This certificate is hereby granted to COMMISSIONERS OF YORK COUNTY LEGAL. ENTITY T0 operate YORK COUNTY OFFICE OF CHILDREN, YOUTH FAMILIES NAME OF FACILITY OR AGENCY Located at 100 WEST MARKET STREET. YORK. PA 17401 ADDRESS OF FACILFTY OR AGENCY) ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE ADDRESS OF SATELLITE SITE. Restrictions: This certificate is granted in accordance with the Public Welfare Code of?1967, 31, as amended, and Reguiations 55 Pa.Code Chapter 3130: Administration of County Children and Youth Services and Other Supplementary Program Regulations (MANUAL NUMBER AND TITLE OF REGULATIONS) and shall remain in effect from Mai/15. 2015 until November 15.. unless sooner revoked for non?compliance with applicable laws and reguiations. Na ?t??72 [magi NOTE: This certificate is issued for the above site(s} only and is not transferable and should be posted in a conspicmus place in the facility. HS 623 12H 4 COMMONWEALTH OF DEPARTMENT OF PUBLIC WELFARE MG 2 5 2M VIA CERTIFIED MAIL Mr. Terry L. Clark, Director York County Office of Children, Youth and Families 100 West Market Street, Suite 402 York, 17401 Dear Mr. Clark: The Department of Human Services (Department) conducted inspections of York County Office of Children, Youth and Families, 100 West Market Street, 4th Floor, York, 17401, on March 18, 19, 20 and 23, 2015, for the purpose of conducting a renewal inspection. The Department also conducted inspections of the agency on February 12, April 6 and April 22, 2015 to investigate complaints. The enclosed Licensing Inspection Summary (LIS) documents include details of the violations of the regulations at 55 Pa. Code Chapters 3130 and 3490 found during these inspections. Many of the areas of noncompliance were previously cited during annual inspections conducted by the Department in 2014. The regulatory violations found preclude the Department from granting York County Office of Children, Youth and Families a regular Certificate of Compliance. The failure to comply with the applicable regulations and failure to comply with the acceptable plan to correct noncompliance items as specified in detail in the enclosed LIS documents, is the basis for issuance of a second provisional Certificate of 5 Compliance (see 62 PS. ?1008; 55 Pa. Code ??20 54 and The Department will issue York County Office of Children, Youth and Families a second provisional Certificate of Compliance (Certificate #315972) for the time period from May 15, 2015 through November 15, 2015 (see 55 Pa. Code ??20 54 and You may appeal the refusal to renew your first provisional Certificate of Compliance and the issuance of a second provisional Certificate of Compliance by filing a written petition within 30 days of service of this letter (see 55 Pa. Code $130.82). Your petition should indicate the reasons for the appeal, being as specific as possible as to the areas of disagreement. Any appeal must be filed with: Director, Bureau of Hearings and Appeais Department of Public Welfare Post Office Box 2675 Harrisburg, 17105 OFFICE OF CHILDREN, YOUTH a FAMILIES PO BOX 2675 HARRISBURG, PA 17120 i 717.787.4756 Fax 717.787.0414 Mr. Terry Clark 2 Your appeal must be received by the Bureau of Hearings and Appeals within 30 days of service of this letter. If you appeal, please also send a copy of your appeal letter to Ms. Gabrielle Williams, Regional Director for the Central Region Office of Children, Youth and Families, Hilltop Building #52, 3 Gingko Drive, 2nd Floor, Harrisburg, 17110. If you do not choose to appeal, the decision of the Department will become final 31 days from service of this letter. The Department has worked closely with you and your staff to identify areas of needed improvement and to provide technical assistance. We stand ready to continue to provide oversight and support to York County throughout this process as required by the Commonwealth Public Welfare Code. We look forward to continuing to work with you and would be happy to address any questions you may have. Sincerely, - :3 Cathy A. Utz Deputy Secretary Enclosures c: The Honorable M. Steve Chronister, President, York County Commissioner The Honorable Christopher 8. Reilly, York County Commissioner The Honorable Doug Hoke, York County Commissioner Ms. Gabrielle Williams, Director, Central Region Office of Children, Youth Families COUNTY CHILDREN AND YOUTH AGENCY ANNUAL SURVEY AND EVALUATION SUMMARY NAME OF TELEPHONE: OCYF REGIONAL STAFF APPROVAL DATE York County Office of Children, Youth, and Families 717?846?8496 I ADDRESS: COUNTY: 100 West Market Street, 4th Floor, York, PA 17401 York ogram Represen a iv . q! ?20 INSPECTED BY: INSPECTION DATES: Colleen Smith, Mark Schrode, Mike Yakum, Faith Blough, Desiree MafCh 18-20. 23. Weisser 2015 1! Supervisor: 3 M1 71( INITIAL RENEWAL COMPLAINT UNANNOUNCED RANDOM "j INSPECTION INSPECTION INSPECTION SAMPLE ., - . . Regional Director: I 7 I The Department of Public Welfare, Central Region Of?ce of Children, Youth and Families conducted the annual/provisional licensing inspection of York County Of?ce of Children, Youth, and Families by means of a random sample record review, interviews with administrative, supervisory, and casework staff, internal policy/procedures review, personnel record review and agency ?scal documentation review. York County Children and Youth Services were issued a first provisional Certificate of Compliance effective November 15, 2014-May 15, 2015. The Department has been monitoring the agency through on site visits, ?le reviews and contacts with staff during the time of the ?rst provisional license. The case sample was drawn from cases assigned to all program units and casework functions within the agency. 10 of 1,470 Child Protective Service intake records, 10 of 573 Placement records, 10 of 2,265 General Protective Services Intake records, 10 of 168 Screen-outs, 52 of 101 Resource Family Home records, 47 of which were new homes, 1 of 15 Adoption records, 10 of 271 Ongoing/in-Home Services records, 42 of 42 personnel records of new employees and 110 of 110 personnel records of tenured employees. In addition, the Department completed 4 foster home visits. York County Office of Children, Youth, and Families (York OCYF) is a public child welfare agency serving primarily an urban population of approximately 440,755 residents in a 3 class county. This is an agency and county rich in resources and innovative practices. There are targeted services available for very speci?c family needs including mental health, drug and alcohol, housing, and truancy. These services are utilized by the agency in many cases and many families are referred and served by the numerous professionals operating in York County. Agency caseworkers and supervisors are aware of the range of services and adept at making referrals to community agencies. The infrastructure observed in the agency allows for quick processing of these referrals. With many of the services . falling under the Human Service umbrella in York County, there is apparent open communication between the agencies and easy access to information. The Human Services Department also offers Family Group Decision Making and/or Family Team Meetings to all families. Human Services staff team with CYF staff and families to hold these family-centered meetings in as little as a few days, when needed. The agency experienced a large flux in administration throughout the past year as the administrator, fiscal officer and a division manager left the agency, more seasoned workers retired or left the agency, and many new caseworkers were hired. This leaves the agency in a position in which new workers spend signi?cant amounts of time in training and the few seasoned workers that remain carry higher numbers of more complex cases. To assist during this time of transition, supervisory staff also carried caseloads, which in turn afforded them less time in one?on-one supervision of caseworkers. York County OCYF is a Phase 1 CQI County, and the Quality Service Review was completed in 2014. The agency plans to complete the next Quality Service Review in 2016. While there was noticeable improvement in some areas of the agency casework, certain areas needing improvement continue to show through licensing reviews, the 2014 Quality Service Review and internal reviews completed by the Quality department over the past year. These areas include family engagement and assuring safety of all children in a family. The management team does understand the importance of remedying these concerns to improve overall functioning, accountability and outcomes for children and families involved with agency services. The agency has taken some of the steps necessary to remedy these issues. All case Specific regulatory references contained within the License and Inspection Summary do not contain speci?c identifying demographic data due to statutory prohibitions relating to confidentiality. SUMMARY OF AGENCY PRACTICES Practice Area: Safety Assessment and Monitoring QSR Indicator: Safety from Exposure to Threats of Harm QSR indicator: Safety from Risk to Self/Others Safety Assessment and Monitoring is an area that has seen some improvement in agency