Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations. HMIS Grant Administration Programmatic Self-Monitoring Guide

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1 Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations HMIS Grant Administration Programmatic Self-Monitoring Guide Background: In 2000 Congress directed HUD to provide data and analysis on the extent and nature of homelessness and the effectiveness of the McKinney Act programs, including: Developing unduplicated counts of clients served at the local level; Analyzing patterns of service use; and, Evaluating the effectiveness of these systems. HUD has defined HMIS as the tool for Continuums of Care (CoCs) to complete these tasks. HUD has designated the CoC as the entity responsible for HMIS implementation. These Guidelines for Self-Assessment provide a process tool for tracking, measuring, and analyzing the overall effectiveness of the HMIS project. Objectives: 1. Assess the HMIS project s consistency and compliance with HUD s HMIS Data and Technical Standards; 2. Provide a formal mechanism to define and undertake corrective action when deemed necessary; 3. Orient and prepare a community for a HMIS project-monitoring visit by the HUD Field Office; and, 4. Provide feedback and recognition to communities on their progress towards full implementation. Instructions for completing the self-assessment process tool: Each community should complete the self-assessment process tool on at least an annual basis but more frequent assessments are an effective management and performance measurement tool to assess a community s HMIS functioning. Ideally an HMIS project manager or HMIS advisory committee will review self-assessment results at least quarterly. Prior to beginning the self-assessment process the HMIS grantee should organize HMIS project materials and documentation to help facilitate the review. A list of project materials will include the following: Project plan Agency participation actual schedule Equipment deployment actual schedule HMIS and other related training actual schedules Documented list of active HMIS users Data on client HMIS coverage up to the monitoring date Data on program HMIS coverage up to the monitoring date Policies and procedures manual Documentation of current privacy notice protocols Documentation of security protocols Documentation of data quality protocols and processes Samples of HMIS reports (e.g. demographic summaries, utilization rates, APR, etc.) The HMIS project manager or advisory team should initially complete the self-assessment. A report of preliminary findings/issues should be prepared for full community input and review. When undertaking the HMIS self-assessment read through the statements in each category and identify with a check mark ( ) your community s status. Add comments and recommendations for changes in the column for all items. At the conclusion of the self- Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 1

2 assessment process, communities should review all checked items in the / No column and develop a comprehensive improvement plan to address all corrective action issues. HUD s National HMIS Technical Assistance Team has organized HMIS TA materials and resources on the website that can be searched using key words. This tool associates keywords with each assessment statement to make it easier for communities to identify TA materials and resources that can help them. Monitoring Area 1. Organization of the HMIS Project 1.1 Steering Committee There is a steering committee or board that oversees the HMIS planning and strategic activities. 1.2 Advisory Meetings There is evidence that the HMIS steering committee or board convenes advisory meetings for the purposes of addressing HMIS implementation and management issues. 1.3 Inclusive Participation Membership on the HMIS steering committee or advisory board is inclusive of decision makers representing the CoC and community. 1.4 Governance Structure The HMIS grantee and the applicable CoC planning body(ies) have entered into a formal agreement that outlines management processes, responsibilities, decision-making structures, and oversight of the HMIS project. Evidence of a formal agreement exists such as a Memorandum of Understanding, Letter of Agreement, or similar such documentation. 2. Leading Agency in the HMIS Project 2.1 Project Milestones The Lead Agency, the grantee and/or the HMIS project manager (if different from the grantee), has identified general milestones for project management, including training, expanded system functionality, etc. There is evidence that milestones are monitored and variances noted. 2.2 Project Management Milestones The lead agency is responsive and flexible in carrying out its role; demonstrates the technical expertise commensurate with the requirements of the project; provides timely support on technical matters; is responsible to the changing requirements of participating agencies; and, generally accommodates special issues brought to it by participating Agency and Program HMIS Participation Rates Project Manager regularly monitors program and agency-level participation in HMIS via comparison of point-in-time census of beds/slots versus clients served. Evidence of monitoring reports is available for review Data Quality Reports Project Manager regularly runs and disseminates data quality reports to participating programs that indicate levels of data entry completion, consistency with program model, and timeliness as compared to the community data quality standards. Project Manager can explain the data quality monitoring process and provide sample reports HMIS IT Issue Tracking Project Manager maintains a regularly updated list of HMIS system service requests, activities, deliverables, and resolutions. The IT issue-tracking list is available for review Project Staff Organization Chart An organization chart clearly identifies all team members, roles and responsibilities, and general work activities/functions. Organization chart is available for review. Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 2

