• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: 737-255-4300

    Email the HIV/STD Program

    Email HIV, STD, Hepatitis C, and TB data requests to the Program – This email can be used to request data and statistics on HIV, STDs, Hepatitis C, and TB in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local health department.

    For information on HIV testing and services available to persons living with HIV, please contact your local HIV services organization.

Quality Management Core Tool - Monitoring Instructions


Review Criteria

Instructions

  • DSHS Monitoring reviews will reflect if the following Review Criteria have been Implemented (I), Partially Implemented (P), Not Implemented (N), Not Applicable (NA), Not Reviewed (NR)
  • Prior to the review, DSHS Monitoring staff will inquire as to whether changes have been made to agency policies/procedures, and DSHS-approved Work Plan, including any changes in response to DSHS guidance or policy changes, or any other review criteria. If so, the agency shall provide copies of related documents specific to grant funded services and other program activities to the monitoring staff prior to the review.
  • Refer to Program Operating Procedures and Standards Policy and Procedures Chapter 16 – Routine HIV Screening in Healthcare Settings for more information on 1) Screening recommendations/guidelines and Standing Delegation Orders, 2) Consent, 3) HIV testing technology, 4) Reporting new and acute HIV diagnosis, 5) Notification of positive HIV test results, 6) Referral and Confirmation to HIV-related medical care, 7) Confidentiality, 8) Quality Assurance, and other resource.
Monitoring Instructions
Review Criteria Instructions
I. Laws, Regulations and Policies

1) Routine HIV screening is carried out according to the CDC's Revised Recommendations for HIV Screening for Adults, Adolescents and Pregnant Women in Health Care Settings,
or
United States Preventive Services Task Force (USPSTF) Recommendations for HIV Screening

The following criteria specific to HIV screening should be included in program policies/procedures (attachment of most recent DSHS-approved Work Plan is acceptable, if all criteria below are included):

  • Definition of the population eligible for routine HIV screening.
  • Screening technology – conventional blood draw, rapid test or both.
  • Routine HIV Screening Protocols, and Standing Delegation Orders ( Health and Safety Code (HSC) §85.085), as applicable.
  • Screening goals, including the number of tests to be performed and number of positive patients to be identified.

DSHS Monitoring staff will observe and document that:

  • Contractor adheres to the routine HIV screening policies/procedures, and DSHS-approved Work Plan.
2) Contractor obtains consent for HIV screening in accordance with Texas law: Health and Safety Code 81.105—Informed Consent and 81.106—General Consent. Oral consent with documentation is allowed; a separate consent form is not required for HIV screening.

Prior to the review, DSHS Monitoring staff will request current or updated policies related to general and informed consent, and the forms/documentation used for the consent for, or declination of, HIV screening.

Monitoring staff will review:

  • Consent policies and documentation used by staff to obtain consent, or refusal, for HIV screening and complies with Texas law. 
3) Contractor ensures at least 90% of persons receive their HIV positive test results, including preliminary and confirmatory results, in accordance with Texas law: Health and Safety Code 81.109 

Prior to the review, DSHS Monitoring staff will request current/updated policies/procedures and ensure that:

  • Policy identifies appropriate procedures and staff responsible for informing patients of their preliminary and confirmatory positive test results.

Monitoring staff will review and confirm with the Contractor:

  • The process for delivering preliminary and confirmatory positive test results comply with Texas law.
  • If 95% or more of patients with an HIV positive test result receive their results.
4) Contractor reports positive HIV test results to appropriate local/regional health authority in accordance with Texas law: Health and Safety Code 81.043-44 and TAC Title 25, Part 1, Ch 97, Subchapter F, Rules 97.132-134.  

Prior to the review, DSHS Monitoring staff will request current/updated policies/procedures to ensure reporting of positive HIV test results to the appropriate local/regional health authority.

