5140. Comprehensive Reviews

Approval: Jennifer Strus, Assistant Secretary

Effective Date: October 31, 2014

Revised Date:  March 31, 2017

Sunset Review: March 31, 2020


Purpose

Comprehensive reviews help Children's Administration (CA) Contracts, Behavioral Rehabilitation Services (BRS) and Division of Licensed Resources (DLR) staff evaluate the ability of contracted licensed BRS providers and other resource providers to meet the health, safety and well-being needs of children in their care.

Scope

This policy applies to DLR regional licensing, BRS program managers and Contract Unit staff.

Policy

  1. Comprehensive reviews measure compliance with licensing standards and contract requirements, while also monitoring the overall performance of a program.
  2. Comprehensive reviews are completed by a CA regional or headquarters staff team consisting of DLR, Division of Children and Family Services (DCFS), BRS, contracts and other program staff. External stakeholders may also participate, e.g. Developmental Disabilities Administration (DDA).
  3. Comprehensive reviews must be conducted on each facility or Child Placing Agency (CPA) under an in-state BRS contract:
    1. Every three years, beginning at or around 18 months after entering into a new license or during each renewal period.
    2. Other times identified by the Comprehensive Review team, i.e., when there is a high score on the Contract Risk Assessment/Analysis tool DSHS 15-466, frequent intakes, a critical incident, or newly identified concerns.
    3. Comprehensive reviews may also be conducted on other licensed or contracted group care facilities or CPAs that do not have a BRS contract when deemed necessary by the review team.
  4. If the BRS provider or other contracted and/or licensed provider has an open DLR/CPS investigation(s) during a comprehensive review, the Comprehensive Review team will notify and invite the DLR/CPS Investigator to participate in the review.
  5. Biannual health and safety reviews are not required for a contracted licensed BRS provider for the review period following completion of a comprehensive review.

