National Monitoring Standards September 15, 2011

Ryan White Part A Technical Assistance Webinar

HIV/AIDS BureauDivision of Service Systems

Presenters

Harold J. PhillipsChief, Northeastern Central Services Branch

Acting Chief, Western Services Branch

LTJG Brittany BovenizerProject Officer, Northeastern Central Services Branch

Tom ButcherNew Haven EMA

Norma Piel-BrownSujata Ramakrishnan

Dallas EMA

Department of Health and Human ServicesHealth Resources and Services Administration

HIV/AIDS Bureau

Presentation Agenda The Purpose of the National Monitoring Standards

The Process of Implementation

Grantee Presentations on Implementation

Common Questions/Concerns

Questions from this Call

Resource Tools for Implementation

Purpose of the National Monitoring Standards

Compliance & Oversight & Expectations• Ryan White Legislation

• Code of Federal Regulations

• HHS Grants Policy Manual

• HRSA/HAB Policies

• Parts A and B Program Guidance

• Title I & Title II Manuals (clarification, best practice)

• Program Terms and Conditions of Award

• OIG/GAO Reports and Recommendations

Purpose of the National Monitoring Standards

• Clarify the oversight expectations of Ryan White Part A & Part B Programs

• Design a specific set of minimum expectations for monitoring

• Provide a single source for both program and fiscal monitoring

• Specify the roles of HRSA and Grantees regarding the monitoring of subgrantees

• Address concerns of HRSA, Congress and OIG regarding oversight issues

Purpose of National Monitoring Standards

OIG Recommendations to HRSA:

• Specify and enforce standards and guidelines for how grantees should monitor grantees

• Standardize a corrective action process and address grantee issues more formally

• Increase the frequency and comprehensiveness of site visits

Purpose of the National Monitoring Standards: OIG Recommendations

• Set standards for grantees monitoring of subgrantees that, at a minimum, require a contract or formal agreement, a program report, and a fiscal report and some consideration for regular site visits

• Require grantees to report how they monitor their subgrantees in accordance with these standards as part of every application

• Increase efforts to monitor grantees’ oversight of subgrantees, including using information grantees report to HRSA regarding subgrantee activities

The Process of Implementation

Implementation impacts contract monitoring & systems for oversight

• Fiscal Monitoring – a system to assess the appropriate use of funds including the control, disbursement, use and reporting of allowable costs

• Program Monitoring – a system to assess whether allowable services are provided to eligible clients according to service limits

• Quality Management – a system to assess the degree to which a service meets or exceeds established professional standards and user expectations

The Process of Implementing The National Monitoring

Standards

May require re-thinking, revising long-used practices with regard to monitoring:

• Changes in tools, process, systems, procedures, staffing patterns, fiscal and program management and reporting

The Process of Implementing The National Monitoring

Standards

National Monitoring Standards Packet for Ryan White Part A contains:

• Universal Monitoring Standards • Fiscal Monitoring Standards**• Program Monitoring Standards**• Frequently Asked Questions

Each individual monitoring standard•Connected to a source which is cited•Has a grantee and/or sub grantee responsibility•Performance measure/method •Clearly stated performance measure and method

Process of Implementation

Grantees are expected to: • comply with all of the standards• comply in FY 2011

Grantees can develop their own ways to measure compliance

There is flexibility regarding how to implement the monitoring standards

Implementation is a process

Implementation of The National Monitoring

Standards

Grantees Should:• Review the Standards

• Share the standards and supporting materials with program and fiscal staff who have monitoring responsibilities

• Share the standards with providers as appropriate

• Review current monitoring systems, procedures, and tools for potential revision

Implementation of The National Monitoring

Standards

Grantees should (cont.)• Meet with legal, contracts, procurement, finance and other

local government entities to familiarize them with the National Monitoring Standards

• Review RFPs and contract language to assure that they specify services to be provided, data collected and reported in accordance with the National Monitoring Standards

Implementation of The National Monitoring

Standards

Grantees must (cont.)• Implement grantee and subgrantee responsibilities (make sure alternate

approaches meet standards)

• Begin integrating the National Monitoring Standards into contracting and monitoring efforts – monitoring tools, site visit schedules and scopes as needed

