Appendix B - 2a - Appendix B - 2a - PPR

OMB Approval: 0930-0169

Expiration Date:

PROTECTION & ADVOCACY for INDIVIDUALS with MENTAL ILLNESS (PAIMI) PROGRAM - ANNUAL PROGRAM PERFORMANCE REPORT (PPR)
STATE		FISCAL YEAR
The Annual PAIMI Program Performance Report (PPR), which is due by January 1st of each year [PAIMI Rules at 42 CFR 51.8 and the PAIMI Act at 42 U.S.C. 10805(a)(7)], contains information provided by the State P&A system on its management and operation of the PAIMI Program. The Advisory Council Report (ACR) section of the annual PPR is the PAIMI Advisory Council’s (PAC) independent assessment of the operations of the P&A system which is signed by the PAC Chair.
The Annual PPR may be transmitted by mail or electronically. However, if submitted electronically, the P&A shall mail to the SAMHSA, Division of Grants Management at least one (1) copy of the Advisory Council Report (ACR) with the original signature of the PAIMI ADVISORY COUNCIL (PAC) CHAIR on the cover page. Send the reports to the following addresses:
ELECTRONIC MAIL: [email protected]	REGULAR MAIL LouEllen M. Rice, Room 7-1091 SAMHSA - Division of Grants Management 1 Choke Cherry Road Rockville, Maryland 20857
FOR CERTIFIED MAIL & OVERNIGHT DELIVERY - Send to the above mailing address BUT CHANGE THE ZIP CODE TO: 20850; Phone No. (240) 276-1400
Electronic submissions of the annual PAIMI PPR, including the ACR, should also be sent to the PAIMI Program Coordinator, [email protected],. If submitted electronically, please ensure that the Division of Grants Management is sent a signed copy of the ACR. Please use the attached glossary and instructions to complete the form. Questions may be directed to Ms. Armstrong, the PAIMI Program Coordinator at (240) 276 1760. Public reporting burden for this section of the annual PAIMI PPR is estimated to average 28 hours per response. This includes the time needed to review the instructions, to search existing data sources, to gather the data needed, and to complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0169); OAS, Room 7-1044; 1 Choke Cherry Rd.; Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0169).

ANNUAL PAIMI PROGRAM PERFORMANCE REPORT (PPR)
TABLE of CONTENTS
SECTION		PAGE
1	GENERAL PAIMI PROGRAM INFORMATION
2	PAIMI PROGRAM PRIORITIES (GOALS) & OBJECTIVES
3	INDIVIDUAL PAIMI-ELIGIBLE CLIENTS
4	CASE COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
5	INTERVENTIONS ON BEHALF OF GROUPS of PAIMI-ELIGIBLE INDIVIDUALS
6	NON-CLIENT DIRECTED ADVOCACY ACTIVITIES
7	GRIEVANCE PROCEDURES
8	OTHER SERVICES & ACTIVITIES
9	ACTUAL PAIMI BUDGET/EXPENDITURES
GLOSSARY

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1.A. Fiscal Year:
State:
Name of P&A system:
Mailing Address & Phone Number of Main Office:
Mailing Address & Phone Numbers of for each Satellite Office:
Name of PAIMI Program, if different from the State P&A agency:
Name, phone number, and e-mail address of the PAIMI Coordinator:
PPR Prepared by: Name: Title: Area Code & Phone Number: E-mail Address:
The name of the Director of the State mental health agency to whom copies of the PAIMI PPR & ACR were sent.*
Date the PAIMI PPR &ACR were sent to the State mental health agency.*
*PAIMI Act [42 USC at 10805 (a)(7) mandates that the Head of the State mental health agency receive a copy of this report on or before January 1.

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. B. GOVERNING BOARD
1.B.1. Does the P&A have a multi-member governing board? If Yes, complete governing board (GB), Table 1.B.3. [See Governing Authority - 42 CFR 51.22(b).].	Yes	No
1. B.2. Is the Chair of the PAIMI Advisory Council (PAC) a member of the GB? An explanation is required if the answer to this question is NO&THE P&A IS PRIVATE non-profit P&A system.	Yes	No

1. B. 3. GOVERNING BOARD (GB) INFORMATION
In the following table, please provide the requested information for the GB members as of 9/30.
a. Total number of GB member seats available.
b. Total number of GB members serving as of 9/30.
c. Total number of GB vacancies on 9/30.
d. Term of appointment for GB members (number of years).
e. Maximum number of terms a GB member may serve.
f. Frequency of GB meetings.
g. Number of GB meetings held this fiscal year .(FY)
h. % (Average) of GB members present at meetings this FY.

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. B. 4 GOVERNING BOARD COMPOSITION
“The governing board shall be composed of members who broadly represent or are knowledgeable about the needs of clients served by the P&A system . . . .” [42 CFR 51.22(b)(2). Count each GB member only once.
a. Number of individuals with mental illness (IMI) who are recipients/former recipients (R/FR) of mental health services or are or have been eligible for services.
b. Number of family members of individuals with mental illness who are R/FR of mental health services.
c. Number of guardians.
d. Number of advocates or authorized representatives.
e. Number of other persons who broadly represent or are knowledgeable about the needs of the clients served by the P&A system.
TOTAL
Section 42 CFR 51.22(b)(2) - mandated GB positions for private, non- profit systems. Count each GB member only once. The Total of 1.B.3.a. must equal the subtotals of 1.B.3.b and 1.B.3.c.