Procedures

  1. Percentage of Information to be reviewed:
    1. Group care facilities
      1. Review a minimum of 20% of all active child files or files of children placed within the last 30 days of the comprehensive review date, with no fewer than six files being reviewed.
      2. For group care facilities with less than 50 personnel files, review a minimum of 20% of personnel files, with no fewer than six files being reviewed.
      3. For group care facilities with 50 or more personnel files, review no fewer than ten files.
      4. If the contractor has fewer than six child or personnel files, complete a 100% review.
      5. Interview a minimum of 20% of children and staff, with no fewer than two youth and staff for each residential living unit.
      6. For group care facilities with 50 or more staff, interview no fewer than ten staff.
      7. If child safety or a health issue is identified during the Comprehensive Review, interview a minimum of 50% of children and staff for the residential living unit with the identified issue.
    2. CPAs
      1. For CPAs with less than 50 active child files, review a minimum of 20% of all active child files or files of children placed within the last 30 days of the comprehensive review date, with no fewer than six files being reviewed.
      2. For CPAs with 50 or more active child files review no fewer than ten files.
      3. Review a minimum of 20% of personnel files, with no fewer than six files being reviewed.
      4. If the contractor has fewer than six child or personnel files complete a 100% review.
      5. Interview at least one staff who is responsible for certifying CPA homes.
      6. Conduct in-person or telephone interviews of ten or more children placed in foster homes through the CPA. If the contractor has fewer than ten children placed in foster homes through the CPA interview all children placed.
  2. The Regional Licensor in each region will:
    1. Facilitate an annual meeting with the Comprehensive Review Team held between October and December. The purpose of the meeting is to identify:
      1. The next year's review schedule.
      2. Licensed or contracted providers to be reviewed.
      3. Individuals leading each review, rotating between DLR, BRS, and Contracts Unit staff.
    2. Search for licensing and/or DLR/CPS investigations for the period under review and provide information found to the review team.
  3. The Comprehensive Review Team Lead will:
    1. Notify the licensed or contracted provider four to six weeks prior to the Comprehensive Review and include the following information:
      1. Date, time, and location of the review.
      2. Questions about their program strengths, challenges, and any technical assistance.
      3. Documents or items to be reviewed.
      4. Copies of the forms/tools that will be used during the on-site visit.
    2. Collaborate with the team members prior to the onsite visit and:
      1.  Review the tools and instructions for use.
      2. Discuss existing concerns.
      3. Identify individual tasks for completion.
      4. Discuss relevant WACs, BRS Handbook, or contract issues.
    3. Facilitate an on-site meeting with the agency director and other agency staff at the start of the review to discuss:
      1. Purpose of the Comprehensive Review.
      2. Comprehensive Review process
      3. Location where the files will be reviewed.
    4. Conduct the Comprehensive Review with team members at the CPA office or group care facility being reviewed. If two or three facilities for the same parent agency are being reviewed, conduct interviews and facility inspection at each facility.
    5. Ensure the comprehensive review team reviews no more than three licensed facilities during each Comprehensive Review. Licensed facilities must be associated with one parent agency under one BRS contract and the license expiration dates are within six months of each other.
    6. Ensure the Comprehensive Review includes (as applicable), but is not limited to, a review of the following:
      1. Program Review
      2. Personnel files
      3. Child files
      4. Youth interviews
      5. Staff interviews
      6. Social Worker questionnaires
      7. Foster parent interviews
      8. Incident reports
      9. Medication logs
      10. Documentation of consultant hours
      11. Staff schedules
      12. Facility inspection
    7. Facilitate a staff debriefing on the last day of the review to:
      1. Ensure all Comprehensive Review forms located on the DLR intranet are completed.
      2. Discuss strengths, concerns, and patterns that will be shared with the agency director and other agency staff during the exit interview.
    8. Facilitate an exit interview on the last day of the review with the agency director and other agency staff to:
      1. Discuss any health and safety, licensing, and/or programming concerns.
      2. Complete an Immediate Action Plan Compliance Agreement DSHS  10-522 if there is an immediate licensing or contracts violation and give it to the licensed or contracted provider to implement.
    9. Notify the agency director that the Final Report and compliance agreement will be sent within 30 days following the review. The compliance agreement will address licensing and programming issues, and the health and safety of the youth being served.
    10. Complete the Final Report DSHS 10-520 with the assistance of the Comprehensive Review team within 30 days following the on-site review.
    11. Provide the Final Report to the licensed and/or contracted provider and staff that participated in the review and place in the DLR and CA Contracts' files.
  4. Disagreement with the Final Report:
    1. If review members disagree about the report, the final decision shall be made by the following members:
      1. DLR Supervisor if WAC is the standard cited for the findings of non-compliance.
      2. BRS Program Manager if the BRS Handbook is cited for the findings of non-compliance.
      3. Contracts Program Manager if the Contract is being cited for non-compliance.
    2. If the licensed and/or contracted provider believes there are factual errors in the report, he/she will submit a written document within 30 days of receipt of the Final Report that outlines his/her concerns. The following members will respond and resolve:
      1. Regional licensor if the concern is a licensing issue.
      2. BRS or Contracts manager if the concern is a program or contracts issue.
  5. Monitoring Compliance Agreements: Responsibility to monitor compliance agreements rests with the regional licensor, BRS program manager, and/or Contracts manager, depending on which standard is used in the plan as noted in Procedures 4.a.

Forms and Tools

The following forms are located on the CA Intranet site under the DLR program:

  • DSHS 10-510 Comprehensive Review: BRS / Contracts Program Review
  • DSHS 10-511 Comprehensive Review: DLR Program Review
  • DSHS 10-512 Comprehensive Review: BRS Contractor Client File
  • DSHS 10-513 Comprehensive Review: DLR Client File
  • DSHS 10-514 Comprehensive Review: Personnel Files
  • DSHS 10-515 CA Worker Questionnaire
  • DSHS 10-516 Youth Interview
  • DSHS 10-517 Staff Interview
  • DSHS 10-518 Foster Parent Interview
  • DSHS 10-519 Incident Report Review
  • DSHS 10-520 Comprehensive Review Final Report
  • DSHS 10-521 Comprehensive Review: Compliance Agreement
  • DSHS 10-522 Comprehensive Review: Immediate Action Plan Compliance Agreement

Resources

Comprehensive Health and Safety Reviews Tips Sheet