casework, ongoing supervision, and insight. The agency continues to utilize their established safety leads and supports to oversee the process of safety assessment. After the previous licensing inspection, there have been many lit-depth discussions about implementation of the safety assessment process and how it could be improved throughout the agency. The agency appeared to take the concerns seriously and began to address issues immediately. The Quality Service department at the agency began to review each safety assessment completed by the intake departments for all accepted cases prior to transfer, and for all GPS and CPS referrals at the conclusion of the investigation. Through this process, progress was noted in terms of increased supervisory oversight around accurate and timely completion of Safety Assessment Worksheets. However, the process revealed that safety was not consistently being adequately assured of children when a report was made to the agency. There were multiple concerns that assigned response times were not commensurate with the level of risk and that caseworkers were not seeing children within designated response times. in order to address these concerns, business practice changes were implemented. The screening manager began to assign, or cause to be assigned, any case that required an immediate or same day response, such as a CPS report. Also of significant concern is the process that is currently in place for oversight of cases that require immediate or same day response times. Currently, when a worker is assigned one of these cases their supervisor is made aware of the situation in which the worker is dispatched immediately into the field. Any oversight that occurs from that point is the responsibility of the worker?s direct supervisor and it is up to the worker to reach out to the supervisor if they require assistance. There does not appear to be any specific protocol for follow up of the caseworker?s initial contacts/actions in a case. It appears to occur at the discretion of the caseworker or at the first 10 day supervisory review which would take place after the timeframe for a supervisor to review an initial safety assessment in the case. The Department recommends that the agency put a process/protocol in place to assure that supervisory staff are not only aware of referrals the worker is out on that required an immediate or same day response time, but that a supervisor is assessing the timeliness and quality of those immediate and same day response contacts so that any necessary supervisory intervention occurs immediately. York County OCYF has implemented a detailed form that is signed along with the safety plans, documenting that the family has been notified of their rights to due process and the ability to request a court hearing. This form was observed throughout the inspection and in subsequent file reviews. A safety plan review hearing was also put in place over the last year. Each time a family enters into a safety plan, a hearing is held within 72 hours to assure that the parents due process rights have been upheld and that all parties continue to be in agreement with the safety plan. The process appears to be implemented weil and the agency is periodically revisiting this with their solicitor and courts to assure that families are receiving appropriate notices of their rights. Practice Area: Casework Visitation with Family QSR Indicator: Planning for Transitions and Life Adjustments QSR Indicator: Parent/Caregiver Functioning Beyond the citation noted below, file reviews completed during the licensing inspection revealed that caseworkers are establishing contact with children and families. The agency has a specific form that is filled out during and after the visit which details the information that was discussed as well as any safety concerns observed by the caseworker, or discussed by the family. This form was easily located in files and did demonstrate that the workers are conducting meaningful visits. Visits with children in foster care and residential settings included a speci?c time where the caseworker was gathering information solely from the child. Supervisors were also able to monitor and track the visitation completed by their worker through these forms located in the files. it was noted during the licensing review, and reflected in citations below, that Family Service Plans were being completed, but there was not always follow through to assure that the family members and other interested parties were engaged in developing or revising the plan, or signing the form. This plan is to be a roadmap for the family to understand the necessity for OCYF involvement, as well as the tasks needed to assure successful case closure. While workers are completing visits with family, it is not apparent that this time is being used to discuss the family plan. It is necessary that the agency develop a practice that includes workers reviewing the Family Service Plan with family members at these visits and making sure that they understand and/or agree with the plan by signing the form. As the agency continues to develop trainings and processes for family engagement, this should be a key component in caseworker instruction. Youth that are involved with York County OCYF receive 16 year and 18 year transition meetings which are used to develop plans for independent living skills and for successful transition into the community beyond their involvement with agency services. Transition plans were found in the ?les and were targeted to each individual child. The agency has a designated independent Living service unit which is active in supporting the transitioning youth. Support groups and other agency services are made available to these youth, even beyond agency involvement. Practice Area: Fostering Connections Activities QSR indicator: Parent! Caregiver Functioning QSR indicator: Role and Voice QSR Indicator: Engagement QSR Indicator: Teaming Fostering Connections remains an area of strength for York OCYF. The agency has the ability to think creatively and "outside the box" to maintain children where they have the most chance of success. Attempts are made to keep children with family, siblings together, and to maintain connections. The agency has established a Family Finding unit which develops an entire file of family search, engagement, and documentation of efforts to keep children within their family tree. Every placement ?le reviewed had one of these specific Family Finding ?les which listed outreach for kin through a variety of diligent and Accurint searches. Kin is being identified, assessed, and used when at all possible. The agency is also making efforts to assure that sibling groups are placed together, or in connected kin. The agency continues to see an increase in the number of kin that come forward to provide for children in need of placement. Over the past years, the number of kinship studies to be reviewed for the licensing inspection have far outnumbered the resource families that are approved for any child. This is an area that will continue to grow, especially in light of new concurrent planning items that will be implemented in the coming years. Agency engagement practices extend to these kin families as FGDM and other multi?disciplinary teams are used to assure successful placement. The agency has improved its ability to complete a kinship home approval in 60 days, and also has a consistent process in place to utilize when an extension is needed. A 45 day meeting is held to include the assigned caseworker, the resource unit and a paralegal. During this meeting a determination is made whether the approval will be completed by the 60th day. if this is not possible, the paralegals ?le a petition to obtain a court order to extend the kinship approval timeframe and allow the children to remain in the resource home. While this is a great support for these workers, it should not become a consistent practice to allow home studies to go beyond this time frame if not necessary. The agency has several Guardian ad Litems (GAL) that are very involved in the placement of the children on their caseload. These individuals provide a clear voice for the children, especially those who are abie to identify kin, and their desire to live with certain family members. The agency is also using Family Group Decision Making to identify and plan for speci?c family members to care for children, both informally and through the agency kinship process. Practice Area: Shared Case Responsibility Activities York OCYF has a concrete Shared Case Responsibility(SCR) Policy and Procedure in place which includes a Memorandum of Understanding established between York OCYF and York Juvenile Probation. Throughout the past licensing year the agency has served many youth in the capacity of SCR. Most of these youth were served in a placement capacity due to juvenile convictions. In these cases, Juvenile Probation takes the lead on the placement casework, with the York OCYF worker visiting with the child periodically, as well as offering any services to the family. Often, when the juvenile charges are resolved, Juvenile Probation closes out, but York OCYF