1. C. PAIMI PROGRAM STAFF
1. Provide the total number of P&A staff who are paid either partially or totally with PAIMI Program funds, including PAIMI Program income. Total: _____
a. How many of the staff listed above are attorneys? Total:_____	b. How many of the staff listed above are non-attorney case workers/mental health advocates? Do not include support or administrative staff in this count. Total:_____

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. D. ETHNICITY/RACE
	GOVERNING BOARD	PAIMI STAFF
American Indian/ Alaska Native
Asian
Black/African American
Hispanic or Latino
Native Hawaiian/Other Pacific Islander
White
Vacancies on 9/30 (Identify by position).
TOTAL

1. E. GENDER
	GOVERNING BOARD	PAIMI STAFF
Male
Female
TOTAL

SECTION 2. PAIMI PROGRAM PRORITIES (GOALS) and OBJECTIVES

In the format provided, please list the program priorities (goals) and activities, as reported in the PAIMI Application (under Priorities and Objectives) for the SAME Fiscal Year (FY) that were used to achieve the annual objectives for this PPR.

The priorities shall be limited and consistent with the current mission and Government Performance Results Act (GPRA) mandates, accountability, and performance-based management requirements of SAMHSA/CMHS.

Refer to the Guidance information included in the annual PAIMI Program Application.

For each priority (goal) identified for the FY, select ONE (1) CASE EXAMPLE THAT BEST ILLUSTRATED THE ACTIVITIES RELATED TO EACH PRIORITY (GOAL). Please provide in narrative form, one (1) example of an individual or systemic case and, if applicable, a legislative or regulatory activity. Remember case examples must illustrate the impact(s) and/or outcome(s) of PAIMI Program efforts.

Write the case example as though you were telling a story. As appropriate, Include the following information in your narrative: the presenting issue/complaint to be resolved; who (the parties involved); what the facts about the situation); where (the event occurred, such as, the type of facility, etc.); why the P&A program was involved; how the P&A program made a difference; and the outcome(s) (what resulted from this P&A activity)? For example, “as a result of P&A intervention, this client lives independently in the community, goes to work every day . . . .”‘

Each narrative shall reflect the activities used to achieve the annual objectives; be brief, concise; use people first language; maintain confidentiality of the individual client; and, be consistent with the priorities and objectives submitted in the PAIMI Program application for same FY. Check narratives for redundancies, typographical, grammatical and syntax errors. IN YOUR NARRATIVES, PLEASE SPELL OUT THE FULL NAME OF AN ENTITY, ETC. BEFORE USING ITS ACRONYM.

TO FACILITATE REVIEW OF THIS REPORT, THE PRIORITIES & OBJECTIVES MUST BE PRESENTED IN THE SAME ORDER AS THOSE REPORTED IN THE PAIMI APPLICATION FOR THE SAME FY.

See the GLOSSARY for definitions of priorities (goals) and objectives.

SECTION 2. PAIMI PROGRAM PRIORITIES & OBJECTIVES

SECTIONS 2.A., 2.B. & 2.C. were previously reported in the priority (goal)/objective table of the PAIMI Application for the same FY.

2. A. PRIORITY (GOAL) - is a broad, general description of what the PAIMI Program hopes to accomplish. Each priority (goal) may have either a single or multiple objectives.

2. B. OBJECTIVE - is the activity or activities undertaken to achieve a particular annual program priority (goal). Objectives have quantifiable targets and measurable outcomes. All objectives listed are to be completed within the FY. Regulatory, legislative and/or litigation activities may span several FYs. Therefore any objectives for these types of activities are to be divided into multiple steps that are achievable within the FY.

2. C. TARGET POPULATION - Identification of a specific PAIMI-eligible population to be served (targeted) under each objective, such as, the elderly, adolescents, etc.

Items 2.D. & 2.E. are to be reported in this section of the PPR.

[Refer to the PAIMI Application for the same FY in which the information in items 2.A. 2.B & 2.C. was provided].

2. D. TARGET - A numerical statement of what is desired or expected as a result of the objective. [Note: Even narrative targets may be expressed in measurable terms/numbers, For example, “Development of one [1] protocol for facility monitoring.”]

2. E. OUTCOME - What was actually achieved as a result of the activity expressed in numerical terms? (See note in 2.D.).

2. F. OBJECTIVE MET OR NOT MET: A statement of whether the expected outcome (target) for this objective was met. If not met, an explanation is required as well as a description of future activities to address the unmet objective, if appropriate.

Insert additional pages into this section as needed.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS

Provide the number of individual PAIMI-eligible individuals for the categories listed below. Count an individual only once during each FY reporting period (even if the client returned for services many times or if many intervention strategies were provided. Include individuals carried over from the previous year but do not include individuals represented as part of a group or a legal class action, and individuals who receive only information or referral services.

Please complete each of the following sections. DO NOT leave any blank spaces. If no individuals were served in any category, list zero. Make sure that the total individuals served in each sub-category is consistent. The total in 3.A.3. should equal the totals listed in each of the following categories: 3.C. Age of Individuals; 3.D. Gender of Individuals; and, 3.F. Individual Living Arrangements.

3. A. NUMBER OF INDIVIDUALS SERVED WITH PAIMI FUNDS.

3. A.1. Total of PAIMI-eligible individuals who were receiving advocacy at start of

FY. ______

[This category reflects the number of individuals supported with PAIMI Program funds or program income who had cases from the preceding FY still open on October 1. DO NOT REPORT INDIVIDUALS SERVED WITH NON-FEDERAL DOLLARS IN THIS SECTION, report these individuals in Section 8].

3. A.2. Total of new/renewed PAIMI-eligible individuals served during the FY. _____

[This is the number of individuals who had a case opened during the reporting period (October 1 and September 30). Do not report individuals served with non-Federal dollars in this section, report these individuals in Section 8].

3. A.3. Total of PAIMI-eligible individuals served in 3.A.1. & 3. A. 2. _____.

Reflects the total number of individuals served with PAIMI Program dollars, including program income, during the fiscal reporting period and is an unduplicated count of all PAIMI-eligible individuals who received individual case representation].