• Hold meetings with providers/subgrantees to introduce the Standards and clarify compliance issues

• Make standards easily accessible to providers/subgrantees

• Fully implement any needed changes in your subgrantee monitoring (policies, procedures, tools, management and reporting)

• Contact Project Officer if there are additional questions or concerns

Implementation of the National Monitoring Standards

Implementation & the FY 2012 FOA Questions:• Grantees should describe steps taken towards implementation

• Summarize, bullet points, outline

• Describe your implementation process and where you are and where you are going

• OIG recommendation that grantees report how they monitor subgrantees in accordance with these standards as part of every application.

Grantee Presentations On Implementation

Tom Butcher | New Haven, EMA

Norma Piel-Brown | Dallas, EMA

Sujata Ramakrishnan | Dallas, EMA

Common Questions/ConcernsImplementation

Annual Site Visits (required)• Comprehensive on-site monitoring visits testing compliance with

fiscal, programmatic and universal standards

• Desk reviews and other types of visits have proven ineffective (OIG Reports)

• Desk audits are not a substitute for comprehensive site visits (OIG)

• Grantees need to review the practice of desk audits in order to enhance site visit monitoring

Common Questions/ConcernsImplementation

Sample size for review of client charts (addressed in FAQ)

• Sample size should be based on size of the client population.

• 100% is the norm for a population of fifty clients. Review all client files

• 50% – 25% for a population of 51-100.

• 10% for a population of 101 - 999

• 3% - 5% for a population of 1,000 +

Common Questions/ConcernsImplementation

Rent is an administrative cost

• Categorization of rent and utility costs as overhead administrative costs codified in 2006 & 2009 Ryan White Legislation

• Supersedes previous grant management and technical assistance guidance, OMB circulars

• Subgrantee administrative costs = 10% of total contracted service amount

• Grantees must review subgrantee budgets to ensure compliance with this requirement in order to avoid unallowable costs

Common Questions/ConcernsImplementation

Determination of Costs

• Reasonable & Necessary – includes local factors: availability of resources, client characteristics, geography, local economy

• Flexibility for the grantees to determine what factors are used to justify costs and determine what is necessary

• Unit costs calculations should include a method for determining what fees are included in the unit figure.

• If administrative fees included, still subject to the administrative cost caps

Common Questions/ConcernsImplementation

Medicaid Certification of Providers• RW providers of Medicaid reimbursable services must be

• participating in Medicaid and

• certified to receive Medicaid payments

• or able to document efforts to obtain certification “timeframe”

• If a RW service is Medicaid reimbursable, Grantees can only contract with those providers who are certified or documenting efforts to obtain certification

• Helps ensure and enforce payer of last resort and collaboration with Medicaid

• Exemption for primary care providers licensed and certified as free clinics

Common Questions/ConcernsImplementation

Sliding Fee Scale & Program Income & Caps on Charges

Complicated issues related to:

• Eligibility, enrollment, sliding fee scale policies, billing and collections systems, caps on charges, program income

• Separate National TA call to address this issue in November

• Specific urgent issues, please contact your project officer

Common Questions and Concerns

The FAQ’s present answers regarding

• National Monitoring Standards Basics

• Structure of the Standards

• Implementation of the National Monitoring Standards

• Each of the Three Sets: Universal, Program and Fiscal

Additional Questions

If time allows, additional questions during this call……..

Summarize

• Consider the National Monitoring Standards like a map with a set of directions

• Implementation is like the road

• DSS needs to know where you are on the journey

• Compliance is the destination

• Together we will get there

Technical Assistance

• Work with your project officer

• Individualized conference calls

• National conference calls

• Review and collection of monitoring tools and systems (began this summer)

• Posting tools to Target Center (this fall)

• All Grantee’s Meeting

Contact Information

Harold J. PhillipsChief, Northeastern Central Services Branch

Acting Chief, Western Services Branch

o: 301.443.8109 e:hphillips@hrsa.gov

LTJG Brittany BovenizerProject Officer, Northeastern Central Services Branch

o: 301.443.0510 e: bbovenizer@hrsa.gov