Review Tool for Potential Residential Treatment Providers

Residential Program Information:

Name of Facility: ______

Address of Facility: ______

______

______

Phone Number:______

Facility Administrator:______

Emergency Phone Number:______

Ages licensed for:______

Gender of clients:______

Maximum Capacity:______

Costs per month:Room/Board ( ) Mental Health ( )

  1. Minimum Standards:

These requirements must be met in order to be approved:

  1. The residential care facility must meet the requirements of Section 3051 of Title 5 of the CCR and maintain documentation supporting the facility’s status as a residential facility that iseither: (1) associated or affiliated with a California -certified NPS (via the master contract of ISA); (2) a California-certified non-public, non-sectarian agency (NPA); or (3) a vendor or contractor of the State Department of Mental Health, or any designated local mental health agency.

(CDE-9/13/11)YesNo

  1. Any residential care provider attached to or associated with a California-certified NPS must be lawfully authorized to provide residential care in its respective state.

Licensed Children’s Institution is defined as a residential facility licensed by the state or other designated public agency to provide non-medical care to children, including, but not limited to, individuals with exceptional needs (CDE 9/13/11).

YesNo

  1. According to 56366.1 There must be separate financial records for respective service activities to ensure that costs associated with NPS and residential care costs are distinguishable.

YesNo

  1. The facility is “Not-for Profit.”???(not required in federal regulations)

YesNo

  1. California non-public school certification is required.YesNo
  1. Ability to provide 24 hour/7 days per week care and supervision to seriously emotionally disturbed youth with high risk behaviors (including but not limited to aggression, run away risk, self- injurious behavior, etc). Yes No

II.Program Requirements

A.Clinical:

1.Qualified facility administratoris available 24/7 per state licensing standards.

YesNo

2.Facility has a licensed psychiatrist available to conduct psychiatric evaluations to include: prescribing/monitoring and managing the need for medication(s), assist with treatment planning, provide consultation to treatment teams and parents and be available in emergency situations if needed. Yes No

3. Services aredelivered in a nurturing, respectful,strength-based, culturally competent manner, utilizing positive behavior supports. Yes No

4.The treatment plan is designed to address IEP mental health treatment goals which will allow students to transition to a less restrictive setting and benefit from their special education program. Yes No

5.There is a plan in place for clinical and educational staff to work together collaboratively to assist clients in meeting their goals. Yes No

6.At time of admission, treatment staff discussestransition/discharge planning with client and family. Yes No

7.Treatment facility has the capacity to assess and screen for suicidal and/or homicidal ideation and provide appropriate crisis intervention services. When indicated, specific plans for management of crisis and emergency psychiatric hospitalization are implemented to ensure the safety of client and others.

YesNo

8.Clinical staff provideindividual, group therapy and family therapy sessionsfor a minimum of:

  • Individual therapy, one time per week for 50 minutes
  • Group therapy, twice per week for 50 minutes each session
  • Family therapy,twice per month for 50 minutes each session.

YesNo

9.Clinical staff to student ratio is(1 FTE)licensed, certified, registered or waivered mental health professional for every 8 children (1:8).

YesNo

10.Facility provides a structured therapeutic milieu.YesNo

11.Facility provides“one to one staffing” of client as needed for the health and safety of the children. Yes No

12.Facility iswilling to participate in interagency review upon request.

YesNo

13.Facilityexceeds minimum state standards for supervision of clients during wake/sleep hours. Yes No

14.Facility conducts multidisciplinary treatment team meetings quarterly.

YesNo

15.Facility evaluates/documents clients need for care based on medical necessity criteria. Yes No

16.Facility is equipped to implement specific behavioral interventions for clients who have severe acting-out and/or self-injurious behaviors.

