intended to provide agencies

with information to plan and evaluate practice improvement activities and to strengthen areas of high performance.

Methodology

The review was conducted according to the methods described in the AIDS CT Quality Assurance Review Manual.

Summary Results

Results for the entire program are presented across three categories; High Quality; Meets Quality; and Needs Stronger

Quality Focus. Based on the review conducted on , the of has been evaluated as:

High Quality: Total Score of 122.5 – 135 with no domains needing stronger focus

Meets Quality: Total Score of 108.5 – 122 with no more than 1 domain needing stronger focus

Needs Stronger Quality Focus: Score of 108 or below or 2 or more domains needing stronger focus

Domain

Available

Points

Program

Points

State

Average

Category

Entire Program 135 - Choose an item.

1: Facilitated Access to Housing and Services 20 - Choose an item.

2: Client Rights, Input and Leadership 20 - Choose an item.

3: Housing Quality & Safety 20 - Choose an item.

4: Support Services Design and Delivery:

Client-Focused/Client-Centered Services &

Client Engagement

20 - Choose an item.

5: Support Services Design and Delivery:

Services that Promote Recovery, Wellness

and Community Integration

20 - Choose an item.

6: Focus on Housing Stability 15 - Choose an item.

7: Building Internal Quality Assurance

Practices, Key Staffing and Coordination

20 - Choose an item.

0.0

Choose one

0.0

Choose one

0.0

Choose one

0.0

Choose one

0.0

Choose one

0.0

Choose one

0.0

Choose one

0.0

Choose one

Effective February 2020

Domain1:FacilitatedAccesstoHousingandServices.of20



HousingResourceUtilization:of5

ProgramOccupancyRateduringtheyear



Comments:



ApplicationProcess:of5



Applicationprocessandeligibilitycriteriaareclear.

Applicationprocessisfullyaccessibletopersonswithdisabilities.

Individualsreceiveaformalnoticeofapprovalordenial.

Individualsarenotifiedthattheycangrieveadenialandaretoldhowtodoso.

Applicantscomefromavarietyofsourcesincludinghard‐to‐reachpersons.



Comments:



ClientSelection:of5

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Theprogramhasclearlystatedeligibilitycriteriaforadmissionintotheprogramthatareincompliancewithfunders’

requirements.

Theprogramusesaconsistentintakeprocess.

Clientselectionisfirstcome–firstservedorbasedonidentifiedwaitlistpriorities.

Name,date,andreferralsourcearedocumentedin intakeforms.

HIVstatusisverifiedwithhandwrittendoctorsigna tureandlicensenumber(scannedorfaxedcopiesacceptable.)

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Comments:

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ClientEligibility:of5



Housingandservicesareforindividualsorheadsofhouseholdwhoarehomeless,oratriskofhomelessness,andhave

anHIVorAIDSdiagnosis.

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Comments:

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0.0

Effective February 2020

Domain2:ClientRights,InputandLeadershi p.of20



ClientLease:of5

Clients’leaseorhousingagreementconformstofairhousinglaw.

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Comments:

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ClientGuide:of5

Thereissignedverificationofreceiptofresidentmanual.

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Comments:

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ClientInput:of5



Clientgroupsandindividualshaveregularopportunitiestoprovideinputintoprogramoperationsandrules,andto

voicecomplaints.

Rulesarecommunicatedclearly,consistentlyenforced,andaredistribu tedtoClientsatintake.

ThereareclearlydefinedgrievanceproceduresthatarecommunicatedtoClientsthatincludereview,disposition

anddecisioncompletedwithin30daysofthereceiptofthegrievancewithanadditional15days,ifapprovedbythe

agencydirector,providedtheClientisnotified.

Residentsatisfactionsurveysarecompletedannuallyandprogramrespondstotheinformationprovided.

Clientsareproactivelynotifiedoftheirrightsincludinghowtoobtainlegalservices.

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Comments:



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ClientRights:of5

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Clientfilesandchartsaresecurelymaintainedtoensureprotectionofconfidentialinformation.

