Good (2 3 Quality Indicators Evident) – Fair (1 Quality Indicator Evident) 0 Quality Indicators Evident 9.6 Additional Comments: 9.7: Provision of Family Planning and Related Services All projects must provide for medical services related to family planning and the effective usage of contraceptive devices and practices (including physician’s consultation, examination, prescription, and continuing supervision, laboratory examination, contraceptive supplies) as well as necessary referrals to other medical facilities when medically indicated (42 CFR 59.5(b)(1)). This includes, but is not limited to emergencies that require referral. Efforts may be made to aid the client in finding potential resources for reimbursement of the referral provider, but projects are not responsible for the cost of this care. Sub-Recipient/ Not Reviewer Implementation Strategy Comments Met Service Site Code Met Score The grantee has written policies and procedures requiring sub-recipients and service sites to provide medical services C related to family planning as indicated in this section. This should also be included in sub-recipient contracts. Current written (i.e., updated within the past 12 months) clinical protocols clearly indicate that the following services will be offered to female, male and adolescent clients as Site A: ___ C appropriate: a broad range of contraceptives, pregnancy Site B: ___ Site C: ___ testing and counseling, services to assist with achieving pregnancy, basic infertility services, STD services, and preconception health services. Breast and cervical cancer screening are available on-site Site A: ___ C Site B: ___ and offered to female clients. Site C: ___ Written collaborative agreements with relevant referral Site A: ___ agencies exist, including: emergency care, HIV/AIDS care C Site B: ___ and treatment providers, infertility specialists, primary care Site C: ___ and chronic care management providers. Medical records document that clients are provided referrals Site A: ___ C Site B: ___ when medically indicated. Site C: ___ 9.7 Additional Comments:
Good (2 – 3 Quality Indicators Evident) Fair (1 Quality Indicator Evident) 0 Quality Indicators Evident 9.6 Additional Comments: 9.7: Provision of Family Planning and Related Services All projects must provide for medical services related to family planning and the effective usage of contraceptive devices and practices (including physician’s consultation, examination, prescription, and continuing supervision, laboratory examination, contraceptive supplies) as well as necessary referrals to other medical facilities when medically indicated (42 CFR 59.5(b)(1)). This includes, but is not limited to emergencies that require referral. Efforts may be made to aid the client in finding potential resources for reimbursement of the referral provider, but projects are not responsible for the cost of this care. Reviewer Code Met Not Met Sub-Recipient/ Service Site Score Implementation Strategy Comments C The grantee has written policies and procedures requiring sub-recipients and service sites to provide medical services related to family planning as indicated in this section. This should also be included in sub-recipient contracts. C Site A: ___ Site B: ___ Site C: ___ Current written (i.e., updated within the past 12 months) clinical protocols clearly indicate that the following services will be offered to female, male and adolescent clients as appropriate: a broad range of contraceptives, pregnancy testing and counseling, services to assist with achieving pregnancy, basic infertility services, STD services, and preconception health services. C Site A: ___ Site B: ___ Site C: ___ Breast and cervical cancer screening are available on-site and offered to female clients. C Site A: ___ Site B: ___ Site C: ___ Written collaborative agreements with relevant referral agencies exist, including: emergency care, HIV/AIDS care and treatment providers, infertility specialists, primary care and chronic care management providers. C Site A: ___ Site B: ___ Site C: ___ Medical records document that clients are provided referrals when medically indicated. 9.7 Additional Comments:
opa_program_rev_tool_2017.docx