3. A.4. The number of PAIMI-eligible individuals who requested individual advocacy services who were not served within 30 days of initial contact either due to insufficient PAIMI funding 3.A.4.i. ______ or non-priority issues 3.A.4.ii ________ [include individuals who received other services such as information and referral in-lieu]. TOTAL 3.A.4. [Equals the sum of 3.A.4.i. &3.A.4.ii] ________.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS
3. A.5. Identify populations, advocacy issues and activities (systemic, legislative, educational, training, etc.) from 3.A.4.i. and/or 3.A.4.ii. that will be addressed in the future.
3. B. NUMBER OF COMPLAINTS/PROBLEMS OF PAIMI-ELIGIBLE INDIVIDUALS.						Total
[3.B. refers to the total number of complaints/problems presented at the time the individual s case was opened.contacted the P&A for assistance. The number may be higher than the total number of PAIMI-eligible individuals served by the P&A because each individual may have more than one complaint/problem to be addressed].
3. C. AGE OF INDIVIDUALS* [See 42 U.S.C. 10804(a)(1)(4), 42 CFR 51.24 (a)]
0 – 4 ___	5 – 12 ___	13 – 18___	19- 25____	25 – 64____	64+______		Total
*The total of 3.C. should equal the total number of individuals served listed in 3. A.3

3. D. GENDER OF INDIVIDUALS*
3.D.1. Male	3.D.2. Female	3.D.3. Total*
*3.D.3. should equal the total number of individuals served listed in 3. A.3

3. E. ETHNICITY/RACIAL BACKGROUND OF PAIMI-ELIGIBLE INDIVIDUALS
1. American Indian/ Alaska Native		4. Hispanic/Latino
2. Asian		5. Native Hawaiian/ Other Pacific Islander
3. Black/African American		6. White
TOTAL
[The data in 3.E. is self-reported. Please do not question self-reported data. Each client may select one or more categories. The totals in this section may exceed those listed in 3.A.3., 3.C.3, or 3.D.3. PAIMI STAFF MUST ASK AND REPORT THIS INFORMATION.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS
3. F. LIVING ARRANGEMENTS of INDIVIDUALS at INTAKE.						TOTAL
1 - Independent
2 - Parental or other family home
3 - Community residential home for children/youth (0-18 years), e.g. , supervised apartment, semi-independent, halfway house, board & care, small group home (3 or less).
4 - Adult community residential home, e. g., supervised apartment, semi-independent, halfway house, board & care, small group home (3 or less).
5 - *Non-medical community-based residential facility for children & youth (Age 0-18)
6 - Foster Care
7 - *Nursing Facilities, including Skilled Nursing Facilities(SNF)
8 - *Intermediate Care Facilities (ICF)
9 - * Public and Private General Hospitals, including emergency rooms.
10 - * Other health facility
11 - Psychiatric wards (public or private)
12 - Public (Municipal or State-operated) Institutional Living Arrangements (e.g., hospital treatment center/school or large group home 4+ beds).
13 - Private Institutional Living Arrangement (e.g., hospital or treatment center, school or large group home more than 3 beds).
14 - Legal Detention/Jail/Detention Center
15 - State Prison
17 – Homeless
18 - Federal Facility (List)	a. Detention	b. Prison	c. Veterans Hospital	d. Military	e. Other (describe)
TOTAL
The TOTAL for 3.F. equals the total listed in 3. A.3 *Expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 - 290jj(2).

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. A.1. AREAS OF ALLEGED ABUSE: Number of complaints/problems – Make every effort to report within the following categories:	OUTCOMES				Number from Closed Cases only Total [Add A,B,C& D]
	A	B	C	D
a. Inappropriate or excessive medication
b. Inappropriate or excessive
1. Physical restraint
2. Chemical restraint*
3. Mechanical restraint*
4. Seclusion
c. Involuntary medication
d. Involuntary Electrical Convulsive Therapy (ECT)
e. Involuntary aversive behavioral therapy
f. Involuntary sterilization
g. Failure to provide appropriate mental health treatment
h. Failure to provide needed or appropriate treatment for other serious medical problems
i. Physical Assault
1. Serious injuries related to the use of seclusion and restraint.*
2. Serious injuries NOT related to seclusion and restraint.
j. Sexual assault
k. Threats of retaliation or verbal abuse by facility staff
l. Coercion
m. Financial exploitation
n. Suspicious death
o. Other - Specify the type of complaint. Please describe on a separate sheet. [This number should be less than 1% of the total # of abuse complaints].
TOTAL
*Expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 -290jj-2]. See also, the PAIMI Act 42 U.S.C. 10802(1)(A) - (D).

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. A.2. ABUSE OUTCOME STATEMENTS

For each area of alleged abuse in 4.A.1., choose one or more outcome statements that best describe or relate to the complaint/problem area. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, and D).

A. Persons with disabilities whose environment was changed to increase safety or welfare.

B. Positive changes in policy, law or regulation re: abuse in facilities (describe facility where impact was made).

C. Validated abuse complaints that were favorably resolved as a result of P&A intervention.

D. Other indicators of success or outcomes that resulted from P&A involvement (explain).

4. A.3. ABUSE COMPLAINTS DISPOSITION
For closed cases listed in Table 4.A.1., provide the number of abuse complaints/ problems for each disposition category.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problem favorably resolved in the client’s favor.
d. Number of complaints/problem not favorably resolved in the client’s favor.
e. TOTAL number of complaints/problem addressed from closed cases. [The sum of Items 4.A.3. a - d equals the total for 4.A.3.e. which must equal the total in Table 4. A.1.].

