Ryan White HIV/AIDS Program Part A Manual

Contract monitoring includes program monitoring and fiscal monitoring. Under Part A of Ryan White, these are grantee responsibilities.

• Program monitoring involves assessing the quality and quantity of the services being provided by a particular contractor. This type of monitoring should include reviewing program reports, conducting site visits, and reviewing client records or charts.
• Fiscal monitoring involves assessing how quickly and efficiently a contractor uses the Ryan White funding it receives and whether funds are used for approved purposes. This type of monitoring includes review and assessment of monthly expenditure patterns for particular contractors and processes to ensure adherence to Federal, State, and local rules and guidelines on the use of Ryan White funds. EMAs/TGAs conduct fiscal audits and record reviews, and require that contractors provide supporting documentation of expenditures and an annual financial audit by a qualified independent accountant.

The examples below show how fiscal and program monitoring are complementary and interrelated:

• Many EMAs/TGAs require program reports to accompany reimbursement invoices in order for payments to be processed
• Grantees that reimburse on a unit cost basis inherently combine fiscal and program information, and
• Site visits to funded providers commonly include a program audit and a fiscal audit.

Grantees can take corrective actions when provider outcomes do not meet program objectives and grantee expectations. These actions may include improved oversight, redistribution of funds, a "corrective action" letter, or locally sponsored technical assistance. Grantee staff generally deal with such problems, with reports to the planning council if warranted.

Contract monitoring can serve as a primary mechanism for documenting grantee compliance with multiple Ryan White requirements, including the following:

• Provision of core medical services, Section 2604(a through d)

• Provision of early intervention services, Section 2604(e)

• Priority for women, infants, children and youth, Section 2604(f)

• Administrative caps for first-line entities, Section 2604(h)

• Imposition of charges for services, Section 2605(e)

• Payer of last resort, Section 2605(a)(6)

• Provision of outreach to low income individuals, Section 2605(a)(7)

• Tracking of expenditures, separately, under formula, supplemental, and MAI and carryover funding, Section 2603(c) implementation as outlined in DSS correspondence and the HRSA/HAB Unobligated Balances provision

• Requirements regarding status of an entity as a Medicaid provider, Section 2604(g)

Grantees can use many methods to monitor contractor program compliance, among them program reports, site visits, client satisfaction reviews, capacity development/technical assistance, and chart or records reviews. A successful monitoring effort should include several of these methods, while keeping to a reasonable level the time and resources contractors must spend to meet their reporting obligations.

1.      Program Reports

Pre-award contract negotiations between grantee and service providers should clearly delineate the program objectives, service units to be provided, number of clients to be served, and outcomes to be measured. In order to assess contract compliance, grantees may require contractors to submit monthly and/or quarterly program reports. Reports may include information on the number of completed service units, progress towards objectives such as percent of each objective completed, staffing and program changes, successes, failures, and status of clinical quality management activities. When reported service delivery drops below a prescribed level, grantees should negotiate some form of corrective action.

2.      Site Visits

Provider site visits are another way to monitor contract compliance. Grantees typically use site visit monitoring forms as a way to collect data that are comparable across sites. A site visit might include a review of files, staff interviews, observation of service provision, tour of the facility, review of program objectives, review of fiscal management system, review of staff licensure requirements, and discussion of other key issues.

3.      Client Satisfaction Reviews

Some grantees require their contractors to conduct periodic client satisfaction reviews. Such reviews can be conducted a number of ways, including written and telephone surveys, interviews, suggestion boxes, focus groups, public hearings (town meetings), and/or use of a hotline.

Results of client satisfaction surveys should be shared with the planning council as soon as results are available. Care should be taken to ensure that individual agencies and consumers are not identified. A summary of aggregate data can help direct future priority setting and resource-allocation decisions. Client satisfaction data can also be a useful tool to determine capacity development needs that may exist in the service delivery system.

Grantees and councils need to be aware of "survey burn-out" due to over surveying of clients. To prevent or lessen this effect, grantees may want to consider surveying certain categories of providers (i.e. substance abuse centers or transportation providers) each year, with all providers included on a rotating basis.