continues to provide supportive services to the family, or independent living services to the youth. There appeared to be a collaborative working environment between York OCYF and York Juvenile Probation. Practice Area: Family Service Planning QSR Indicator: Assessment and Understanding QSR Indicator: Long-Term View QSR Indicator: Child/Youth and Family Planning Process QSR Indicator: Planning for Transitions and Life Adjustments QSR indicator: Intervention Adequacy and Resource Availability QSR indicator: Maintaining Family Relationships QSR Indicator: Tracking and Adjustment The agency uses a standardized Family Service Plan that includes sections detailing all of the items required by regulation. Agency caseworkers are able to clearly identify the reason for agency involvement and the of the family and children on this form. However, Family Service Planning as it relates to Family Engagement continues to be an area of signi?cant concern for the agency. It was observed in some cases that families were being invited to participate in plan development, and possibly having discussions at court or during initial contacts, but there was no documentation of detailed family involvement in planning. Furthermore, as was noted earlier, families were not experiencing the opportunity to sign the plans and continue to discuss them throughout the life of the case. This continues to be an area that should be addressed by agency administration. The agency has a system in place to track aging out youth and assuring that they have life connections. Most of these children are involved with the independent Living program, which can maintain connections beyond their involvement with the agency. The agency also works to assure that the children complete the surveys for the National Youth in Transition Database (NYTD). Youth are surveyed at 3 month intervals to determine if they have a residence, income, and have maintained life connections. Throughout the past year, agency IL staff have been prompt in responding to questions regarding these youth, and have provided detailed information to the department when necessary. It is obvious that these workers have a dedication to their assigned youth and promoting successful . transition well beyond agency involvement. The agency is consistently assigning MCI numbers to each child that becomes involved with agency services. This identi?er is documented in the agency case ?le, and in the internal computer system. The assigned staff that perform the clearances are also noting the other agencies which have cleared the children, to make connections with the already existing services to the families. Practice Area: Family Engagement Practices QSR Indicator: Physical Health QSR Indicator: Emotional Well-Being QSR Indicator: Early Learning and Development QSR Indicator: Engagement Efforts QSR Indicator: Role and Voice As a Quality Service Review county, York OCYF has taken family engagement very seriously and attempted to use the guidelines provided by the QSR as a directive for their service. As has been noted, due to such a high volume of cases, and caseworker turnover, it is unknown how much direct engagement activity is occurring on a daily basis. Workers are in attendance at established implementation team meetings that look at ways to improve practice and engage families. The agency is seeking to increase services to family, especially in regard to visitation and engagement of families in order to complete tasks and reuni?cation plans more quickly and efficiently. The agency does struggle to keep caseworkers established in one unit of service, and to keep the level of support at what is needed to maintain quality work and efficient service. The management team is aware of this, and the impact it can have on the level of work and family engagement. It is recommended that the agency continue to ?nd ways to address worker burnout and turnover, as this directly affects the level of service that can be provided to families. The agency was consistently completing the Ages and Stages assessment with the target early child population, and were including the parents, where possible, to get a truly accurate reading of the child's deveiopment. Early 4 QSR Indicator: Teaming Intervention and health services were enlisted to address any de?ciencies. The agency has a policy targeted to this requirement which is monitored by the Quality Assurance unit through periodic reviews. York County has a designated Family Group Decision Making (FGDM) unit through the Human Services Department that is able to tailor conferences to meet the needs of any family unit. This unit does not only serve the agency, but has also expanded to provide FGDM through the local schools, probation, hospitals, and to other community members in need of family support. These families need not be involved with York OCYF, but are able to receive the same family planning services independent of the agency through their involvement with FGDM. These meetings were essential in family service planning, transition planning, and to prevent children from coming into placement. York. County has an active Roundtable led by the Honorable Marceca-Strong. This well-attended group contains key stakeholders in the work that OCYF is doing in York County. There is vibrant discussion at the Roundtable meetings surrounding famin engagement topics, new initiatives and opportunities for funding that are occurring in the county, and trends and issues that are concerning and may need to be addressed through one of the agencies represented at the table. Judge Marceca?Strong often reaches out to the group and the surrounding community for presentations and topics of discussion. York County OCYF employees are active in this group and forthcoming with information, or with sharing needs of the agency which may be addressed through one of the other agencies at the table. In the past year, the Roundtable has focused on the prison population and how the agency can engage parents that are incarcerated and allow them to still work on a plan fortheir children. Afamily visitation program has been established between CYF and the York County Prison over the past year. Dependent children in care are now able to have contact visits with incarcerated mothers and fathers if a court order is obtained. Practice Area: Permanency Activities QSR Indicator: Stability QSR Indicator: Living Arrangement QSR Indicator: Permanency QSR Indicator: Academic Status QSR indicator: Pathway to Independence QSR Indicator: Parent and Caregiver Functioning QSR Indicator: Efforts to Timely Permanence York County OCYF is involved in the Permanency Practice Initiative (Phase 1) and consistently records three month reviews for their court involved cases. This allows for the cases to be reviewed month marks as expected, and more frequently as needed. Children consistently have concurrent plans developed to assure that they are receiving the appropriate preparatory services. Child Permanency Plans in tandem with the Family Service Plan reflect the child?s placement goal and service objectives necessary for the child, and providers for the placement goal to be met. All permanency activities are well documented in the agency files. Parents are provided plans in their Child Permanency Plan for visitation. The agency reported 52 adoptions throughout the last licensing year as well as Subsidized Permanent Legal Custodianships (SPLC). The agency continues to consistently use SWAN services to provide child preparatory understanding and recruitment of potential permanent families. The agency has also established a core group of individuals that are working to develop policies and protocols, as well as to identify training needs, for the implementation of the concurrent planning bulletin in 2015. These activities will have a direct impact on the adoption and SPLC supportive services in the coming years. As of this inspection, York County OCYF has 70 children with a goal of APPLA. These are mostly older teenage youth who are remaining in care due to behavioral or mental health issues, or to remain in school and continue to receive services. Some of these youth have chosen to stay in care to continue receiving these additional supports that will help them transition into the community at the appropriate time. The agency is prepared to continue to work with youth who would have previously aged out of care, but who are now able to remain in care to finish school and work. APPLA youth are consistently discussed at Permanency Review hearings and agency quality reviews. Practice Area: Placement Settings QSR Indicator: Living Arrangement At the time of inspection, York County OCYF had a total of 344 children in placement. 