3 2.2.6 Training - HMIS users receive regular and sufficient (semiannual or annual) training or communication on business practices to support CoC and HMIS policies (these might include CoC-specific protocols, ethics, strategies for communicating consent protocols to clients). Project Manager can describe the training curricula, frequency of trainings, participation rates in training Performance Measurement Reports HMIS is capable of preparing performance measurement reports for CoC homeless assistance providers participating in the HMIS. Reports include summary of program activities, outputs, and outcomes. 3. Participating Agencies 3.1 Training and Orientation All required HMIS participants (McKinney-Vento funded programs such as ESG, SHP, S+C, SRO, and HOPWA projects that target homeless) have received training and orientation to the HMIS project. 3.2 Participating Agency Documentation Documentation of the number of participating agencies (utilizing the system) is up-to-date. A comparative analysis of planned versus actual deployments at the project level is highly desired but not compulsory. 3.3 Participation Rates ES-IND (emergency shelter for individuals) coverage rates are at or above 75% of the bed inventory (from the most recent Housing Inventory Chart). If coverage rates have not achieved a 75% level of participation, the Lead Agency can provide an explanation for the barriers to implementation at specific 3.4 Participation Rates ES-FAM (emergency shelter for families) coverage rates are at or above 75% of the bed inventory (from the most recent Housing Inventory Chart). If coverage rates have not achieved a 75% level of participation, the Lead Agency can provide an explanation for the barriers to implementation at specific 3.5 Participation Rates TH-IND (transitional housing for individuals) coverage rates are at or above 75% of the bed inventory (from the most recent Housing Inventory Chart). If coverage rates have not achieved a 75% level of participation, the Lead Agency can provide an explanation for the barriers to implementation at specific 3.6 Participation Rates TH-FAM (transitional housing for families) coverage rates are at or above 75% of the bed inventory (from the most recent Housing Inventory Chart). If coverage rates have not achieved a 75% level of participation, the Lead Agency can provide an explanation for the barriers to implementation at specific 3.7 AHAR Participation in the AHAR (Annual Homeless Assessment Report) is evident or planned for the intermediate future (within 2 years). 4. Implementation 4.1 Project Plan The project has a documented project plan that expands the proposed milestones articulated in the application and technical submission process. The plan describes numerous interrelated activities or tasks that describe the project s progress over time. The project plan may be a narrative document with accompanying schedules that describe what will be accomplished, when, and by whom, and with what resources. 4.2 Project Communication Strategies The project plan includes mechanisms to communicate with HMIS stakeholders about changes to the plan. Communication strategies can include user meetings, newsletters, listservs, conference calls, annual reports, as well as many other types of regular communication. Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 3

4 4.3 HMIS User Feedback The project includes mechanisms for soliciting, collecting, and analyzing feedback from end users, program managers, agency executive directors, and homeless persons. Feedback includes impressions of implementation milestones and progress, system functionality, and general HMIS operations. Examples of feedback include satisfaction surveys, questionnaires, and focus groups. 5. System Operation 5.1 Policies and Procedures. The existence and use of Policies and Procedures is evident. Policies and procedures may cover a wide range of issues, but at a minimum a community must have established protocols for the following: Agency Participation Agreement describes the protocols for agency participation in the HMIS Data Sharing Agreements define the level of data element or program information sharing among participating HMIS HMIS End-User Agreement each authorized user of the HMIS should have a user agreement that defines participation protocols, including training criteria, consent protocols, system use, and privacy and security standards Privacy Policy The CoC and/or implementing jurisdiction geography of the HMIS grantee has developed a privacy policy that outlines privacy practices for all participating HMIS users. The policy is communicated or otherwise made available to clients Client Consent The CoC and/or implementing jurisdiction geography of the HMIS grantee has defined a client consent protocol for use as a baseline practice among all participating HMIS users Data Release The CoC and/or implementing jurisdiction geography of the HMIS grantee has defined an HMIS data release protocol that governs release of all data from the HMIS. 5.2 Training. Training on use of the HMIS software and general system operation procedures is a consistent and ongoing activity of the project. Evidence exists of a training schedule and training curriculum. All current end users of the system should receive training at a minimum of an annual basis. 5.3 System Users. The number of actual authorized system users is consistent with the current project plan and level of funds budgeted in the approved technical submission. 5.4 Unduplicated Client Records. The HMIS is able to generate a summary report of the number of unduplicated client records that have been entered into the HMIS. 5.5 APR Reporting. The HMIS is consistently able to produce a reliable APR. 5.6 HMIS Reports. The HMIS generates other client served, utilization summary, and demographic reports both at the system and program levels for purposes of understanding the nature and extent of homelessness in the CoC. 6. Data Collection 6.1 Universal Data Elements HMIS is able to manage the collection of each data variable and corresponding response categories. An HMIS software check verifies ability to collect the following: Name Social Security Number Date of Birth Ethnicity and Race Gender Veteran Status Disabling Condition Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 4