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. B.1. AREAS OF ALLEGED NEGLECT – [failure to provide for appropriate . . .] - Number of Complaints/Problems:	Outcomes					Number from Closed Cases only. TOTAL [Add A,B,C,D,&E]
	A	B	C	D	E
a. Admission to residential care or treatment facility
b. Transportation to/from residential care or treatment facility
c. Discharge planning or release from a residential care or treatment facility
d. Mental health diagnostic or other evaluation (does not include treatment)
e. Medical (non-mental health related) diagnostic or physical examination
f. Personal care (e.g., personal hygiene, clothing, food, shelter)
g. Physical plant or environmental safety
h. Personal safety (client-to-client abuse)
i. Written treatment plan
j. Rehabilitation/vocational programming
k. Other. [Please describe. However, make every effort to report within the above categories.
TOTAL

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. B.2. NEGLECT OUTCOME STATEMENTS

For each area of alleged neglect listed in Table 4.B.1. , choose one or more outcome statements that either best described or related to the complaint/problem. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, D, and E).

A. Validated neglect complaints that have a favorable resolution as a result of P&A

intervention.

B. Positive changes in policy, law, or regulation regarding neglect in facilities

(describe facilities).

C. Persons with disabilities discharged consistent with their treatment plan after

P&A involvement.

D. Persons with disabilities whose treatment plans met selected criteria.

E. Other indicators of success or outcomes that resulted from P&A involvement

(explain).

4. B.3. NEGLECT COMPLAINTS DISPOSITION
For closed cases listed in Table 4.B.1., provide the numbers of neglect complaints or problem areas for each disposition category. [See, 42 U.S.C. 10802(5)].
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by the client.
c. Number of complaints/problem favorably resolved in the client’s favor.
d. Number of complaints/problem not favorably resolved in the client’s favor.
e. TOTAL number of complaints/problem addressed from closed cases. [The sum of Items 4.B.3. a - d equals the total for 4.B.3.e. which must equal the total in Table 4. B.1.].

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. C.1. AREAS OF ALLEGED RIGHTS VIOLATIONS ; Number of Complaints Problems	Outcomes				Number from Closed Cases only Total [Add A,B,C,& D]
	A	B	C	D
a. Housing Discrimination
b. Employment Discrimination
c. Denial of financial benefits/ entitlements (e.g., SSI, SSDI, Insurance)
d. Guardianship/ Conservator problems
e. Denial of rights protection information or legal assistance
f. Denial of privacy rights (e.g., congregation, telephone calls, receiving mail)
g. Denial of recreational opportunities (e.g., grounds access, television, smoking)
h. Denial of visitors
i. Denial of access to or correction of records
j. Breach of confidentiality of records (e.g., failure to obtain consent before disclosure)
k. Failure to obtain informed consent (see also, involuntary treatment)
l. Failure to provide education (consistent with IDEA and state requirements)
m. Advance directives issues
n. Denial of parental/family rights
o. Consumer financial issues
p. Immigration issues
q. Criminal justice issues
r. Denial of community habilitation services
s. Health insurance/managed care issues
t. Other. [Please describe separately. Make every effort to report within the above categories.]
TOTAL (Sum of items a. - t.)

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. C.2. RIGHTS VIOLATIONS OUTCOME STATEMENTS

For each category of alleged rights violation listed in Table 4.C.1., choose one or more outcome statements that either best described or related to the complaint/problem. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, or D).

A. Persons with disabilities served by the P&A whose rights were restored as a result of P&A Intervention.

B. Persons with disabilities whose personal decision making was maintained or expanded as a result of P&A intervention.

C. Policies or laws changed and other barriers to personal decisions making eliminated as a result of P&A intervention.

D. Other outcomes as a result of P&A involvement:

4. C.3. RIGHTS VIOLATIONS DISPOSITION
For closed cases listed in Table 4.C.1., provide the numbers of rights complaints or problem areas for each disposition category.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problems favorably resolved in the client’s favor.
d. Number of complaints/problems not favorably resolved in the client’s favor
e. The TOTAL number of complaints/problem addressed from closed cases. [The sum of items 4.C.3. a - d equals the total for 4.C.3.e. which must equal the total in Table 4. C.1.].

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. D.1. INTERVENTION STRATEGIES

Report the number of intervention strategies and the outcomes used to address each individual complaint/problem area in Section 4. D.3.

Some clients may have more than one complaint/problem and each may require more than one intervention strategy, therefore, the total number of intervention strategies used may exceed the total number of individuals served.

DO NOT REPORT EACH PHONE CALL, LETTER, MEETING OR OTHER ACTION TAKEN ON BEHALF OF A CLIENT AS A SEPARATE INTERVENTION STRATEGY. [Referrals, counseling, and negotiation are considered cumulative processes]. See Glossary for the definitions of “Intervention Strategies.

4. D. 2. INTERVENTION STRATEGY OUTCOMES
Strategy	Outcomes
	A	B	C	D	E	F	G	Total
1. Short Term Assistance
2. Abuse/Neglect Investigations
3. Technical Assistance
4. Administrative Remedies
5. Negotiation/ Mediation
6. Legal Remedies

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. D.3. OUTCOME STATEMENTS FOR COMPLAINTS/PROBLEMS OF INDIVIDUALS

As applicable, for each area of client advocacy activity listed in 4.D.2., select one (1) or more of the following outcome statements that either best describe or relate to the complaint(s)/problem(s) of PAIMI-eligible individuals. Record your choices in 4.D.2.

Enter the appropriate letter(s) in the “outcome” column of Table 4.D.3.

A. Persons with disabilities (or their family members) served by the P&A whose complaint of abuse, neglect, or rights violation were remedied by the P&A.

B. Persons with disabilities (or their family members) who secured access to administrative remedies, received education or training about their rights, and as a result were empowered to become more effective self advocates.

C. Persons with disabilities who secured information about their rights and rights enforcement strategies as a result of P&A intervention.

D. Persons with disabilities who advocated on their own behalf as a result of P&A intervention.

E. Allegations of abuse or neglect that were substantiated by P&A.

F. Allegations of abuse or neglect that were not substantiated by P&A.

G. Other outcomes as a result of P&A involvement.

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4.E. DEATH INVESTIGATION ACTIVITIES

See, the PAIMI Act 42 U.S.C. at 10801(b)(2)(B) and 10802(1), and PAIMI Program expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 - 290jj-2.