168 children were in traditional foster care and 88 children were in kinship placement. Additionally, there were 88 youth in some form of congregate care. The congregate care settings included Residential Treatment, community based group homes, and MA placements. The agency is very aware of the movement to not maintain children in congregate care settings if at all 5 possible. In the past year, the agency enacted a team which met regularly to analyze the current situation of the youth in placement and to develop action steps to be taken to safely reduce the number of youth that are currently in the shelter and residential placements it is suggested that this team work closely with the Family Finding Unit and FGDM to identify potential resources that could care for these, most often older, youth, and provide them with the training and means to do so. The agency has established protocol for reaching out to, and engaging kin as a means of permanency for the children that are coming into placement, or to prevent formal placement and further involvement in the system. Siblings are also being placed together whenever safely possible. If siblings are separated either because of the sheer size of the group, or for behavioral or medical issues, the agency is making efforts to assure that the resource caregivers are connected and that visits are occurring between siblings. The following chapters 3350, 3700, 3130, 3490, CPSL and Chapter 20 were reviewed during the annual licensing review. Based on violations with regard to chapters 3700, 3130, 3490 and CPSL, the Department of Public Welfare, Of?ce of Children, Youth and Families is issuing the following citations which require a plan of correction. REGULATORY FINDINGS REQUIRING PLAN OF CORRECTION the 2014 annual licensing visit and the interim review US which was issued in September 2014. 39 the State?approved risk assessment model developed by the Department in consultation with the Risk Assessment Task Force. March 23, and ongoing. at Aim summit? eras; tat: Caseworker complete a Risk Assessment at the conclusion of every GSPICPS investigation, on or before the date of disposition, within 60 days of the referral date. The Risk Assessment will also be $3919 ln 1 of 10 In?Home Case The Quahty Service department at updated per the intervals set by state 5 Files, the Risk Assessment the agency began to review each regulation for all ongoing cases. The 0W7 was completed late. case completed by the intake assessment will be ?lled out in its Concluding risk assessment due on 5/31/14, completed on 9/30/14. in 1 of 10 In-Home Case Files, all household members were not listed on the Risk Assessment. In ?1 of 10 CPS Case Files, there is no evidence that any Risk Assessments were completed. departments for all accepted cases prior to transfer, and for all GPS and CPS referrals at the conclusion of the investigation. This review has allowed for incomplete or missing papenivork to be completed or located in a more timely fashion. The Department recommends that the agency continue to implement this process and that they periodically evaluate the effectiveness of this plan of correction so that they can make appropriate changes in a timely entirety, and will include and assess all children, parents, and house hold members. Supervisor will review the Risk Assessment within 10 days to ensure all areas are accurately complete and signed within required time frames. Caseworkers will utilize the checklists for each report to assure regulations are being met. All supervisors must obtain the checklists upon completion to check for accuracy and to ensure that all fashion. items are completed within the required time frames. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi~weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 31302100) This is a repeat citation from the 2014 annual licensing visit and the interim review 1.18 which was issued in September 2014. ln 1 of 10 In-Horne Case Files, the Safety Assessment Worksheet was completed late. Date safety assessed: 4/17/15, date safety assessment completed: 4/21/15. ln 1 of 10 In-Home Case Files, the Safety Assessment Worksheet was signed late by the supervisor. Date of SAW: 8/7/14, CW signature: 8/7/14, The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. The Safety Assessment and Management Process require that the caseworker completes and signs the safety assessment within 72 hours and the supervisor within 10 days. The Quality Service department at the agency began to review each case ?le completed by the intake departments for all accepted cases prior to transfer, and for all GPS and CPS referrals at the conclusion of the investigation. This review March 23, 2015 and ongoing. Caseworkers will see the victim child and all other children in the household immediately, within the identi?ed response time, upon receiving a CPS report. Upon safety being assured a preliminary Safety Assessment Worksheet and Structured Case Note will be completed together. This will occur no later than 72 hours from when the victim child was seen. Supervisors will review the Safety Assessment and Structured Case Note together, and sign both, within 10 days of caseworker?s completion. Caseworkers will additionally complete a Safety Assessment per ?le? M?i \ICi/tfvd' 0M 41049 Supervisor signature: 10/16/14. ln 1 of 10 ln-Home Case Files, the Safety Assessment Worksheet was not signed by the worker or supervisor. ln 3 of 10 CPS Case Files, Preliminary Safety Assessment Worksheets were not completed. has allowed for incomplete or missing paperwork to be completed or located in a more timely fashion. The Department recommends that the agency continue to implement this process and that they periodically evaluate the effectiveness of this plan of correction so that they can make appropriate changes in a timely fashion. the interval as outlined by state regulation. Caseworker will sign and date the completed assessment at the time of completion. Supervisors will review and sign the assessment within 10 days of the caseworker?s completion. Upon further review, it was decided that the Quality Assurance Unit will only review each case ?le completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3490.232 3490.232 ln 2 of 10 Intake Case Files, children were not seen immediately or within the response time. 1)Date of referral: 12/10/14, Assigned to CW on 12/15/14 with a 7 day response time. CW made contact with child on 12/18/14. One day late. 2) Date of referral: 12/12/14, Assigned to CW on 12/17/14 with a 72 hour response time. CW made contact with child on The county shall see the child immediately if emergency protective custody has been taken, is needed, or if it cannot be determined from the report whether or not emergency protective custody is needed. The county shall provide or arrange appropriate services to assure the safety of the child during the assessment period. The screening department reviews all referrals upon receipt and makes March 23, 2015 and ongoing. The screening department will review all referrals upon receipt and will immediately make a determination as to whether or not emergency protective custody is needed. An appropriate response time will be assigned based on the risk factors alleged in the referral. GPS referrals will be immediately reviewed and assigned within 24 hours. The assigned caseworker, plat/Vi accept/cl, in mi ifs/L524 0m 1410- l9 12/18/14. Three days late. Case was assigned to CW two days after the 72 hour timeframe expired. The delay . in assignment of this referral impeded the caseworker?s ability to see the child within the assigned timeframe. [n 3 of 10 Intake Case Files, the initial response time assigned by the agency was not appropriatebased on referral information. in 1 of 10 Intake Case Files, the level of service provided by the agency was not appropriate given the level of risk. a determination as to whether or not emergency protective custody is needed. if it is not known whether or not emergency protective custody is need, an appropriate response time is immediately assigned based on the risk factors alleged in the referrals. GPS referrals that require additional discussion as to whether or not criteria are met for assignment are reviewed Monday through Friday by intake managers and supervisors. During this discussion, a decision is made to determine if the referral is accepted as well as an appropriate response time. Supervisors review assigned supervision logs on the same day to assure response times are appropriate and met. it is the recommendation of the Department that the agency re? evaluate the effectiveness of this process to be sure that all cases that require immediate or same day response times are in fact given immediate or same day response times. in addition, it is the recommendation of the Department that a supervisor be assigned to monitor all case activity of immediate or same day response cases on the day in which the case is assigned such a response time. supervisor, and manager will each receive a copy of the report at the time case is assigned. Verbal noti?cation will be received by the screener that the receiving caseworker, supervisor, or manager understands the referral and can meet the assigned response time. The assigned caseworker will see the victim child dependent upon the response time. The assigned supervisor (or manager, if the supervisor is not available) will have immediate follow up with the caseworker and document on the supervision log to indicate how safety was assured. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi?weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. Flam qcceM, \W'f not cwi 3490.55 In 3 of 10 CPS Case Files, safety of all children was not assured. The county shall begin the investigation immediately upon receipt of a report of suspected March 23, 2015 and ongoing. Upon receipt of CPS referral, the Screening Department will write up the referral in its entirety. The In 1 of to CPS Case Files, there was no documentation to show that the investigation began immediately, if the child was not safe, or within 24 hours, if the child was safe. child abuse and see the child immediately if one of the following applies: Emergency protective custody has been taken or is needed or it cannot be determined form the report whether or not emergency protective custody is needed. The screening department reviews all referrals upon receipt and makes a determination as to whether or not emergency protective custody is needed. If it is not known whether or not emergency protective custody is need, an appropriate response time is immediately assigned based on the risk factors alleged in the referrals. GPS referrals that require additional discussion as to whether or not criteria are met for assignment are reviewed Monday through Friday by intake managers and supervisors. During this discussion, a decision is made to determine if the referral is accepted as well as an appropriate response time. Supervisors review assigned supervision logs on the same day to assure response times are appropriate and met. it is the recommendation of the Department that the agency re- evaluate the effectiveness of this process to be sure that all cases that require immediate or same day response times are in fact given immediate or same day response times. In addition, it is the recommendation of the Department that a supervisor be assigned to monitor all case activity of immediate or same day response cases on the day in which the case is assigned such a response time. referral will be provided to the assigning supervisor to document and assign immediately. The assigned caseworker, supervisor, and manager will each receive a copy of the report at the time case is assigned. Verbal noti?cation will be received by the screener that the receiving caseworker, supervisor, or manager understands the referral and can meet the assigned reSponse time. The assigned caseworker will see the victim child and all other children within the home immediately to determine if Emergency Protective Custody is needed, or whether that cannot be determined by the report. The assigned supervisor, or manager, will have immediate follow up with the caseworker to determine the outcome and next steps. The assigned supervisor (or manager, if the supervisor is not available) will have immediate follow up with the caseworker and document on the supervision log to indicate how safety was assured. Upon safety being assured a preliminary Safety Assessment Worksheet and Structured Case Note will be completed together. This will occur no laterthan 72 hours from when the victim child was seen. Supervisors will review the Safety Assessment and Structured Case Note together, and sign both, within 10 days of caseworker?s completion. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed Vim attend, liv?l \lelf VFW 0M air-l9 10 by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3490.55 3490.55 ln 1 of 10 CPS Case Files, there was no documentation of interviews with the child, parents, alleged perpetrator, or others with information. in ?l of 10 CPS Case Files, the file did not contain color photographs of the injury. When conducting its investigation, the county agency shall, if possible, conduct an interview with those persons who are known to have or may reasonably be expected to have, information relating to the incident of suspected child abuse including, but not limited to, all of the following: (1) The child, if appropriate. (2) The child's parents or Other person responsible for the child?s welfare. (3) The alleged perpetrator of the suspected child abuse. (4) The reporter of the suspected child abuse, if known. (5) Eyewitnesses to the suspected child abuse. (6) Neighbors and relatives who may have knowledge of the abuse. (7) Day care provider or school personnel, or both, if appropriate. The county agency shall record in writing the facts obtained as a result of the interviews conducted under subsection and any other March 23, 2015 and ongoing. For every report, the assigned caseworker will make every attempt possible to conduct an interview with the child, parent/caretaker, alleged perpetrator, siblings, household members, as well as anyone who may have knowledge of the alleged abuse. Caseworker will document interviews on a structured case note, and maintain it in the agency file. Priorto disposition the supervisor will review all structured case notes in the ?le, and initial them to indicate review was completed. Caseworker will take photos of the victim child (head body) and any/all injuries to the child at initial contact as part of the investigation. if there is an alleged injury to the child but upon seeing the child the caseworker does not see visible injuries, caseworker will take photos of any/all areas in Plain accth ll am $72045 ?11 interviews it conducts. (1) When conducting its investigation, the county agency shall maintain a written record of the facts obtained from each interview it conducts. (2) At the conclusion of its investigation, when the report is determined indicated, founded or unfounded and accepted for services, under 3490.59 (relating to action by the county agency after determining the status of the report), the county agency shall enter a written summary of the facts obtained from each interview in the case record. When investigating a report of suspected child abuse in which a child has sustained visible injury, the county agency shall, whenever possible and appropriate, take, cause to be taken or obtain color photographs of the injury. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsibie for the review and assurance of completion of this policy with staff. which injury was alleged. The photo will be printed in color, appropriately labeled, and maintained in the agency file. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi?weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during monthiy supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3490.58 (60 ln 1 of 10 CPS Case Files, determination letters were sent late. Date of CY-48 determination sent to Child Line: 1/30/15, Date of determination ietters: 3/10/15 Except for the subject child, the county agency shall notify all subjects in writing of one of the following when the county agency determines that the report is unfounded: (1) The information will be kept on file at the county agency and clearly identified as an unfounded report of suspected child abuse when the family has been accepted for services. (2) The report is unfounded and because the family has not been accepted for services that all information will be expunged at the county agency upon notification from ChiidLine and that the report will be expunged March 23, 2015 and ongoing. Upon disposition of a referral, the caseworker will complete determination letters within the required time frames. Caseworker wiil provide the disposition letter along with the CY 48 during 10-day supervision. Supervisor shall document that paperwork is completed during weekly supervision with assigned caseworker on the 10?day supervision logs. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Flam accepted?; but not \lemcw Um glow is 12 from the pending complaint file within t20-calendar days of receipt of the report at ChildLine. The county agency shall provide the noti?cation required under subsection when it noti?es ChildLine of the status of the report. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. Focused Training through the Child Welfare Resource Center. 3490.61(a) ln 2 of 10 CPS Case Files, there were one or more required 10 day supervisory meetings in which supervision between caseworker and supervisor was not documented in the file. The county agency supervisor shall review each report of suspected child abuse which isunder investigation on a regular and ongoing basis to ensure that the level of services are consistent with the level of risk to the child, to determine the safety of the child and the progress made toward reaching a status determination. The supervisor shall maintain a log of these reviews which at a minimum shall include an entry at ill?calendar day intervals during the investigation period. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Face to face contact between the caseworker and supervisor Will occur on every active case at least one time every 10 days. The supervisor is responsible for scheduling and documenting supervision on the supervisor log. Supervision logs will be ?led with the case at the conclusion of the investigation, or every 10 days for accepted cases. if the caseworker is unavailable the supervisor will be responsible for oversight of the case, and will document what has occurred during the workers absence on the supervision log. - Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments priorto passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly Plan acct/9M. der?lfuol' OM 13 basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3130.61(a) This is a repeat citation from the 2014 annual licensing visit and the interim review US which was issued in September 2014. in of 10 ln-Home Case Files, the Family Service plan was completed late. FSP was due by 7/30/14. FSP completed on 8/12/14. The county agency shall prepare, within 60 days of accepting a family for service, a written family service plan for each family receiving services through the county agency. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Caseworker will complete the Family Service Plan with families for ongoing services within 60 days of case acceptance, or within the required time frames per state regulation. Supervisors will monitor compliance and deadlines in 10?day supervision and ensure completion by due date. The due date and date compieted will be clearly documented on the supervision log. Upon further review, it was decided that the Quality Assurance Unit will only review each case ?le completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Soiution Plain Wl?) min? Focused Training through the Child Welfare Resource Center. 3130.61 This is a repeat citation from the 2014 annual licensing visit. In 5 of 10 ln?Home Case Files, there was no documentation to show that the family was given the opportunity to participate in the deveIOpment of the plan and the plans were not signed by family members. The service plan shall be signed by the county agency staff person responsible for management of the case. The parent or legal guardian and the child, if 14 years of age or older, shall be given the opportunity to sign the service plan. The county agency shall inform the parent or guardian that signing the plan constitutes agreement with the service plan. The county agency shall provide family members, including the child, their representatives and service providers, the opportunity to participate in the development and amendment of the service plan if the opportunity does not jeopardize the child?s safety. The method by which these opportunities are provided shall be recorded in the plan. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Caseworker will contact the family by phone, letter, e-mail, or face to face contact to invite them to participate in developing the Family Service Plan. Documentation will be maintained in the agency ?le. Caseworker will hold a meeting with the family to develop the Family Service Plan, and gather the families input. if a Family Group Decision Making is held to develop the Family Service Pian, this will be indicated on the Family Service Plan. Caseworker will sign the plan and attach documentation of the engagement efforts to the Family Service Plan for the supervisor to review, prior to the supervisor signing the Family Service Plan. A follow up meeting will be held with the family to obtain agreement/disagreement and request that the Family Service Plan be signed by all family members listed on the signature page. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review ?rm Wmf?, mt V2 on was 15 evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. This is a repeat violation from the 2014 annual licensing visit. In 1 of10 Placement Case Files, the Child Grievance Form could not be located. Notation shall be made in a child?s record that the agency?s grievance procedure was explained to the child. The grievance procedure shall be explained to children who can be reasonably expected to understand it, as determined by the county agency. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Upon a child entering placement, the caseworker will complete a Child Grievance Form with that identified child. If the child is unable to reasonably understand the Child Grievance Form, it will be reviewed with that child?s current caretaker. The form will be signed by the child, caretaker, and caseworker and maintained in the agency file. The Child Grievance Form will be updated every time a child changes placement, or there is a change in personnel working with the child. Supervisors will review the placement checklist within 10 days of completion to ensure that the Child Grievance Form, and other required documentation, was completed. The supervisor will sign and date the placement checklist to confirm accurate completion. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Vim vented?- Mm ?rHO-l? 16 Managers will complete hands on. reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. In 1 of ?10 Placement Case Files, there was not documentation of regular supervision by the supervisor. There shall be supervision of caseworkers and other direct service staff to ensure the following: Ongoing support and direction for the case activities of supervised staff. A plan should be developed to assure that this mandate is being met. The plan shouid state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Face to face contact between the caseworker and supervisor will occur on every active case at least one time every 10 days. The supervisor is responsible for scheduling and documenting supervision on the supervisor log. Supervision logs wiil be ?led with the case at the conclusion of the investigation, or every 10 days for accepted cases. Upon further review, it was decided that the Quality Assurance Unit will oniy review each case ?le completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training 17 and Strength Based Solution Focused Training through the Child Welfare Resource Center. Bulletin 3490- 08-04 This is a repeat citation from the 2014 annual licensing visit and the interim review US which was issued in September 2014. in ?l of 10 Placement Case Files, there was one visit that was not completed by the caseworker with the child. The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. According to the Bulletin on Frequency and Tracking of Caseworker Visits of Children in Federally Defined Foster Homes, the quali?ed worker is expected to visit with the child every thirty days. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Caseworkers will conduct home visits with the identi?ed child, one time every 30 days. if the case is considered high risk, the identified child will be seen on a weekly basis. Caseworkers will complete a structured case note outlining the date, time, and content of the visit, and how safety of the identi?ed child was assured. Caseworker will provide the completed structured case note to the supervisor for review, and to place on the 10-day supervision log. The supervisor will sign or initial the case note to indicate it has been reviewed. The Quality Assurance Unit and Management will review each case ?le completed by all departments prior to passing between the units to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. We Vivi V?ittalz CU) Cirith 31302103) Act 126 This is a repeat citation from the 2014 annual licensing visit. in 2 of 10 Placement Case Fiies, there was not an annual dated photo of the child. The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. Act 126 requires an annual dated photo of the child to be in the case file. March 23, 2015 and ongoing. For every case accepted for ongoing services, a color photo will be taken of the identified child (head body), one time every 12 months. Caseworker will appropriately label the photo and maintain it in the case record. 18 A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. Wig) for l/xenhool CM Crib-[S 3130.21 Kinship Care Bulletin 00-03?03 In 1 of 10 Placement Case Files, a kinship care foster home did not contain documentation that the foster home approval checklist was completed or that the home met applicable requirements. The executive of?cers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. The Kinship Care Bulletin requires that foster homes meet applicable requirements prior to the placement of a child in the home. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Prior to a child entering an unlicensed kinship home, the caseworker will complete a home assessment, Emergency Caretaker Checklist, criminal clearances, and Childline clearances and be verbally reviewed with the supervisor. Upon return to the office, a copy of the case note, completed Emergency Caretaker Checklist, Criminal and Childline Clearances, and kinship referral will be provided to the supervisor for review and to signed and maintained in the case record. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor than NJ, Whitta- 00?7 Clio-W 19 compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. This is a repeat citation from the 2014 annual licensing visit and the interim review 1.18 which was issued in September 2014. In 1 of 10 Placement Case Files, the child received a late initial dental exam. Date of piacement: 4/22/14, Date of initial dental: 7/10/14. In 1 of 10 Placement Case Files, the child?s updated dental exam was late. Child received a dental exam on 9/20/13 and there did not receive the updated exam by 6/20/14. Ch went on runaway status on 8/13/14 and there was no updated dental in the record. The FFCA shall ensure that a child, 3 years of age or older, receives a dental appraisal by a licensed dentist within 60 days of admission, unless the child has had an appraisal within the previous 6 months and the results of the appraisal are available. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Upon a child entering placement, the caseworker will ensure that the child receives a dental appraisal by a licensed dentist within 60 days of admission, unless the child has had an appraisal within the previous 6 months and the results of the appraisal are available. After the initial appraisals, the caseworker shall ensure that dental examinations are given to children 3 years of age or older at least once every 9 months of placement. The caseworker will maintain a copy of the dental exam in the agency case record. Supervisors will review the Child Permanency Plan to ensure that it is clearly documented when the appraisal was due, when it was completed, and when the next is upcoming. The supervisor will sign Vim Ml? ??l-io-iS 20 the Child Permanency Plan within 10 days of receipt from the caseworker, to ensure that the information is accurate. Upon further review, it was decided that the Quality Assurance Unit will only review each case file completed by all departments prior to passing between the units, to monitor compliance with this regulation. During the review period, the assigned direct service caseworker is responsible to oversee the case until it is transferred and formally assigned to a new worker. Managers will complete hands on reviews of 5 cases on a bi-weekly basis, and complete a case review evaluation. This information will be provided to the senior manager (or director) during supervision. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3700.62(c) and the CPSL This is a repeat citation from the 2014 annual licensing visit. In 1 of 52 New Foster Family Homes, a household member?s FBI clearance was dated after the home was approved. Home approved 1/6/15, FBI clearance received 1/9/15. in 3 of 52 New Foster Family Homes, 2 household member?s criminal clearances were obtained late and 1 adult HHM criminal clearance was not completed at all. Foster family care agencies shall require prospective foster parents to comply with section 23.1 of the Child Protective Services Law (11 P. 8. 2223.1) and Chapter 3490 (relating to protective services). A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Resource caseworkers will enter dates of clearances in CAPS. The resource supervisor will check CAPS alerts to track due dates at least one time a month. Resource supervisor will review each record at the time of foster home approval to ensure documentation is complete and in record. Resource supervisor will use a checklist to monitor compliance of foster family files will be utilized to ensure documentation is completed and in record. 5 Foster Family files will be reviewed each month utilizing 21 licensing checklists to ensure compliance. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. 3130.90 This is a repeat citation from the interim review US which was issued in September 2014. in 1 of 52 New Foster Family Homes, the Home Liability/Fire Insurance was not current at the time of approval. if the county agency directly approves and supervises foster family homes, persons providing foster family care shall purchase or otherwise obtain general liability insurance and ?re insurance coverage for the premises where foster family care is provided as a condition of approval. A plan should be developed to assure that this mandate is being met. The plan shouid state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing. Resource caseworkers enter dates of liability/?re insurance in CAPS. The resource supervisor will check CAPS alerts to track due dates at ieast one time a month. Resource supervisor will review each record at the time of foster home approval to ensure documentation is complete and in record. Resource supervisor will use a checklist to monitor compliance of foster famiiy files will be utilized to ensure documentation is completed and in record. 5 Foster Family ?les will be reviewed each month utilizing licensing checklists to ensure compliance. All direct service supervisors have completed Criticai Thinking Training and Strength Based Soiution Focused Training through the Child Welfare Resource Center. Pica/i back is? with 09' Co?) Clemo- l5 3130.21 as it relates to Act 160 of 2004 ln 2 of 52 New Foster Family Homes, the Resource Family Registry was not noti?ed/updated in accordance with applicable mandates. The executive officers shaii ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. Per-Act 160, resource parents must be registered within 30 days of approval. The resource parents must report any change in household composition to the approving agency within 30 days of such change. The approving March 23, 2015 and ongoing. Resource caseworker will notify/update the Resource Family Registry within 30 days of approval, or within 30 days of any change in household composition. Resource supervisor will review each record at the time of foster home approval to ensure documentation is complete and in record. Supervisor will use a checklist to monitor compliance of foster family 22 agency has 30 days of learning of a change in household composition to submit an updated registration form to the Resource Family Registry. The agency shail also assure that the Family Registry is updated within 30 days of an individual residing in the household turning 18 years of age. A plan should be deveioped to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and assurance of completion of this policy with staff. ?les wiil be utilized to ensure documentation is completed and in record. 5 Foster Family files will be reviewed each month utilizing iicensing checklists to ensure compliance. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center. ln 1 of 52 New Foster Family Homes, there was no evidence of partial appraisal of the family prior to placement of a child in the home. Children were placed in the home on 7/5/14 but the date of initial home assessment is 7/7/14. The FFCA may authorize temporary approval of a foster home only if a partial assessment of the family indicates that a foster child?s health or safety will not be jeopardized if placed with the temporarin approved foster family. A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is reSponsible for the review and assurance of completion of this policy with staff. March 23, 2015 and ongoing Resource caseworker will complete a home assessment and complete-a partial assessment of the resource home, prior to considering any child being placed in that home. The assessment wili be provided to the resource supervisor within 24 hours of the review of the home. Resource supervisor will review each record at the time of foster home approval to ensure documentation is complete and in record. Supervisor will use a checklist to monitor com piiance of foster famiiy files will be to ensure documentation is completed and in record. 5 Foster Family fiies will be reviewed each month utilizing licensing checklists to ensure compliance. All direct service supervisors have completed Critical Thinking Training and Strength Based Solution Focused Training through the Child Welfare Resource Center 23 24 DEPARTMENT OF SERVICES June 15, 2015 York County CYS 100 West Market Street, Suite 402 York, PA 17401 Dear Provider: We are in receipt of your Plan of Correction for the areas of non-compliance for York County Children 81 Youth. This office has accepted your Plan of Correction and will monitor your plan through program evaluations and visits by this 'office, If you have any questions or comments, please feel free to contact me at 717-772~7702. Thank you for attention to this matter. Sincerely, leek gnarl/US have?? Colleen Smith Human Services Program Representative Department Human ServicesiOi?ce of Children. Youth and Families, Central Region 3 Ginko Dc, Hilltop Bldg, 2? Fin, PO Box 2875 Harrisburg, PA 1?110 Yi7.7?2.7702 i PO Box 319. Hoilidaysburg Community Service Center PA16648 814.696.6174 1 814.698?6180 mwr?hsstatepaus SUMMARY NAME OF AGENCYIFACILIW: York County Children, Youth and Families TELEPHONE: (717)846?8496 ADDRESS: COUNTY: ?100 West Market Street, Suite 402 York I York, PA 17401 INSPECTED BY: Colleen M. Smith 021?12/15 gm. giggle a 1 I . {5?37" iti'xiai (j if y, .ngw'lge ,1 62 1'14 r/S? - if During a complaint investigation, ?le reviews of 3 investigation records were performed at York County Children and Youth Agency on February 12, 2015. During that ?le review, areas of non?compliance were noted surrounding the safety and risk assessment process. A record review of all three reports on 02/12/15 along with a follow up review on 4/6115 revealed the following areas of non?compliance: 3130,2103) In one of three records reviewed, the Preliminary Safety Assessment Worksheet did not contain dates of completion or a supervisory signature. The executive of?cers shall ensure that the agency is operated in compliance with applicable Federal, State, and local statutes, ordinances and regulations. The Safety Assessment and Management Process requires that Safety Assessment Worksheets contain dates of completion as well as supervisory signatures. A planlpolicy should be developed to review and - enforce this regulation with staff. The plan should state the staff position that is connection-n Date of plan of correction and ongoing Supervisors will review all safety assessments to assure all required information is listed on the form and to sign the plan. All intake referrals will be reviewed by QA at the conclusion of the investigation. The ?ndings will be reported on a licensing checklist and review with the supervisor. The findings will also be shared with the manager, division manager and director for additional oversight. - ACQEWEB l5 responsible for the review and enforcement of this policy with staff. 