Quality Site Visit Report - TARGET Center of Training •Provide consultants with additional guidance for generating a quality site visit report •Shorten the editing process once

Quality Site Visit Report

Part C HIV Early Intervention Services (EIS)

Part D Grants for Coordinated HIV Services and Access to

Research for Women, Infants, Children, and Youth (WICY)

Part F - Dental Programs

Health and Human Services

Health Resources and Services Administration

HIV/AIDS Bureau

Division of Community HIV/AIDS Programs

Director: Polly E. Ross, M.D.

Deputy Director: Lynn R. Wegman, M.P.A.

Purpose of Training

• Provide consultants with additional guidance for

generating a quality site visit report

• Shorten the editing process once a draft report is

submitted

• Reduce the amount of time that is necessary to

finalize a report and have the report released to

the grantee

Key Points When Writing the

Site Visit Report

• Report should be a stand alone document

• Two audiences: HRSA Staff and Grantee

• Initial Site Visit Report submitted to the Project

Officer by the Team Leader should be written:

• In concise and complete sentences

• Free of spelling and grammatical errors

• Free of duplicate information within the Overview

• With Findings and Recommendations numbered

Essential Resources

HRSA/HAB/DCHAP Site Visit Assessment Tool

(most recent version: February 6, 2015)

Utilize the tool throughout the Site Visit to identify

findings and craft language for reporting the findings

within the online system.

HRSA/HAB/DCHAP Site Visit Report Guidance

Refer to the HRSA/HAB/DCHAP Site Visit Report

Guidance throughout the process of completing the

Site Visit Report template within the online system.

Team Members’ Responsibilities

• Complete and submit the assigned section to the Team

Lead within 5 business days of Exit Conference

• Check grammar, spelling, and sentence structure

• Verify that all information within the Overview adheres to

what is requested by DCHAP within the Guidance

• Only use statements that are fact based

• Do not include proper names of staff, only position titles

• Never include confidential client information or client

identifiers

• Avoid including sensitive information

Team Leader Responsibilities

• Submit a Site Visit Report that is limited to a total of 10

pages for a Part C and 15 pages for a Part C and D

Program within 10 business days of the Exit

Conference

• Prior to submitting the initial Site Visit Report to the

Project Officer:

• Check all Team Members entries for spelling,

grammar, and content

• Verify that all information within the Overview adheres

to what is requested by Program within the Guidance

and is not duplicative

Site Visit Report Template

General Information

• Grantee Information: Grantee Name; Grant

Number; Grantee Address; Project Period; and

Awardee Amount

• Type of Visit

• Date(s) of Visit

• Project Officer

• Contractor Staff

• List names of the consultants and their respective roles.

• DO NOT include personal contact information.

• Purpose of Visit

Reference pages 2-4 of the Site Visit Report Guidance

Site Visit Report Template Sections

Site Visit Report Template Sections

Site Visit Report Template (continued)

• Overview of Grantee Organization

• Introduction

• Administrative Overview

• Clinical Overview

• Fiscal Overview

• Requirements/Authorities:

• Finding(s)

• Recommendation(s)

Site Visit Report Overview

• Limit to 2 pages in length (including Introduction and

all three sections: Administrative, Clinical, and Fiscal)

• Do not include Finding(s) and Recommendations

• Description of “Technical Assistance” or guidance

provided by consultants can be included

• Remember to cite or reference all resource materials

used to develop the overview section of the report


Introduction

• Name of grantee

• Location of grantee’s service site(s)

• Programs reviewed:

• RWHAP Part C and / or RWHAP Part D

Overview Format

Broad Statements Concerning Grantee Activities

Location

Demographics

Specific Healthcare Services

or Challenges

Administrative Overview

• What is the length of time the

organization has served in the target

community?

• How long has the program served

people living with HIV?

• Include the State’s status as it relates

to the Affordable Care Act

Reference page 5 of the Site Visit Report Guidance


• Describe the program’s service area,

services provided, and how it effects the

Affordable Care Act

• Include the most recent demographic

data on clients receiving services

• Describe the organization’s model of care

and administrative structure


Reference pages 5 of the Site Visit Report Guidance


Models of

Care

AIDS Service

Organizations /

Community Based

Organizations

Academic or

University Medical

Centers / Hospitals

Departments of

Health

Federally Qualified

Health Centers

Models of Care

Clinical Overview

• Describe model of clinical care and what services

are available on site

• Do not have to include an extensive list and can

summarize “fully comprehensive and includes….”

• Number of HIV patients receiving services funded

by Ryan White HIV/AIDS Program

• Note if numbers are not reflective of approved work

plan goals

• If patient numbers are higher it may be due to

different funding streams or due to insurance status


Clinical Overview

Clinical Overview (continued)

• Client demographics by race, age, gender, and

mode of transmission

• Should not duplicate information included in the

Administrative section

• Where do new patient referrals come from?

