Housing Service Standards

Approved March 3, 2020

Prepared by

Service Standards and Integrated Care Plan Committee of the 

Middlesex-Hunterdon-Somerset HIV Health Services Planning Council

Housing Services Definition:


Housing provides transitional, short-term, or emergency housing assistance to enable a client or family to gain or maintain outpatient/ambulatory health services and treatment, including temporary assistance necessary to prevent homelessness and to gain or maintain access to medical care. Activities within the Housing category must also include the development of an individualized housing plan, updated annually, to guide the client’s linkage to permanent housing. Housing may provide some type of core medical (e.g., mental health services) or support services (e.g., residential substance use disorder services).


Housing activities also include housing referral services, including assessment, search, placement, and housing advocacy services on behalf of the eligible client, as well as fees associated with these activities.


Program Guidance:

HRSA RWHAP recipients and subrecipients that use funds to provide Housing must have mechanisms in place to assess and document the housing status and housing service needs of new clients, and at least annually for existing clients.

HRSA RWHAP recipients and subrecipients, along with local decision-making planning bodies, are strongly encouraged to institute duration limits to housing activities. HRSA HAB recommends recipients and subrecipients align duration limits with those definitions used by other housing programs, such as those administered by the Department of Housing and Urban Development, which currently uses 24 months for transitional housing.

Housing activities cannot be in the form of direct cash payments to clients and cannot be used for mortgage payments or rental deposits,* although these may be allowable costs under the HUD Housing Opportunities for Persons with AIDS grant awards. 


*See sections 2604(i), 2612(f), 2651(b), and 2671(a) of the Public Health Service Act.


Source: HIV/AIDS Bureau Policy Clarification Notice (PCN) #16-02 (2018)


HUD: New Homeless Definition


Who Does This New Rule Apply To?

The rule applies to programs funded by HUD differently depending on the type of program (formula or competitive) and,

for competitive programs, when your operating year begins. The final rule applies to:

  1. All recipients of Emergency Solutions Grants (ESG) program funds.
  2. All recipients of SHP and S+C funding awarded through the FY 2011 CoC Competition at the point that their

renewal award takes effect. For example, a project with a start date of May 1 would be subject to the new

definition regulation on May 1 when their 2011 renewal grant agreement takes effect.

  1. This definition does not apply to HPRP programs or competitive projects that did not renew in the 2011

Continuum of Care competition.

How Does the Rule Define Homelessness?

The final rule on the Definition of Homeless establishes four categories under which an individual or family may qualify

as homeless. The categories are: 

Category 1

Literally homeless individuals/families

Individuals and families who lack a fixed, regular, and adequate nighttime residence, which includes one

of the following:

  • Place not meant for human habitation
    • Living in a shelter (Emergency shelter, hotel/motel paid by government or charitable organization)
    • Exiting an institution (where they resided for 90 days or less AND were residing in emergency
    • shelter or place not meant for human habitation immediately before entering institution)

    Category 2

    Individuals/families who will imminently (within 14 days) lose their primary nighttime residence, which

    includes ALL of the following:

    • Have no subsequent residence identified AND
    • Lack the resources or support networks needed to obtain other permanent housing

    Category 3

    Unaccompanied youth (under 25 years of age) or families with children/youth who meet the

    homeless definition under another federal statute and includes ALL of the following:

    • Have not had lease, ownership interest, or occupancy agreement in permanent housing at any
    • time during last 60 days
    • Have experienced two or more moves during last 60 days
    • Can be expected to continue in such status for an extended period of time because of: chronic
    • disabilities, OR chronic physical health or mental health conditions, OR substance addiction, OR
    • histories of domestic violence or childhood abuse (including neglect) OR presence of a child or
    • youth with a disability, OR two or more barriers to employment

    Category 4

    Individuals/families fleeing or attempting to flee domestic violence, dating violence, violence, sexual

    assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the

    individual or family member and includes ALL of the following:

    • have no identified residence, resources or support networks
    • Lack the resources and support networks needed to obtain other permanent housing

    Source: http://www.hudhre.info/documents/HEARTH_HomelessDefinition_FinalRule.pdf

    HUD definition of homeless:

    Being at risk of being homeless is defined as:

    1. When an individual self identifies as needing assistance with housing budgets OR
    2. Does not have sufficient resources or support networks immediately available to prevent them from moving to an emergency shelter or another place defined in Category 1 of the “homeless” definition; AND (iii) Meets one of the following conditions: 
    1. Has moved because of economic reasons 2 or more times during the 60 days immediately preceding the application for assistance; OR 

    (B)  Is living in the home of another because of economic hardship; OR 

    (C)  Has been notified that their right to occupy their current housing or living situation will be terminated within 21 days after the date of application for assistance; 

Staff Service Standards

(Housing Services)

Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism
1.1Staff hiringStaff will have necessary skills and experience determined by
*Written application
*Personal interview

Application, resume, and communication with personal references are documented in personnel files.