Staffadvocatewithlandlordsand/orpropertymanagersregardingClients’rights.

StaffunderstandstheexpectationsregardingClientrightsandhassignedconfidentialitypledgesannually.

AllpartnersinvolvedintheprogramunderstandtheexpectationsregardingClientrightsandconfidentiality.

ProtectedinformationissharedonlywithClientconsent.

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Comments:

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0.0

Effective February 2020

Domain3:HousingQuality&Safety.of20



HealthandSafety:of5

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TheprogramcomplieswiththefederalDepartmentofLaborOccupationalSafetyandHealthAdministration(OSHA)

“EnforcementProceduresfortheOccupationalExposuretoBlood‐bornePathogenStandards”,assetforthin29CFR

1910.1030.

Theprogramfacilities,incompliancewithallstateandlocalhealth ,fire,andbuildingcodesincludingoffices,fire,

alarm,ifapplicableelevatorhasbeeninspectedandQualifiedFoodOperatorcertificateavailable,ifapplicable.

TheprogramhasprotocolsforeducatingstaffandClientsabouthealthissues,includingbutnotlimitedto:

Tuberculosis,HepatitisBandC.

Communitybasedservicesandtransportationareeasilyaccessible.

Thereisadequatespaceforservicedelivery,community‐building, meetingsandpropertymanagementactivities.

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Comments:



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AssessmentofHousing:of5



StaffmeetwithClientsintheirapartmentsatleasteverysixmonthsandreviewmaintenance,health,safetyand

quality.

Initialinspectionwillsatisfylead‐freehousingrequirementifchildren6oryoungerpresentandifthehousingunit

wasbuiltbefore1978.



Comments:



EmergenciesandCriticalIncidents:of5

Incidentsthataredeemedcriticalbytheagencypolicyareverballyreportedtomanagementwithin3hoursofincident

discoveryfollowedbyawrittenreportwithin1businessday,withformalmanagementreviewwithin30to60daysafter

theverbalreport.Housingconditionemergenciesareaddressedwithin24hoursofdiscovery.

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Comments:

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ChildAbuseandNeglect:of5

Suspectedchildabuse/neglectisreportedbytheproviderorcollaboratingproviderviaanoralreporttoDCFassoonas

practicalbutnolongerthan12hoursaftersuspectedabusewithawrittenfollow‐upreporttoDCFnolongerthan48

hoursaftertheoralreportandincidentisreviewedbymanagement.

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Comments:

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0.0

Effective February 2020

Domain4:SupportDesign/Delivery‐Client‐Focused/Client‐CenteredServices&Engagement.of20

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ClientEducationandEngagement:of5

PercentofClientswhoagreeorstronglyagreewith"Staffhelpedmeobtaini nformationIneededsothatIcouldtake

chargeofmanagingmyillness"onconsumersurvey.

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Comments:

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AcuityAssessment:of5

Theclient’smostrecentassessmentiscompleted,containsallinformationnecessarytoplanandprovideservices.

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Comments:

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ServicePlan:of5

Serviceplangoalsarebasedontheresultsoftheacuityindex(orotherperson‐centeredgoals, ifdesiredbyclient).

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Comments:

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ServiceProvision:of5

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CasemanagercontactsClientsatleast2timesper month(includingatleastoneface‐to‐face)orforClientswithless

intensiveneedsanalternateplanofcontact approvedbysupervisorisimplemented.

CasemanagersareflexibleintheirresponsetoClientmeetingtimes/locationsandservicesprovided.

Clientswhorefuseservicesareregularlyengagedusingdifferentmethodsinanattempttoincreaselikelihoodof

serviceparticipation.

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Comments:

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0.0

Effective February 2020

Domain5:SupportDesign/Delivery‐ServicesPromoteRecovery,of20

WellnessandCommunityIntegration.

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ConnectiontoBenefitsandIncome:of5

PercentofClientswhomaintainedorincreasedtheirincomefromallsourcesduringtheyear.(Ifzeroincome,toreceive

points,thereisdocumenta tionprovide dshowingduediligencewiththeagency.)

