DEPARTMENT OF PUBLIC SAFETY Monitoring Review Report for Residential Services (Emergency/Runaway Shelters, Specialized Foster Care, Temporary Foster Care, Residential Group Homes) PROGRAM INFORMATION County: Sponsoring Agency: Component Name: Component Funding ID #: Service Delivery by Type of Residential Service (Select one category.) Emergency/Runaway Shelter. The program operates 24 hours per day. 17. Residential Services, C. 1. The program’s license to provide services is current. The program is in compliance with all state and federal licensure requirements. 17. Residential Services, C. 2. The program is available for emergency placement 24 hours a day. 17. Residential Services, C. 2. a. The program’s capacity does not exceed the number permitted by its license. 17. Residential Services, C. 4. The program provides a response to the referring agency regarding admission decisions within 10 business days of receiving the referral. 17. Residential Services, D. c. iii. The program does not use volunteers to provide primary supervision of juveniles in the program. 17. Residential Services, E. 1. c. v. Specialized Foster Care The program operates 24 hours per day. 17. Residential Services, C. 1. The program’s license to provide services is current. The program is in compliance with all state and federal licensure requirements. 17. Residential Services, C. 2. . The program’s capacity is limited to no more than 2 juveniles at any given time. 17. Residential Services, C. 4. A written individual service plan is developed within 30 days of admission. 17. Residential Services, D. 2. a. The program provides a response to the referring agency regarding admission decisions within 10 business days of receiving the referral. 17. Residential Services, D. c. iii. The program does not use volunteers to provide primary supervision of juveniles in the program. 17. Residential Services, E. 1. c. v. The program provides after-hours access to a social worker or mental health worker for the benefit of the foster parents and foster children. 17. Residential Services, E. 2. d.
Terminated Client Review All Programs Residential Svc. Only Client Name Termination Date (matches client tracking) Referral Form Referral Source (matches client tracking) Referral Reason (matches client tracking) Parental Consent to Participate Medical / Medication Information (if applicable) Consent for Release of Information (if applicable) Individual Service Plan - ISP n/a for assessment only programs ISP shows expected changes in behavior, attitude, performance, and/or skills ISP shows Interventions / Activities to be provided ISP shows expected duration of services ISP shows how progress/changes will be measured Contact Record with activities, dates, times, duration, results each time the youth and/or family is seen Hard Copy of Client Tracking Data in Record Copy of Progress Reports to Juvenile Court Counselors at least every 30 days (if applicable) Termination Summary with date and reason for termination (matches client tracking) Documentation of legal custodian/s placement authority (residential programs only) Consent for Placement (residential programs only) Consent for medical records inc. physical & immunization records (residential programs only) Social History information (residential programs only) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.