31 30.21 in one of three records reviewed, the Date of Report was 09/0311 4 and the ?le did not contain a Preliminary Safety Assessment Worksheet - The executive of?cers shall ensure that the agency is operated in compliance with applicable Federal, State, and local statutes. ordinances and regulations. The Safety Assessment and Management Process requires that an initial safety assessment be completed within 3 days of the ?rst face to face contact with the identi?ed child and {or caregiver(s) of origin. A planfpolicy should be developed to review and enforce this regulation with staff. The plan should state the staff position that is responsible for the review and enforcement of this policy with staff. Date of plan of correction and ongoing All supervisors will receive a copy of a referral each time a caseworker is assigned to a new a referral. in the ?rst ?10 day supervision on the case. the supervisor will assure that once the response time is met the caseworker completes the preliminary safety assessment Supervisors will review all safety assessments in supervision. Supervision logs will remind the supervisors to check for completion of the safety assessments. Supervisors will check that all caseworker are using?the blue CPS or pink GPS checklist to complete all required paperwork for the investigation. All intake referrals will be reviewed by QA at the conclusion of the investigation. The ?ndings will be reported on a licensing checklist and review with the supervisor. The ?ndings will also be shared with the manager, division manager and director for additional oversight Pit-?till A??m g. ?i l5 31302100) in one of three records reviewed, the Concluding Safety Assessment Worksheet was completed late. The The executive of?cers shall ensure that the agency is operated in compliance with applicable Federal, State, and local statutes, ordinances and regulations. Date of plan of correction and ongoing Supervisors will review steps needed for case closure and required timefrarnes for documentation with caseworkers. Supervisors will help prioritize requirements to assure all safety assessments are completed on time. case was closed on The Safety Assessment and and the Management Process At the time of case closure, Concluding Safety requires that a safety caseworkers will submit the structured Assessment assessment be completed case note, concluding safety Worksheet was at the conclusion of the assessment risk assessment closing Art 59mm meet-m gm 6 completed on 01/09f15. investigationfassessment when a decision Was made whether or not to accept the case for ongoing services. This may not exceed 60 calendar days from the date the referral was received. A planfpoiicy should be developed to review and enforce this regulation with staff. The plan should state the staff position that is responsible for the review and enforcement of this policy with staff. letters and CY48 to the supervisor for review and signatures. Supervision logs will remind the supervisors to check for completion of the safety assessments. All intake referrals will be reviewed by GA at the conclusion of the investigation. The ?ndings will be reported on a licensing checklist and review with the supervisor. The ?ndings will also be shared-with the manager, division manager and director for additional oversight. Supervisors will document and report any failure to complete required steps in the investigation to the manager. The manager will reportthis to the division manager and a decision will be made what steps will be taken to correct the issue, depending on the situation. This will include a performance improvement and progressive discipline when needed and appropriate. 3490.321 In one of three records reviewed, the Risk. Assessment was completed late. The case was closed on 12122/14 and the Risk Assessment Was completed on 01 5. A periodic assessment of risk must be completed at the conclusion of the investigation which may not exceed 60 calendar days. A planf policy should be developed to review and enforce this regulation with staff. The plan should state the staff position that is responsible for the review and enforcement of this policy with staff. Date of plan of correction and ongoing Supervisors will review steps needed for case closure and required timeframes for documentation. Supervisors will help prioritize requirements to assure all risk assessments are completed on time. Supervision logs will remind the supervisors to check for completion of the risk assessments. All intake referrals will be reviewed by QA at the conclusion of the investigation. The ?ndings will be reported on a licensing checklist and review with the supervisor. The ?ndings will also be shared with the manager, division manager and director for additional oversight. Supervisors will document and report noose-Eu gni is 0?0 any failure to complete required steps in the investigation to the manager. The manager will report this to the division manager and a decision will be made what steps wili be taken to correct the issue, depending on the situation. This include a performance improvement and progressive discipline when needed and appropriate. .. . it .1 . Massiomm?smc - -. . . ifs] gt}? gi-E??gigii-?fg? 5 fr' 3:215 irgf?jg' {.1325 f-?ir tit/41%" ?7/7 7 7f?? :57 ?7 f: .I --: DEPARTMENT OF HUMAN SERVICES May 28, 2015 York County CYS, 100 West Market Street, Suite 402 York, PA 17401 Dear Provider: We are in receipt of your Plan of Correction for the areas of non?compliance for York County Children Youth. This office has accepted your Plan of Correction and will monitor your plan through program evaluations and visits by this office. If you have any questions or comments, please feel free to contact me at 717-772-7702. Thank you for attention to this matter. Sincerely, Cal WA ?yvi??kw Colleen Smith I Human Services Program Representative Department Human Sewicelef?ce of Children. Youth and Central Region 3 Ginko Dr., Hilltop Bldg. 2? Fin. PO Box 26% Harrisburg, PA 17110 717.7?2.?702 PO Box 319. Hoilldaysburg Community Service Center I Hollidaysburg. PA16648 814.696.6174 I 814.696-6180 mwr?hssiaiepeus SUMMARY NAME OF FACILITY: TELEPHONE: York County Children, Youth and Families (717)846-8496 ADDRESS: COUNTY: West Market Street, Suite 402 York Yerk. PA 17401 i5 INSPECTED BY: INSPECTION Colleen M. Smith 04522115 - i i I Job During a compiaint investigation, a ?le review was performed at York Coun During that ?le review, an area of non-compliance The record review revealed the following area of non?compliance: ty Children, Youth and Families on Aprii 22, 2015. was noted surrounding the initial response time determined by the county. 3490.232(c) In one record reviewed, the initial response time that was determined by the agency Was not appropriate based on the referral information. The county agency shall be the sole civil agency responsible for receiving and assessing all reports alleging a need for general protective services. The agency shall see the child immediately if emergency protective custody has been taken, is needed, or if it cannot be determined from the report Whether or not emergency protective custody is needed. Otherwise, the county agency shall prioritize the response time for an assessment to assure that children who are most at risk receive an assessment ?rst. A plan/policy should be developed to review and enforce this regulation with staff. The plan should state Date of plan of correction and ongoing The screening department will review all referrals upon receipt and will immediateiy make a determination as to whether or not protective custody is need ed. An appropriate response time will be assigned based on the risk factors aifeged in the referrals. GPS referrals that require additional discussion as to whether or not criteria is met for assignment will be reviewed Monday-Friday by intake managers and supervisors. During this discussion, a determination will be made whether the referral will be assigned for investigation and what the appropriate response time will be. Supervisors will review assigned supervision logs on the same day in which they are assigned to assure that response times are appropriate and met. the staff position that is responsible for the review and enforcement of this policy with staff. I 5/8/1 5 3W6