YesNo

B.Specialized Treatment Services:

  1. Evidenced-based practices______
  2. Chemical Dependency______
  3. Sexually Reactive Treatment______
  4. Offense Specific Treatment______
  5. Trauma Informed Care______
  6. Eating Disorders______
  7. Medically Fragile services______
  8. Spectrum Disorders______
  9. Social Skills Building______
  10. Recreational Therapy______
  11. Animal Assisted Therapy______
  12. Other______

C.Therapeutic Milieu:

  1. Positive/strength based Behavior Management System (points/levels/phases)
  2. Community Meetings______
  3. Daily Goal Setting______

III.Written Policies & Procedures:The facility’s written policies and procedures are in compliance with state standards to include the following:

1.A Group Home Program Statement includes: program identification, population served, services and capabilities. List characteristics and/or behaviors of clients the program is not able to serve. Yes No

2.Description of staffing ratios: Awake ( ) Asleep ( )

Weekends & Holidays ( ) Yes No

3.Organizational chart documents director, mental health staff, and other treatment staff Yes No

4.Provides a list of all personnel and annual staff trainingsYesNo

5.Provides documentation of criminal background checks for all staff Yes No

6.Provides schedule of daily activities to include: educational, treatment and recreational activities and staff supervision during these periods Yes No

7.Provides procedures/protocol to maintain safety, supervision and manage crisis situations with clients on and off campus Yes No

8.Policy regarding utilization of safe and approved physical restraint methods including description of method used Yes No

9.Policy regarding reporting special/critical incidents immediately to placing agency, parents and licensing institution(s) and in writing within 24 hours

YesNo

10.Documentation for proper administration of medications per licensing standards

YesNo

11.Procedures to follow guidelines for HIPPA Compliance and Confidentiality Yes No

12.Mandatory Child abuse Reporting PolicyYesNo

13.Medical protocols and emergency procedures and notification to parents Yes No

14.Procedures related to high risk behaviors including self-injury,

suicidal behaviors YesNo

15.Procedures for preventing, intervening and reporting of

run-awaysYesNo

16.Transportation Policies regarding safety & insurance YesNo

17.Policy regarding termination of clients prior to a planned

dischargeYesNo

18.Policy regarding availability of emergency staff when

neededYesNo

19.Formal complaint/grievance/resolution procedure for

clients in treatmentYesNo

IV. Mandatory Reports/Documentation Requirements:

  1. Provides a comprehensive mental health assessment upon intake.
  2. Develops comprehensive mental health treatment plan with baseline information.
  3. Provides comprehensive quarterly treatment reports and also address client’s progress towards IEP mental health goals. Include restraints/seclusions and frequency of disruptive behaviors and emotional dysregulation.
  4. Maintains client medical record including: health issues, allergies, mental health diagnostic information including multiaxial diagnosis,dangerous propensities, maintain appropriate clinical documentation.
  5. Mental Health Case Managers, School District staff & licensing agencies (as appropriate)are informed of special/critical incidents.

V.Facility Requirements:

  1. Secure management of residents regarding exit doorsYesNo
  2. All areas must be clean and neatYesNo
  3. Common areas must be free from hazardous materials and safe

for children and adolescentsYesNo

  1. Menu of nutritious meals and snacksis available & displayedYesNo
  2. Adequate arrangement of bedrooms/sleeping quarters for clients YesNo
  3. Frequency of safety/room checks providedYesNo
  4. Shower/Restroom policyYesNo
  5. Policy/Procedures regarding locking up potential unsafe objects

(knives, razors,etc.)YesNo

VI.Cost Effectiveness

  1. Ease of accessibility for parents/case managersYes No
  2. Proximity to existing approved placementsYes No

VII.Monitoring:

  1. Facility Report of Complaints/Concerns made to licensing?

YesNo

(If yes, describe complaint & action)

Notes:______

______

  1. Community Care Licensing Review Conducted and Results noted below:

______

______

______

VIII.Result of Facility Review:

  1. Residential Treatment Facility Met All Criteria Listed Above?YesNo

If No, Reason: ____________

______

______

______

  1. Presentation to Steering Committee:
  1. Mental Health Review:Date:______
  1. Educational Review:Date:______
  1. Discussion Summary:

______

______

______

______

______

______

______

______

  1. Outcome of Review Process:

Add to Case Management Project Approved List and/or maintain on list?

YesNo

If no, reason: ______

______

______

______

______

Reviewers SignatureDate

______

Senior Director of Special Education Date

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