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Comments:

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ConnectiontoPrimaryHealthcare:of5

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PercentofClientswhohaveaprimaryhealthcareprovider.

Programdemonstratesconsistenttrackingofclients’viralloadandCD4counts.

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Comments:

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EvaluatingServiceProgress:of5

Progressnotesreflectactivitiestakentomeetserviceplangoals.

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Comments:

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ServiceCoordinationandConnectiontoResources:of5

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CasemanagersassistClientsinidentifyingandaccessingcommunityprovidersandresources.

Servicesarewell‐coordinatedwithotherprovidersandreferralsaredocumentedandtracked.

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Comments:

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0.0

Effective February 2020

Domain6:FocusonHousingStability.of15

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HousingStability:of5

PercentofClientswhoexitedtonon‐homelessness.

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Comments:

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DischargePractices:of5



Programhasacomprehensivedischargepolicy.

DischargedClientsgiveninformationr egardingdischargegrievanceprocedure.

Dischargegrievancereviews,dispositions,anddecisionsarecompletedwithin30daysofthereceiptofthegrievance

withanadditional15days,ifapprovedbytheagencydirector,providedtheformerClientisnotified.

Clientsarenotremovedfromhousingwithoutlegalevictionproceedings,ifatenantholdsthelease.

Fortenantswithprogramagreements,thisdischargeisinaccordancewithprogrammaticdischargepolicy.

Foralldischarges,appropriatecommunicationexistswithproviders,landlord,andothersasappropriate.

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Comments:

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ContinuityofSupport:of5

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Thedischargesummaryincludesidentif icationofproviderscontinuingservices,reasonfordischarge,locationofnew

residence,assessmentofongoingneeds,andabilitytomaintainhousing.

Clientdischargeplanningoccursatleast3monthsinadvanceofdischargedatewherepossible.

Thereareatleast3attemptstofollow‐upwithdischargedClientstodeterminestatusregardlessofthereasonfor

discharge.

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Comments:

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0.0

Effective February 2020

Domain7:BuildingInternalQualityAssurancePractices,KeyStaffingandCoordination.of20



DocumentationQuality:of5



Acuityindexsignedanddatedbycasemanagerandsupervisor.

Dischargesummariessignedanddatedbycasemanagerandsupervisor.

ServiceplanssignedanddatedbyClient,casemanagerandsupervisor.

Progressnotesenteredwithin1weekofservices.

Progressnotesincludedateofservice,typeofcontact,dateofnote,andperso nenteringnote.

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Comments:

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StandardsforPlanningandDocumentingServices:of5



Serviceplangoalsaremeasurable.

Clientinputisapartofserviceplandesign.

Thereisacollaborativerelationshipwhichexistsandisdocumentedbetweencasemanagersandotherproviders

andlandlord.

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Comments:



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TimelinessofServiceProvision:of5

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Acuityindexcompletedwithin30daysofentryandrepeatedatleastevery6month.

Theserviceplanbasedontheacuityindex(orotherperson‐centeredgoals,ifdesiredbyclient)developedwithin60

daysofadmission.

Serviceplansupdated/amendedatleasteverysixmonthsbaseduponthemostrecentAcuityindexand/orother

person‐centeredgoals.

Progresstowardmeetingserviceplangoalsisdocumentedatleast2timespermonthunlessanalternateplanis

documented.

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Comments:

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Staffing:of5



Staffmeetsorexceedsthecurrentcaseloadrequirements.

Casemanagersattend10hoursormoreofcasemanagementtrainingduringtheyear,3ofwhichmustbeHIV

medicallyspecific.

Coveragehoursclearlydefinedandinclude24on‐callsupervision.

Casemanagerandprogramsupervisorjobdescriptionsandqualificationsarestandardizedandcontainclearly

definedrolesandresponsibilities.

Thereisaclearandongoingevaluationofemployeeperformance.

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