Yes No A review of clinic/pharmacy records demonstrates no C of any contraceptive method that is routinely offered occurred during the past 6 months. Documentation that clinical staff has participated in training on Yes No C QFP (e.g., training available from the Title X National Training Centers). A review of the service site’s FPAR data demonstrates that the Yes No A proportion of males receiving family planning services is close to or above the national average. Yes No A review of medical records confirms that adolescents have C been counseled about abstinence, the use of condoms and other contraceptive methods, including LARCs. Yes No + Additional quality indicators, best practices, or highly innovative If Yes, describe: / A C approaches Exceptional (All 5 Quality Indicators Evident + Best Practices In Place) Good (3 5 Quality Indicators Evident) – 9.8 Quality Assessment Score: (1 2 Quality Indicators Evident) Fair – 0 Quality Indicators Evident 9.8 Additional Comments: 9.9: Durational Residency Requirements Services must be provided without the imposition of any durational residency requirement or requirement that the client be referred by a physician (42 CFR 59.5(b)(5)). Sub-Recipient/ Not Reviewer Implementation Strategy Comments Met Service Site Code Met Score The grantee has a written policy stating that sub-recipient and service must provide services without the imposition of A any durational residence requirement or a requirement that the client be referred by a physician. Site A: ___ Written clinic policies explicitly address this requirement. A Site B: ___ Site C: ___ 9.9 Additional Comments:
C Yes No A review of clinic/pharmacy records demonstrates no of any contraceptive method that is routinely offered occurred during the past 6 months. C Yes No Documentation that clinical staff has participated in training on QFP (e.g., training available from the Title X National Training Centers). A Yes No A review of the service site’s FPAR data demonstrates that the proportion of males receiving family planning services is close to or above the national average. C Yes No A review of medical records confirms that adolescents have been counseled about abstinence, the use of condoms and other contraceptive methods, including LARCs. A / C Yes No + Additional quality indicators, best practices, or highly innovative approaches If Yes, describe: 9.8 Quality Assessment Score: Exceptional (All 5 Quality Indicators Evident + Best Practices In Place) Good (3 – 5 Quality Indicators Evident) Fair (1 – 2 Quality Indicators Evident) 0 Quality Indicators Evident 9.8 Additional Comments: 9.9: Durational Residency Requirements Services must be provided without the imposition of any durational residency requirement or requirement that the client be referred by a physician (42 CFR 59.5(b)(5)). Reviewer Code Met Not Met Sub-Recipient/ Service Site Score Implementation Strategy Comments A The grantee has a written policy stating that sub-recipient and service must provide services without the imposition of any durational residence requirement or a requirement that the client be referred by a physician. A Site A: ___ Site B: ___ Site C: ___ Written clinic policies explicitly address this requirement. 9.9 Additional Comments:
opa_program_rev_tool_2017_0.docx