1.2(a)Staff qualifications (housing coordinator)Staff have the following credentials:
*Bachelor’s degree in social work, sociology, or a related field
*2+ years of housing coordination experience
*Participation in county/community housing related meetings and events
*Training in “Truth in Renting”

100% of staff possess the education and experience documented in the personnel file.
1.2(b)Staff qualifications
(Peer Navigator)

A member of the peer community living with HIV/AIDS with a high school diploma or GED, plus two years of social service experience. Peer must demonstrate understanding of HIV services and healthcare service navigation.

100% of staff possess a diploma, certificate or license (if appropriate) or experience documented in personnel file.

1.3Staff job descriptions

Staff will be given a written job description. The job description includes the definition of housing services.

100% of staff has a job description and service standard documented in the personnel file.

1.4Staff trainingStaff are trained and knowledgeable on:
*HIV/AIDS and the affected tri county community including disease process, co-morbidities and psychosocial effects of the disease.
*Cultural humility
*Entitlement programs, benefits to clients, and community resources/support services
*Client confidentiality, client rights, agency grievance procedures
*Local housing resources and support services covering all three counties

100% personnel files document training.

1.5Staff continuing education

Staff participate in at least one continuing education training per year that is available and appropriate.

100% personnel files document training.
1.6Staff supervisionSupervisors are knowledgeable about Ryan White HIV psychosocial support services and procedures including fiscal and program.

Staff will receive (at minimum) one-hour supervision per week to develop skills.
100% of supervisors are knowledgeable about the RW program. Supervision is documented in personnel files.
1.7Policies and proceduresSigned form is documented in the personnel file.

100% of staff agrees to follow agency policies and procedures.

1.8Staff evaluationStaff evaluations are documented in personnel files.
100% of staff is evaluated on their performance annually.

1.9DocumentationStaff will keep written documents of contact with clients in accordance with Ryan White data collection procedures.

100% of all contacts are documented in client files.

Client Service Standards

(Housing Services)

Activity/IssueMinimum Acceptable Threshold of ServiceAccountability Mechanism

2.1EligibilityIn order to be eligible for services, individuals must meet the following:
*Residing or receiving services in the Middlesex, Somerset, Hunterdon TGA
*Income at or below 80 percent of area median income (HUD, 2014)
*Client is homeless or is in at risk of being homeless
*Client must be 18 years of age or represented by parent/guardian of legal age

100% of clients have eligibility documentation in their file.

2.2IntakeEach client has a formal assessment completed within (30) days of initial visit which addresses the following content:
*Housing history
*ADA needs
*Household composition
*Employment, financial status and/or income sources
*Credit history
*Legal issues
*Medical diagnoses and client acuity
*Mental health diagnoses
*Substance use or abuse
*Medication adherence and access to primary care
*Need for help in filling out forms and getting on wait lists
*Need for enhanced services

90% of clients have an intake documented in their file.
2.3Linkage to existing resourcesHousing coordinator will provide access to shelter options when a client is homeless and all other housing resources have been exhausted.

80% of client charts have documentation of efforts to link clients to existing programs.

2.4Provide interim temporary emergency shelter

Emergency shelter is provided in accordance with HUD guidelines while the client is enrolled into existing housing programs.
*Number of nights
*Date check provided
*Amount of check

80% of client charts have documentation of shelter payment details.
2.5Budgeting counselingReview management of monthly expenses and monthly income for housing coordination.
*Review utilities payment history
*Review all other household expensesReview income
*Review available credit
*Review other available resources
90% of client charts have documentation of budget counseling
2.6Housing coordinationProvide information and coordination of housing resources.
*Assist clients to determine housing options
*Assist with housing applications
*Assist with background and credit checks
*Provide rental and lease education

90% of client charts have documentation of housing options counseling and coordination of housing resources.
2.7LinkageThe housing coordinator will assist clients in finding affordable housing through direct assistance and referral.

The housing coordinator will link clients with existing programs such as:
*Home Share
*Subsidized housing

90% of client charts have documentation of direct service or linkage to housing services.
2.8Coordination with other Ryan White providers

Housing coordinator will coordinate services with the client’s Ryan White case manager to ensure completion of the referral process.

90% of client charts have documentation of coordination.
2.9Housing educationHousing coordinator will link clients with existing programs or provide workshops on topics such as:
*Good tenancy
*Landlord requirements (Truth in Renting)
*Roommate education
*Other housing related topics as needed

80% of client charts have documentation of ‘Truth in Renting’ material shared verbally, through workshops or in brochure form with applicable clients.
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