Monitoring staff will review the following processes with the Contractor to ensure:

  • Positive test results are documented and reported to appropriate health authority within stated timeframe in accordance with Texas law. For more information, refer to the DSHS HIV/STD disease reporting page.
  • Contractor has identified staff and back-up staff responsible for reporting positive HIV tests, including laboratory and provider reporting to appropriate health authority.
  • Contractor has developed a protocol that identifies staff responsible for initiating public health follow up and documentation. 
5) Contractor complies with all applicable DSHS Security Policies and Procedures [refer to Section VI. Data, 18) Data Security
  • Data Security Policies and Procedures are reviewed in Section VI, 18) Data Security.
II. Personnel  
6) Contractor reports to DSHS any changes or reassignment of staff funded through the HIV/ROUTN grant to prevent a potential decrease of grant funds. Prior to the review, DSHS Monitoring staff will request the current/updated listing of HIV/ROUTN funded staff and verify all positions are filled, and/or vacant positions have been posted for employment through the Human Resources Department to ensure best efforts to fill vacancies within 90 days.  
7) Contractor maintains current Contact List with appropriate back-up staff to ensure timely communication between Contractor and DSHS. Prior to the review, monitoring staff will request the current/updated Contact List including In-Kind and DSHS funded staff dedicated to HIV/ROUTN Grant services and activities.
III. Training  
8) DSHS Required Trainings  Prior to review, DSHS Monitoring staff will request a listing of new staff and documented completion of DSHS training requirements.
a) Contractor ensures grant-supported staff have completed DSHS Core Required Trainings during the first year of employment, including Certificates of Completion are on file.

Trainings to be completed during the first year of employment. Trainings include:

  • HIV Navigation in Texas (HNT)
  • Gender and Sexual Diversity Training
  • Social Determinants of Health
  • Trauma Informed Care (TIC)
  • Health Equity Training

Contractor has documentation, including Certificates of Completions on file, of staff attendance at all DSHS-directed trainings, conferences, and meetings.

b) Contractor authorizes and requires staff (including volunteers) to attend DSHS-identified training, conferences, and meetings as directed by DSHS.
9) Contractor has a written orientation plan for new staff. 

Prior to review, DSHS Monitoring staff will request a copy of the new staff orientation plan designed to ensure new staff are aware of the Routine Screening Program goals, policies, and clinical operations.

10) Contractor ensures Routine HIV screening services are carried out by qualified clinical staff, which is ensured through appropriate and on-going trainings or continuing education opportunities. Note the orientation plan may include much of the required information. [Refer to No. 9 above, Orientation Plan] 

Prior to review, DSHS Monitoring staff will request documentation to determine trainings are available to:

  • Educate health care organization providers and staff about the routine screening program, HIV transmission and prevention.
  • Ensure health care providers that participate in the routine screening project have access to trainings about the health disparities and biases related to persons living with HIV.
  • Ensure health care organization clinical staff have access to receive at least one training and/or continuing education opportunity relevant to the routine HIV screening project.
11) Contractor provides or has made available appropriate trainings in accordance with the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care for grant supported staff to perform routine HIV screening and related services. 

The DSHS Monitoring staff will review with Contractor a sample of trainings offered to grant funded routine HIV program staff.  Trainings may include, but are not limited to:

  • Annual training and educational updates related to HIV screening and services.
  • Annual cultural competency training.
  • Job skills training to staff in their respective roles to performing duties including:
    • Informing patients of routine HIV screening and obtaining consent;
    • Providing positive test results;
    • Providing referrals and confirming patients to HIV medical care, prevention counseling, partner services and other related services; and
    • Reporting positive HIV test results to local/regional health authority.
12) Contractor provides staff development based on grant supported employee needs. 

DSHS Monitoring staff verifies that the staff development plan is based on an assessment of training needs, quality improvement indicators, and changing regulations or requirements.

Indicators for staff training needs assessments may include surveys, discussions at staff meetings, employee suggestions, and performance evaluations. Staff development is documented to include continuing education for grant-funded credentialled professional staff.

Contractor maintains monitoring and evaluation records of grant-supported program staff development.

IV. Delivery of Services - Screening and Confirmation to HIV Medical Care   
13) At least 90% of all eligible patients, as defined by the Contractor, receive an HIV test, unless they decline.

Prior to the review, DSHS Monitoring staff will request the current/updated definition of the population eligible for routine HIV screening, and the total number of HIV tests to be performed during the contract period.

The monitoring staff will review with Contractor staff to determine:

  • The percent of eligible patients that have had an HIV test to date.
  • If the Contractor is on track to meet their screening goal by the end of the contract term.