4. E.1. The number of deaths of PAIMI-eligible individuals reported to the P&A for investigation by the following entities:

4. E.1. a. The State.

b. The Center for Medicaid & Medicare Services (Regional Offices).

c. Other Sources. Briefly list the source for each death reported in this

category, e.g., newspaper, concerned citizen, relative, etc.

d. TOTAL

4. E.1.e. If the information requested in 4.E.1. was not available, please explain.

4. E.2. All P&A Death investigations conducted involving PAIMI-eligible individuals related to the following:	Total
a. Number of deaths investigated involving incidents of seclusion (S).
b. Number of death investigated involving incidents of restraint (R).
c. Number of deaths investigated NOT related to incidents of S & R.
d. Total Number of deaths investigated [Sum of 4.E.2. a-c].

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4.E. DEATH INVESTIGATION ACTIVITIES

4.E.3. If you reported deaths in categories 4.E.2.a., 4.E.2.b., and/or 4.E.2.c., then

please provide the following information on one (1) death from

each category, as appropriate:

• A brief summary of the circumstances about the death.

• A brief description of P&A involvement in the death investigation.

• A summary of the outcome(s) resulting from the P&A death investigation.

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI- ELIGIBLE INDIVIDUALS
This section captures information, which is NOT reflected in previous sections of this report, on how the P&A program used its PAIMI Program funds (including PAIMI Program income) to support non-individual client activities To complete Table 5.F. TYPES of INTERVENTIONS, refer to the guidance in Sections 5.A. – 5.E.
Under each intervention, as applicable, report each annual program priority activities for the FY & the other information requested. The items listed in the table’s left column and the numbers reported for each category should relate to the narrative section that follows.
5. A. GUIDANCE FOR REPORTING NUMBERS OF INDIVIDUALS POTENTIALLY IMPACTED BY P&A INTERVENTIONS
TYPES OF INTERVENTION	GUIDANCE FOR DETERMINING NUMBER* OF INDIVIDUALS * [The number of persons potentially impacted within the fiscal year for which the PPR is submitted].
GROUP ADVOCACY (non-litigation)	Estimated number of people with disabilities impacted by this change, i.e., Count of People with Disabilities (PWD) that are normally impacted by this practice, policy and or structure.
INVESTIGATIONS (non-death related)	Estimated number of PWD impacted by this change.
FACILITY MONITORING SERVICES	Estimated number of PWD impacted. (i.e., Count of PWD living in facility)
COURT ORDERED MONITORING	Estimated number of PWD impacted by this change, (i.e., Count of PWD impacted by COM)
CLASS LITIGATION	Estimated number of PWD impacted by this change (i.e., Count of PWD impacted by this litigation).
LEGISLATIVE & REGULATORY ADVOCACY	Estimated number of PWD impacted by this change, (i.e., Count of PWD that are normally impacted by this practice, policy and or structure)
OTHER	Estimated number of PWD impacted by this change, (i.e., Count of PWD impacted specified intervention).

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI-

ELIGIBLE INDIVIDUALS

5. B. GUIDANCE FOR DETERMINATION OF CONCLUDED SUCCESSFULLY* FOR INTERVENTIONS ON BEHALF OF GROUPS OF PAIMI-ELIGIBLE INDIVIDUALS.

Interventions reported in the Table 5. A., are considered to be concluded successfully if they meet any one of the following six (6) positive outcome statements:

1. The intervention resulted in a positive change in a policy, law, regulation, or other barrier for persons with disabilities.

2. The intervention changed the environment to increase safety or welfare for persons with disabilities

3. The intervention resulted in a positive change through the restoration of client rights, the expansion or maintenance of personal decision-making, or the elimination of other barriers to personal decision-making for persons with disabilities

4. The intervention resulted in persons with disabilities securing access to administrative or judicial processes.

5. The intervention resulted in persons with disabilities securing information about their rights and strategies to enforce their rights.

6. The intervention resulted in persons with disabilities taking action to advocate on their own behalf.

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of

PAIMI- ELIGIBLE INDIVIDUALS

5. C. GUIDANCE FOR DETERMINATION OF CONCLUDED UNSUCCESSFULLY* FOR INTERVENTIONS ON BEHALF OF GROUPS OF PAIMI-ELIGIBLE INDIVIDUALS.

Intervention activities reported in Table 5.F. ARE CONCLUDED UNSUCCESSFULLY IF THEY DO NOT MEET ANY OF THE OUTCOMES STATEMENTS IN SECTIONS 5.A. OR 5.B.

5.D. GUIDANCE FOR DETERMINATION OF ONGOING INTERVENTIONS ON BEHALF OF GROUPS OF PAIMI-ELIGIBLE INDIVIDUALS

SAMHSA/CMHS recognizes that LEGISLATIVE, LEGAL AND/OR OTHER SYSTEMIC REFORM ACTIVITIES (E.G., FACILITY MONITORING, LITIGATION PREPARATION, ETC) MAY TAKE MORE THAN ONE FISCAL YEAR TO COMPLETE and sometimes these types of interventions take years before they are completed successfully. It is these types of situations where the use of ongoing is most appropriate. The interventions reported in Table 5. F. are considered ONGOING, IF THEY WERE STARTED IN EITHER A PRIOR YEAR OR THE CURRENT FISCAL YEAR AND WERE NOT CONCLUDED BY 9/30 OF THIS FY.  