• Part D: Average number of HIV-positive pregnant

women each year, as well as number of women,

infants, children and youth.



• Provide a brief overview of medical care

provided including a description of whether the

care is consistent with HHS Guidelines

• Describe whether there are clinical policies

and procedures in place for HIV medical

management



• Provide a brief overview of the clinical chart

review to include:

• Number of charts reviewed

• Overall assessment of documentation

• Results from the following two clinical quality

measures

Viral Load Suppression / Retention in HIV Medical Care

Note: outcomes should be based on use of the HAB

performance measure definitions for numerator

and denominator



• Provide a brief description of the clinical

quality management (CQM) program to

include:

• Status of a CQM plan

• CQM meeting structure and frequency

• Are consumers involved in program

development, implementation, and evaluation

activities?

• If so, how is this accomplished?


Clinical (continued)

Consumer Panel Overview

• Number of consumers in attendance and

demographics

• Were they new or established patients

• What services have they received

• Briefly describe any concerns they expressed

• If positive feedback obtained, briefly describe

that also


Fiscal Overview

Fiscal Overview (continued)

• Describe the organization’s accounting

structure, funding sources, and revenue streams

• Include the payer mix, debt to asset ratio, and

the process for tracking FTE’s associated with

the grant

• Describe the organization’s process for

collecting and tracking program income

• Provide the expenditure rate for the Part C

and/or Part D Program


Reference pages 6 of the Site Visit Report Guidance

• Note the date of the most recent audit

and any weaknesses or deficiencies

• Describe how the organization utilizes

opportunities available through the

Affordable Care Act (ACA)

Fiscal Overview (continued)


Requirements and Authorities

Requirements and Authorities

• If a Requirement is Met – then place “None” next to

Finding(s) and also next to Recommendation(s)

• Requirements that are “Partially Met” or “Not Met” require at

least one finding and a corresponding recommendation

• Findings and Recommendations must be related to one of

the 12 Requirements and documented in the appropriate

Requirement section

• Findings should clearly state reason why grantee is not in

compliance with the legislative or programmatic

requirement and demonstrate a weakness

• Use complete sentences that are fact based

• Do not include “Improvement Options” or “Best Practices”


Requirements and Authorities (continued)

• Recommendation(s) should correlate with Finding(s)

• Each Finding(s) and Recommendation should be

numbered the same starting from #1 under each

Requirement:

Findings:

Finding 1: XXX

Finding 2: XXX

Recommendations:

Recommendation 1: (based on Finding 1)

Recommendation 2: (based on Finding 2)

Recommendations

• Clearly state the recommendation and

include recommended steps/actions needed

for the grantee to address the specific

Finding(s) and achieve compliance with the

Requirement(s)

• Describe the role and/or technical assistance

HRSA can provide or help to facilitate for the

grantee

Additional Tips

• Ryan White Program should be written out as:

Ryan White HIV/AIDS Program (RWHAP)

• Be sure to spell out acronyms with initial use and

then the acronym can be used for the remainder of

the Site Visit Report

• Avoid use of tables – only narrative format

• Only documents vetted by HAB/DCHAP can be

shared with grantees

Combined Part C & D Site Visits

• The Site Visit Report format will vary if the

Part C & Part D programs function as two

separate programs

• Discuss Site Visit Report format with Project

Officer in advance of the site visit

Additional Tips

Subheaders must be used to identify RWHAP

Part C and RWHAP Part D content


Combined subheaders must be used to identify RWHAP

Part C/RWHAP Part D content when applicable


Part C & Part D programs functioning

separately require two Consumer Panels

Overall assessment of a Requirement, as

well as individual Finding(s) and

Recommendation(s) must be identified as

to whether it applies to RWHAP Part C,

RWHAP Part D or both

Formulating Report

Requirement #1:

RWHAP Part C

Met

Finding(s): None

RWHAP Part C

Recommendation(s):

None

Requirement #1

RWHAP Part D

Partially Met

Finding 1: XXX

Finding 2: XXX

RWHAP Part D

Recommendation 1:

(Based on Finding 1)

Recommendation 2:

(Based on Finding 2)

Formulating Report

RWHAP Part C

Formulating Report

RWHAP Part D

Formulating Report

Combined RWHAP Part C & Part D

It takes the entire Site Visit Team working

together to produce a Quality Site Visit Report!

Questions

Thank you for your participation

in today’s webinar!

Documents

Quality Site Visit Report - TARGET Center of Training •Provide consultants with additional guidance for generating a quality site visit report •Shorten the editing process once