14) Grantee will ensure at least 75% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 1 month and at least 90% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 3 months.

Grantee will ensure that at least 75% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 1 month and at least 90% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 3 months.

In addition to HIV medical services, Grantee will ensure individuals are referred to other services, including housing, legal assistance and violence prevention as needed.  

Prior to the review, DSHS Monitoring staff will request current/updated protocols regarding confirming persons who test positive for HIV to medical care and other services.

The monitoring staff will review the following:

  • Protocols to ensure patients who receive a positive HIV diagnosis are referred to HIV medical care and other services as appropriate.
  • Contractor has documentation tracking referrals and medical appointments with an HIV clinician for a medical assessment and other related services.
  • Signed formal agreements of collaboration and coordination with 1) local providers of HIV medical care and other services specific to the needs of the patient, and 2) local health department partner services, and data to care, if applicable. 
15) Delivery of services 
a) Program delivers all services in a culturally responsive and sensitive manner, taking low health literacy into account, using the National CLAS in Health and Health Care. 

a) DSHS Monitoring staff will observe and review the following procedures to ensure services are delivered in a culturally responsive and sensitive manner, including low health literacy:

Informing patients of routine HIV screening program with the option to decline, or opt-out; and

Delivering positive test results.

b) Resources are available to ensure that services are provided in a culturally and linguistically appropriate manner. 

b) DSHS Monitoring staff will review relevant resources available to ensure services are provided in a culturally and linguistically appropriate manner, which may include but are not limited to:

  • Employment of personnel that speak the language/s of persons served.
  • Employment of the AT&T 24/7 Language Line Services or another platform.
  • Contracting with appropriate interpreters including signers for the deaf or hearing impaired or using another platform.

Patient/client information/education materials are available in appropriate language/s.

V. Continuous Quality Improvement (CQI) and Monitoring Plan  
16) Contractor has a written and implemented internal Continuous Quality Improvement (CQI) Plan to evaluate all services, processes and operations including routine HIV screening within the agency on an annual basis including a review of client grievance policy and procedures that includes:

The CQI Plan describes the process for conducting quality assurance activities including:

  • A schedule to conduct CQI activities (conducted annually at a minimum).
  • A procedure for activities, i.e. self-monitoring tool, CMS credentialing tool, DSHS QM tool, etc.
  • Regular monitoring of program data and DSHS Performance Measures to evaluate and improve program planning, activities and services.
  • Review of client satisfaction/grievance policy and procedures.
  • Documentation of results, and corrective action plans are tracked and evaluated for improvement of services; results and follow-up activities are reflected in reports to the CQI Committee or in committee meeting minutes.

Refer to Ch. 16, Routine HIV Screening in Healthcare Settings, 16.9 Quality Assurance section

a) Establishment of CQI Committee

The CQI plan describes the establishment of a multidisciplinary CQI Committee to include:

  • Membership includes key leadership of the organization including the Executive Director/Chief Executive Officer and Medical Director, or designee as applicable, and key staff responsible for the routine screening program grant requirements.
  • CQI Committee meets at least quarterly or more often as needed. 
b) Maintenance of CLIA certification and current screening/laboratory procedures   CQI Plan ensures maintenance of CLIA certification, and if applicable, CLIA Waivers to ensure screening is conducted in accordance with manufacturer’s instructions.
c) Monitoring DSHS Routine Screening Performance Measures (PM) to track progress to meet annual PMs by the end of contract term. (Refer to Appendix A for current DSHS Routine HIV Screening PMs)  This activity is part of the DSHS desk audit and is reviewed at least semi-annually as part of the Interim and Annual Progress reports and will be reviewed with the Contractor as needed.
17) Contractor submits Interim and Annual progress reports to DSHS in accordance with contract requirements by required submission date. This activity is part of the DSHS desk audit; DSHS will follow-up with the Contractor as needed.
VI. Data   
18) Data Security
Contractor is in compliance with all applicable DSHS Security Policies and Procedures.
DSHS Monitoring staff will review the following:
a) Confidentiality
  • Contractor reports breaches of confidentiality/privacy incidents to DSHS TB/HIV/STD section Security officer, and fully assists DSHS in any breach-related investigations in compliance with DSHS Policies 2011.01, 2011.04, 2016.01
b) Data Release Agreement
c) Access to DSHS designated reporting systems
  • All contractor staff assigned to work with HIV prevention program data maintain access to DSHS designated reporting system including e-authentication for access to EvaluationWeb for HIV testing data.
d) Annual Security Trainings
  • All contractor staff assigned to work with HIV prevention program data complete required annual security trainings including:
    • DSHS Security and Confidentiality, and
    • HHS Information Security/Cybersecurity.
19) Data Collection and Submission  
Contractor submits required data set to the Texas Department of State Services via the reporting system/s designated by DSHS. 
Activities 19) a) and b) are part of the DSHS desk audit performed monthly; DSHS will follow-up with the Contractor as needed.
a) Data is submitted by the 20th of each month, or per DSHS instructions.
  • Data is submitted according to DSHS requirements.
  • Timely communication notifying DSHS of delayed data submissions; reasons for delayed data submissions will be considered on a case-by-case basis. 
b) Data submission is accurate and complete.
  • Contractor ensures data is accurate and complete prior to uploading, including line level data and any DSHS-specific reports (monthly or quarterly), to EvaluationWeb, GlobalScape, or other reporting system designated by DSHS. 
  • Contractor communicates with DSHS regarding improving data quality (accuracy and completeness), and any IT or computer issues.
VII. Financial  
20) Contractor submits financial reports to DSHS by required submission dates. Activities 20) a), b) and c) are part of the DSHS desk audit performed monthly; DSHS will follow-up with the Contractor as needed.
a) Requests for reimbursement or payment are submitted by the last business day of the month following the month expenses were incurred or services provided.   Contractor submits monthly requests for payments using the State of Texas Purchase Voucher (Form B-13) and the Voucher Support Form (VSF) with acceptable supporting documentation for reimbursement of the required services/deliverables within allowable timeframes. Grantee is required to identify expenditures by budget category and funding code. Forms can be found on the Client Services Contracting Forms page.
b) Financial Status Reports (FSR) are submitted by required due dates documented in the current contract.
c) Expenditures are in accordance with the DSHS HIV Prevention approved line item categorical budget.  
VIII. Sustainability  
21) Contractor has implemented systems changes to work towards sustainability of routine HIV screening as a standard of care.

Activities should include but are not limited to:

  • Information Technology has made or is working to incorporate changes that support data collection and reporting positive HIV test results to appropriate local/regional health authority in accordance with Texas law, tracking project activities including electronic medical records, lab orders and test results, notification of positive HIV test results, and HIV-related medical/services referrals, confirmation to medical care, and quality assurance improvement activities.
  • Contractor is working with community partners through networks and collaborations to ensure sustainability of routine HIV screening.
  • Contractor cooperates with any DSHS-funded activities to raise awareness of HIV and promote prevention services.
  • Contractor participates in local HIV planning and evaluation activities, as well as in local efforts to coordinate HIV prevention and treatment services.
  • Contractor participates in the Texas HIV Syndicate, HIV Planning Councils, Fast Track City, or other collaborations to raise awareness of HIV in their communities, and to increase awareness of routine HIV screening in their facilities and other HIV prevention activities in their communities.
Appendix A

Performance Measures – Routine Screening Program Contractor Performance Measures to be met by the end of the 2021 contact term:

  • Grantee will conduct at least 90% of the total projected number of HIV tests by the end of the contract term.
  • Grantee will ensure that at least 95% of individuals with a positive HIV test receive their test results.*
  • Grantee will ensure that at least 75% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 1 month.
  • Grantee will ensure that at least 90% of individuals newly diagnosed with HIV will be linked to HIV-related medical care within 3 months.
  • Grantee will ensure that at least 75% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 1 month.
  • Grantee will ensure that at least 90% of individuals who have been previously diagnosed with HIV will be linked to HIV-related medical care within 3 months.
  • Grantee will achieve a minimum of 0.1% overall positivity rate.
  • *While the goal is to link 100% of persons living with HIV to HIV-related medical care, this performance measure reflects DSHS minimum performance standards.


Guidance last revised April, 2021



Last updated June 1, 2021