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI- ELIGIBLE INDIVIDUALS
5. E. TYPES OF INTERVENTIONS	Potential number of Individuals Impacted	Concluded Successfully	Concluded Unsuccessfully	On-going
1. Group Advocacy non-litigation
2. Investigations (non-death related)
3. Facility Monitoring Services
4. Court Ordered Monitoring
5. Class Litigation
6. Legislative & Regulatory Advocacy
7. Other
TOTAL

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI-

ELIGIBLE INDIVIDUALS

In the PAIMI Application [at Section IV.2.2.], you were instructed to provide information on the objectives for these types of interventions in sequential steps that are achievable within the annual reporting period, such as, conducting research, identifying legal issues, filing the class action, etc.

5. F. In the space below, provide at least ONE (1) EXAMPLE that reflected the

outcome of EACH sub-category listed in Table 5.E. In the narrative for each example, briefly describe the PAIMI Program activity, include factual information (who, what, when, where, how) and the outcome(s) that resulted from the intervention.

Use work examples that illustrate the impact of PAIMI Program activities, especially

how the activities made a difference to the clients served, such as, improved

quality of life, etc. If PAIMI Program funds were used to support any of the above activities, then describe how their availability furthered the purposes of the PAIMI

Act.

INSERT ADDITIONAL PAGES INTO THIS SECTION AS NEEDED.

SECTION 6. NON-CLIENT DIRECTED ADVOCACY ACTIVITIES
6. A. INDIVIDUAL INFORMATION AND REFERRAL (I&R) SERVICES. Refer to the Glossary for the definition of I& R. [See also, PAIMI Rules, 42 CFR 51.24].
Provide the number of PAIMI Program I&R services.	TOTAL
6.B. STATE MENTAL HEALTH PLANNING ACTIVITIES
Briefly list P&A collaboration/involvement in State Mental Health planning activities.
6. C. EDUCATION, PUBLIC AWARENESS ACTIVITIES AND/OR EVENTS
6.C.1. List the number of public awareness activities or events AND the number of individuals who received the information. [Refer to the Glossary].
6. C.1. a. Number of public awareness activities or events.		Total
6. C.1. b. Number of individuals receiving the information.		Total
6. C.2. Number of education/training activities undertaken.		Total
6.C.2 refers to either the number of training programs sponsored by the P&A or the number of events sponsored by another organization WHERE P&A STAFF ARE THE TRAINERS. The training must have provided specific information to participants regarding their rights. If the P&A only provided general program information then report the number of individuals trained in section 6.C.1.b. [PAIMI Rules 42 CFR 51.31(c)].		Total
6. C.3. Number (approximate) of persons trained. [Only include those individuals who attended a 6.C.2. type education/training program(s). See PAIMI Rules 42 CFR 51.31].		Total

SECTION 6. NON-CLIENT DIRECTED ADVOCACY ACTIVITIES

6. C. EDUCATION, PUBLIC AWARENESS ACTIVITIES AND/OR EVENTS

DISSEMINATION ACTIVITIES. Provide the number of articles, films, reports, etc. developed/produced. Provide an estimate for the number of people who received the information. For example, an article published about the P&A in a newspaper with a circulation of 200,000 readers; a television appearance on a station with 100,000 viewers in that time spot, etc.

6. C.4. OUTCOME STATEMENTS for DISSEMINATION ACTIVITIES

For each non-client directed advocacy activity listed in the Table 6.C.5., choose one or more outcome statements that either best describe or relate to the TYPE of ACTIVITY. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, and C).

A. Persons who received information about the P&A and its services.

B. Persons disabilities (or their family members) who received education or training about their rights, enabling them to be more effective self advocates.

C. Other outcomes that resulted from PAIMI Program involvement.

SECTION 6. NON-CLIENT DIRECTED ADVOCACY ACTIVITIES
6. C.5. TYPES OF DISSEMINATION ACTIVITIES	NUMBER OF ITEMS	NUMBER OF EVENTS	# of persons who received the information	OUTCOMES
				A	B	C	Total -Add A-C C.
a. Radio/TV appearances.
b. Newspaper articles (attach copies of articles).
c. Public Services Announcements (PSA), videos/films/, etc.
d. Reports
e. Publications, including articles in Professional journals.
f. Other P& A disseminated information, includes general training, outreach activities or presentations, brochures and handouts that were not included/counted under training activities).
g. Number Website hits, include visits.
h. Describe other media activities.
TOTALS

SECTION 7. GRIEVANCE PROCEDURES [42 CFR Section 51.25]
7.1. The number of grievances filed by PAIMI-eligible clients, including representatives or family-members of such individuals receiving services during this fiscal year. TOTAL ____
7.2. The number of grievances filed by prospective PAIMI-eligible clients (those who were not served due to limited PAIMI Program resources or because of non-priority issues. TOTAL _____
7.3. Total [Add 7.1 & 7.2] _____ [42 CFR Section 51.25(a)(1),(2)]
7.4. The number of grievances appealed to:
7. 4.a. The Governing Authority/Board	Total	7. 4.b. The Executive Director	Total
c. TOTAL = 7.4a. & 7.4b. _____
7.5. The number of reports sent to the governing board AND the Advisory Board (mandatory for private non-profit P&A systems) at least one annually) that describe the grievances received, processed, and resolved. Total _______
7.6. Please IDENTIFY ALL INDIVIDUALS, by name & title, responsible for grievance reviews.
7.7. What is the timetable (in days) used to ensure prompt notification of the grievance procedure process to clients, prospective clients or persons denied representation, and ensure prompt resolution? __________ [42 CFR 51.25(b)(4)]
7.8. Were written responses sent to all grievants? YES ____, NO ___ If no, explain below.
7.9. Was client confidentiality protected? YES____, NO____. If no, explain below. [42 CFR 51.25(b)(6)]

SECTION 8. OTHER SERVICES AND ACTIVITIES
The PAIMI Rules [at 42 CFR at 51.24(b)] mandate that “Members of the public shall be given an opportunity, on an annual basis, to comment on the priorities established by, and the activities of, the P&A system. Procedures for public comment which must provide for notice in a format accessible to individuals with mental illness, including such individuals who are in residential facilities, to family members and to representatives of such individuals and to other individuals with disabilities. Procedures for public comment must provide for receipt of comments in writing or in person.”
8. A.1. Does the P&A have procedures established for public comment? a. Yes __ PROVIDE A COPY OF A NOTICE and briefly describe how the notice is used to reach persons with mental illness and their families. b. No __, If no, briefly explain.
8. A.2. Were the notices provided to the following persons?
a. Individuals with mental illness in residential facilities?	YES	NO*
b. Family members and representatives of such individuals?	YES	NO*
c. Other Individuals with disabilities?	YES	NO*
d. *Brief explanation is required for each NO answer in 8. A.2. a., b., or c.