4.      Capacity Development/Technical Assistance

If common problem areas are noted across providers during program monitoring visits, grantees can support local technical assistance (TA) programs or capacity development activities. They can help solve problems once identified, prevent the same problems from occurring in newly funded providers, and prevent problems from escalating to a serious level.

During the process of monitoring contractors, grantees often discover exemplary tools, methods, and practices. As part of a grantee's local TA efforts or capacity development curriculum, these "best practices" should be introduced to all providers. Grantees could consider having quarterly provider meetings where this information is shared in a non-threatening manner. Highlighting model practices is a way to acknowledge innovations and quality performance, judging projects according to objective criteria.

5.      Chart/Record Reviews

Grantees can conduct client records reviews to assess providers' performance with respect to area-wide standards of care and adherence to established clinical quality management programs. Record reviews typically involve on-site data collection by a monitoring team, followed by aggregation of data within and comparisons of findings across providers. This kind of monitoring can be costly because of the time required for designing an approach, collecting and analyzing data, and reporting on findings. However, it is particularly useful where detailed and reliable client-level assessments are needed to assess the quality and effectiveness of care services.

Grantees can use a variety of methods to monitor the fiscal performance and practices of their contractors. In an era of managed care and shrinking resources, it is in a grantee 's best interest to know how well agencies function in spending and managing service dollars. Fiscal monitoring data also play an important role in resource allocations made by the planning council, ensuring that the grantee is purchasing high quality services, and identifying capacity development needs early in a contract year. Some fiscal monitoring tools include monthly disbursement reports and redistribution of funds, as described below.

1.   Monthly Disbursement Reports

Monthly disbursement reports can aid grantees and planning councils in recognizing over- or under-spending patterns of providers. If an agency is expending funds too slowly or too fast, the grantee staff should undertake a review of potential contributing factors. Once the problems have been identified, a corrective action plan should be implemented with the agency.

2.      Redistribution of Funds

Grantees may discover that redistribution of funds is necessary at some point during a fiscal year in order to ensure that all funds are expended and necessary services provided. It is particularly important for grantees to reallocate funds in a timely manner in order to comply with unobligated balances provisions for Part A grantees (see Section 2603(c) and HAB's Policy on Unobligated Balances). Redistribution can include:

• Internal re-budgeting and redistribution of funds across line items within a contract budget
• Redistribution of provider funds that were awarded but unspent, and
• Redistribution of remaining funds from terminated contracts.

When funds are available for redistribution, grantees can use a competitive process for new awards similar to the original request for proposals (RFP) process. An objective review panel perhaps the same committee that does annual provider grants reviews should conduct selection of new grant recipients. Funds may also be redistributed to fund original proposals that were unfunded or under-funded due to insufficient funds.

The grantee must share information with the planning council so that both can review the rate at which money is spent in each of the service categories identified as priorities by the planning council. If money is not being spent in a timely fashion, the planning council can recommend that funds be reallocated. The grantee and council must work together to ensure that any changes are in agreement with the priorities established by the council.

As with the initial disbursement of funds, the outcome of the redistribution must be consistent with the priorities and resource allocations of the planning council. The grantee must also inform the planning council of any changes to service priority allocations that result from the redistribution of program funds. The planning council may file a grievance over changes that are not consistent with the service priorities and resource allocations originally determined by the planning council for those funds.

When problems with a contractor become apparent, the grantee should take corrective action. Grantee staff and the provider generally meet first to discuss specific problems. Indicators for corrective action include:

• Under- or over-spending
• Improper invoicing
• Improper payments
• Failure to fully meet program goals and objectives
• Repeated staff turnover and prolonged vacancies
• Missing or incomplete client records
• Failure to submit reports in a timely manner
• Failure to serve an eligible client, and
• Other budget or workplan failures.

Grantee staff should inform the contractor of problems verbally and then in writing if necessary.

Grantees should offer technical assistance when appropriate, but written "Corrective Action Plans" are recommended when non-compliance reaches a serious level. If necessary, the grantee can mail the provider a "Show Cause" or "Corrective Action" letter officially requesting information, timelines, or other matters.