5 6.1.8 Residence Prior to Program Entry Zip Code of Last Permanent Address Program Entry Date Program Exit Date Unique Person Identification Number Program Identification Number Household Identification Number 6.2 Program-Specific Data Elements HMIS is able to manage the collection of each data variable and corresponding response categories. An HMIS software check verifies ability to collect the following: Income and Sources Non-Cash Benefits Physical Disability Developmental Disability HIV/AIDS Mental Health Substance Abuse Domestic Violence Services Received Destination Reason for Leaving Employment* Education* General Health Status* Pregnancy Status* Veteran s Information* Children s Education* *Recommended but not required 7. Privacy 7.1 Privacy Policy - the CoC has developed privacy policies and procedures to ensure that all agencies and users share a common understanding of client notification and/or consent procedures as well as processing of Personal Protected Information (PPI) Privacy Notice The CoC and all Covered Homeless Organizations (CHOs) 2 post or otherwise make available to clients (via website) a notice of the privacy practices relating to the following: What the notice covers How and why personal information is collected Uses and disclosures of personal information Inspection and correction of personal information Quality of data Complaints and accountability History of changes 7.3 Client Consent for Data Collection The CoC has adopted a client consent protocol and the HMIS software and management support the stated policy (allowing clients to opt out if desired). 8. Security 1 PPI Protected Personal Information. Any information maintained by or for a CHO about a homeless individual that identifies the individual. 2 CHO Covered Homeless Organization. Any organization that records, uses or processes PPI on homeless clients for an HMIS. Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 5

6 8.1 Information Security Protocol The CoC has established a baseline set of security protocols that address all security aspects of the HUD HMIS Data and Technical Standards where PPI is stored, including networks, desktops, laptops, mini-computers, mainframes, and servers. 8.2 station Authentication Every individual with HMIS access employs a user authentication system for their individual computer or terminal, consisting of a username and password. Passwords consist of at least eight characters with at least one number and one letter. 8.3 Virus Protection Each CHO protects the HMIS from viruses by using commercially available virus protection software. 8.4 Firewalls There is a firewall between each workstation and any systems located outside the CHO. 8.5 Limited Public Access (PKI) HMIS that use public forums for data collection or reporting must be secured to allow only connections from previously approved computers and systems. 8.6 Limited Physical Access to Systems HMIS computers and workstations that are in public areas (used to collect and/or store HMIS data) are staffed and/or secured at all times. 8.7 Disaster Protection and Recovery All HMIS data is copied on a regular basis to another medium (e.g. tape) and stored in a secure off-site location where the required privacy and security standards apply. If HMIS uses a central server, the central server is stationed in a secure room with temperature control and fire suppression systems. 8.8 Storage A CHO must retain client data for a period of seven years after the PPI was created or last changed. 8.9 Disposal When client data is deleted from a storage medium (eg. tape, diskette, CD), the CHO reformats the storage medium more than once before reuse or disposal System Monitoring Each CHO and the CoC must monitor security systems. Any entity that has access to the HMIS must be documented in a user access log HMIS Software Application Security A CHO must apply the following application security provisions to the software during data entry, storage and review or any other processing function: User Authentication User access to the HMIS software is control by a password consisting of at least eight characters with at least one number and one letter Encryption A CHO must use 128-bit encryption for all HMIS data that are electronically transmitted over the Internet Electronic Data Storage A CHO must store all HMIS data in a binary, not text, format Hard Copy Security A CHO must secure any paper or other hard copy containing personal protected information that is either generated by or for HMIS, including but not limited to reports, data entry forms and signed consent forms. 9. Data Quality 9.1 Data Quality Plan The CoC has initiated a Data Quality Plan that minimally addresses the uses of data, protocols for proper collection, and standards for relevancy, accuracy, completeness, and timeliness. 9.2 Relevancy PPI collected in an HMIS must be relevant to the purpose for which it is to be used. 9.3 Accuracy PPI collected in an HMIS must accurately represent the case characteristics, demographics, service transactions, and history for all client data entered into the HMIS. 9.4 Completeness All HMIS participating programs collect a minimum of the universal data elements for each client record entered into the HMIS. Completeness includes universal elements for all participants and program elements for APR projects, Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 6

7 9.5 Timeliness All HMIS participating programs enter client data into the HMS within a time period specified in the CoC Data Quality Plan. 10. Other Federal Requirements 10.1 Drug-Free place The HMIS Grantee has adopted a drug-free workplace policy. The policy is posted and available for review Homeless Client Participation At least one homeless person or formerly homeless person participates in policymaking. Participation can include but is not limited to governing board leadership, advisory committees, staff positions, and sub-committee positions Conflict of Interest The HMIS Grantee has adopted a conflict of interest policy for board members, staff, and volunteers Equal Opportunity and Non-Discrimination Policy The HMIS Grantee has adopted an equal opportunity and nondiscrimination policy. Persons/Review Body Completing the Self-Assessment Process: Date: Guidelines for Self-Assessment of HMIS Grantee Implementation and Operations 7