8. A.3. Do the procedures provide for receipt of the comments in writing or in person? YES* _____; NO _____.

8. A.3.a. If YES*, ATTACH A COPY OF THE AGENCY’S POLICIES/PROCEDURES PERTAINING TO PUBLIC COMMENT.

8. A.3.b. If NO, EXPLAIN WHY THE AGENCY DOES NOT HAVE SUCH PROCEDURES IN PLACE.

SECTION 8. OTHER SERVICES AND ACTIVITIES
8. B.1. Was the public provided an opportunity for public comment?	YES	NO
8. B. 2. If you answered YES to 8.B.1., then briefly describe the activities used to obtain public comment.
8. B. 3. What formats and languages (as applicable) were used in materials to solicit public comments?
8. B. 4. If you answered NO to 8.B.1., BRIEFLY EXPLAIN WHY THE PUBLIC WAS NOT PROVIDED AN OPPORTUNITY TO COMMENT.

8.C. LIST GROUPS (e.g., States, consumer, advocacy, service providers, professional organizations and others, including groups of current and former mental health consumers and/ or family members of such individuals) with whom the PAIMI Program coordinated systems, activities, and mechanisms. [42 U.S.C. 10824(a(D)].

SECTION 8. OTHER SERVICES AND ACTIVITIES
8. D. Briefly describe the outreach efforts/activities used to increase the numbers of ethnic and racial minority clients served and/or educated about the PAIMI Program. [This information will be evaluated by using the Demographic/State Profile information contained in the PAIMI Application for the same FY].
8. E. Did the activities described in 8.D. result in an increase of ethnic and/or minorities in the following categories?
1. Staff	YES	NO
2. Advisory Council	YES	NO
3. Governing Board	YES	NO
4. Clients	YES	NO
If the answer to any item 8.E.1 - 4 is NO, please provide a brief explanation, such as 8.E.1., 2., or 3. – no vacancies.

8. F. PAIMI PROGRAM IMPLEMENTATION PROBLEMS

8. F.1 External Impediments

Describe any problems with implementation of mandated PAIMI activities, including those activities required by Parts H and I of the Children’s Health Act of 2000 that pertain to requirements related to incidents involving seclusion and restraint and related deaths and serious injuries (e.g., access issues, delays in receiving records and documents, etc.).

SECTION 8. OTHER SERVICES AND ACTIVITIES

8. F.2. Internal Impediments

Describe any problems with implementation of mandated PAIMI activities, including any identified annual priorities and objectives (e.g., lack of sufficient resources, necessary expertise, etc).

8. G. ACCOMPLISHMENTS

For this fiscal year, briefly describe the most important accomplishment(s) that resulted from PAIMI Program activities. PROVIDE copies of supporting documents, e.g., case law, news article, legislation, etc.

SECTION 8. OTHER SERVICES AND ACTIVITIES

8. H. RECOMMENDATIONS

Please provide recommendations for activities and services to improve the PAIMI Program. Include a brief description of why such activities and services are needed. [42 U.S.C. 10824(a)(4)]].

8. I. PLEASE IDENTITY ANY TRAINING & TECHNICAL ASSISTANCE REQUESTS. [42 U.S.C. 10825]

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 200_
In this section, provide actual expenditures for the FY. Refer to the PAIMI Application [Appendix C] submitted to SAMHSA/CMHS for the same FY.
9. A. PAIMI PROGRAM PERSONNEL – INSERT ADDITIONAL ROWS AS NEEDED. ++ List vacancies by position, annual salary, percentage of time & costs that will be charged to the PAIMI Program grant when the position is filled.
Position Title	Annual Salary	Percent/Portion Of Time Charged To PAIMI	Costs Billed to PAIMI
SUBTOTAL
++Vacant positions
Volunteer positions
TOTAL POSITIONS

9. B. CATEGORIES	COST
Fringe Benefits (PAIMI only)
Travel Expenses (PAIMI only)
SUBTOTAL

9. C. EQUIPMENT - TYPE (PAIMI ONLY)	COST
SUBTOTAL

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 200_
9. D. SUPPLIES - TYPE (PAIMI ONLY)						COST
SUBTOTAL
9. E. CONTRACTUAL COSTS (including Consultants) for PAIMI Program Only
Position Or Entity	Service Provided	Salary/Fee	Fringe Benefit Cost	Travel Expenses	Other Costs
SUBTOTAL

9. F. TRAINING COSTS FOR PAIMI PROGRAM ONLY
Categories	#Of Persons/ Travel Costs	#Of Persons/ Training Costs	# Of Persons/ Other Expenses
Staff
Governing Board
PAC Members
Volunteers
Subtotal

9. G. OTHER EXPENSES (PAIMI PROGRAM ONLY)	COST
LITIGATION
SUBTOTAL

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 200_
9. H. Indirect Costs (PAIMI only):		COST
1. Does your P&A have an approved Federal indirect cost rate?	YES	NO
If YES, what is the approved rate?
2. Total of all PAIMI Program costs listed in 9.A. - 9.G.		$
3. Income Sources and Other Resources (PAIMI Program Only)		$
4. PAIMI Program carryover of grant funds identified by FY.		$
5. Interest on Lawyers Trust Accounts (IOLTA).		$
6. Program income (PAIMI only).		$
7. State		$
8. County		$
9. Private		$
10. Other funding sources. [IDENTIFY each source].		$
11. Total of all PAIMI Program resources.		$
SUBTOTAL		$

GLOSSARY

Closed case - is when the advocate/attorney closes the client record or case file after providing advocacy interventions on behalf of a client, and determining that the client either has no need of further intervention services or that the agency has no other services available to address the issue(s) or complaint(s) for which the case was initially opened.

Grievance Procedures – are policies and procedures developed by the P&A system to ensure that its clients and prospective PAIMI-eligible clients, their family members, or representatives have full access to the system services and that the system is fully compliant with the provisions of the PAIMI Act and Rules.

Information and Referral (I&R) Services - is the provision of brief written or oral information, such as generic information about the P&A, including information about additional programs and resources external to the P&A that relate to the individual’s service needs and statutory or constitutional rights as a person with a disability. I &R services are generally of short duration, typically range from a few minutes to an hour, do not involve direct advocacy intervention by staff, and any type of staff follow-up. I&R services may include mailing generic agency information. Individuals receiving I &R services are not counted as PAIMI clients.

Intervention Strategies:

• Abuse/Neglect Investigations - a systemic and thorough examination of information, records, evidence and circumstances surrounding an allegation of abuse and neglect. Investigations are undertaken to determine if there is a basis for administrative or legal action on behalf of the client. Investigations require a significant allocation of time to interview witnesses, gather factual information, and to issue a written report of findings.

• Administrative Remedies - includes the use of any systems for appeal within an agency or facility, or between agencies, which does not involve adjudication by a court of law.

• Legal Remedies - the legal representation of clients in litigation in court processes concerned with rights, grievances, or appeals of such rights or grievances.

• Legislative/Regulatory Advocacy activities involve monitoring, evaluating, and commenting upon the development and implementation of Federal, State, and local laws, regulations, plans, budgets, taxes and other actions which may affect individuals with mental illness. [The PAIMI Rules at 42 FCR at 51.24 mandates that legislative activities shall also be addressed in the development of program priorities].

• Negotiation/Mediation - is a informal, non-legal intervention by a PAIMI representative, attorney or case manager used to resolve problems with facility staff or other agency representatives; (does not involve a formal appeal).

• Short Term Assistance - Time limited advice and counseling assistance, which may include reviewing information, counseling a client on actions one may take, and assisting the client in preparing letters, documents or making telephone calls to resolve the issue.

• Technical Assistance - includes the provision of information, referral or advice to clients by a PAIMI Program representative, attorney, or advocate, (e.g., coaching the client in self-advocacy, explaining service delivery system(s) available to meet needs, dissemination of information and materials to client, etc.). Follow-up is required.

Objectives - are activities undertaken to achieve annual program priorities (goals). All objectives required to have measurable outcomes and the use of numerical targets is encouraged. Each objective must clearly state why the activity was undertaken, who will benefit from the objective (the target population), how the activity will be accomplished, and what is the expected outcome for the activity? Generally, with the exception of litigation, legislative or regulatory activities, objectives shall be attainable within the fiscal reporting period (within one (1) fiscal year).

Open Case - is when a PAIMI-eligible individual with a complaint is accepted as a client by the P&A system. A case record or case file is opened for that individual. System staff maintain all intervention services provided to the client and other information t are maintained in this case record/file.

Outreach - is an activity that targets information on PAIMI Program activities to specific populations (e.g., cultural, ethnic and racial minorities, and other underserved or un-served populations, etc. The activity is linked to an objective of a specific annual priority.

PAIMI Clients (for purposes of this report) - are individuals who meet the PAIMI eligibility criteria as defined in the PAIMI Act [42 U.S.C. 10802(4) and its Rules at 42 CFR 51.2 Definitions, who have a complaint, for whom demographic data is collected, and for whom the PAIMI Program, or any of its subcontractors, provides an intervention (as reported under Intervention Strategies in this form).

Priorities (Goals) – are broad general descriptions of short term activities for the P&A system to accomplish within one (1) fiscal year (FY). [The exceptions are generally regulatory, legislative, and litigation activities]. The priorities must be directly related to the purpose of the enabling Federal legislation and the requirements of the Federal-funding agency and consistent with the priorities included in the PAIMI Application for the same FY. [See PAIMI Act at 42 U.S.C. 10801, PAIMI Rules at 42 CFR 51.24 (a) – Program Priorities, and the Children’s Health Act of 2000 at 42 U.S.C. at 290ii-ii-1 and 290jj-jj-2].

Public Awareness Activities - provide general information on disability rights and the purpose and mission of the P&A system. Public awareness activities include public service announcements, newsletters, radio or television, publications in legal journals, web site services, general distribution of agency brochures, etc.

Public Education and Constituency Training - is the dissemination of information to one or more persons through an interactive event, which often promotes a greater understanding of the constitutional or statutory rights of persons with disabilities. Contrasted to Public Awareness Activities, education and training must be specifically targeted to meet the unique need of the group(s) trained.

Racial/Ethnic Background - for the purposes of this report, the ethnicity categories are Hispanic or Latino and Not Hispanic or Latino. The race categories are American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White.

Resolution of Complaint/Problem Area – is in a client’s favor when ( 1) the client is satisfied with the result of the intervention or (2) the expressed wish or stated goal of the client is either fully attained or negotiated to an agreeable outcome, or (3) the violation in the stated case complaint/problem area was remedied.

Systemic Advocacy Activities – are the efforts taken to implement changes in policies and practices of systems that impact persons with mental illness. These "systems" include, but are not limited to, State agencies, various public and private residential care and treatment facilities, and other service providers, etc. [The PAIMI Rules at 42 CFR 51.24 (a) PAIMI Priorities state that systemic activities shall be addressed in the development and implementation of program priorities].

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