Form Report

OMB Approval: 0930-0169

Expiration Date: 9/30/XXXX

Protection and Advocacy for Individuals with Mental Illness

(PAIMI)

Annual Program Performance Report (PPR)

Substance Abuse Mental Health Services Administration (SAMHSA)

U.S. Department of Health and Human Services

Table of Contents

Section A: General Program Information

1. P&A Identification

2. Main Office

3. Satellite Offices (if any)

4. Executive Director/Chief Executive Officer Contact Information

5. PPR Preparer Contact Information

6. Governing Authority President/Chair

7. PAIMI Advisory Council President/Chair

8. Name of P&A Chief Financial Officer/ Accountant

9. Governor’s Liaison

10. Commissioner/Director of the state Mental Health Agency Name

11. Demographic composition of Governing Board, Advisory Counsel and PAIMI staff

12. Governing Board (GB) Type and Number of Members

13. Governing Board Information

14. Governing Board Composition

15. Executive Director (ED)

16. PAIMI Advisory Council

17. Staff assigned to the PAIMI Program

Section B: Demographics - Interventions on behalf of Individuals

1) Age of PAIMI-eligible Individuals Served

2) Sex of PAIMI-eligible Individuals Served

3) Racial and Ethnic Diversity of Individuals Served

4) PAIMI-Eligible Individuals served with PAIMI Program funds

5) Living Arrangements of PAIMI-eligible Individuals at Intake

Section C: Complaints/Problems of PAIMI-eligible Individuals

1) Complaints/Problems of PAIMI-eligible Individuals - Abuse

2) Abuse Complaints Disposition

3) Complaints/Problems of PAIMI-eligible Individuals – Neglect

4) Neglect Complaints Disposition

5) Complaints/Problems of PAIMI-eligible Individuals - Rights

6) Rights Complaints Disposition

7) Reasons for Closing Individual Intervention Files

8) Intervention Strategies

9) Death Investigation Activities

1. The number of deaths of individuals reported to the P&A for investigation by category

2. All Death investigations conducted involving PAIMI-eligible individuals by category.

3. Brief summary examples of an individual’s death, P&A involvement, and outcome.

10) Intervention on Behalf of Groups of PAIMI-Eligible Individuals (count by type).

11) Intervention on Behalf of Groups of PAIMI-Eligible Individuals (number and outcome by type of intervention).

Section D: Non-Client Directed Advocacy Activities

1. Individual Information and Referral

2. State Mental Health Planning Activities

3. Education, Public Awareness Activities and Events

Section E: Grievance Procedures

Section F: Other Services and Activities

Section G: Actual PAIMI Budget/Expenditures for FY___

Section H: Statement of Goals and Priorities

1) Report on previous FY Statement of Priorities and Objectives (SPO)

Section I: Glossary

Section A: General Program Information for FY___

1. P&A Identification

Name of state/jurisdiction
Name of P&A system

2. Main Office

Mailing address of main office
Phone number of main office
Toll free Phone Number
e-mail address
website address
TTY phone number
County or Main Office

3. Satellite Offices (if any - add rows, if needed)

Mailing address (each satellite office)
County of each satellite office (location)

4. Executive Director/Chief Executive Officer Contact Information

Name
Address
Phone number & extension
e-mail address

5. PPR Preparer Contact Information

Name
Title
Phone number & extension
e-mail address

6. Governing Board President/Chair

Name
Mailing address
County of residence
e-mail address
Current term started
Current term expires

7. PAIMI Advisory Council President/Chair Name

Name
Mailing address
County of residence
e-mail address
Current term started
Current term expires

8. Name of P&A Chief Financial Officer/Accountant

Name
Title
Phone
e-mail address

9. Governor’s Liaison

Name
Official title
Mailing address
Phone number
e-mail address

10. Commissioner/Director of the State Mental Health Agency

Name
Mailing address
Phone number
e-mail address

11. Demographic Composition of PAIMI Governing Board, Advisory Council, and Program Staff

		Governing Board	Advisory Counsel	Program Staff
Ethnicity	Hispanic/Latino
	Non-Hispanic/Latino
Race	American Indian/ Alaskan/Native
	Black/African American
	White
	Two or more races
Sex	Female
	Male

12. Governing Board (GB) Type and Number of Members

Governing board	Minimum number of members	Maximum number of members
Private, non-profit with multi-member
State-operated with governing board
State-operated with no governing board

13. Governing Board Information

Total seats available
Total members serving as of 9/30/___
Total vacancies on 9/30/___
Term of appointment (number of years)
Term maximum
Meeting frequency
Number of meetings held this fiscal year (FY)
Percentage of members present at meetings during the FY

14. Governing Board Composition

Number of individuals with mental illness who are recipients/former recipients (R/FR) of mental health services or have been eligible for services.
Number of family members of individuals with mental illness who are R/FR of mental health services.
Number of guardians.
Number of advocates or authorized representatives.
Number of other persons who broadly represent or are knowledgeable about the needs of the clients served by the P&A system.
Total

15. Executive Director (ED)

Initial Appointment Date
	(MM/DD/YYYY)
Recent performance evaluation completed
	(MM/DD/YYYY)
Date of previous performance evaluation
	(MM/DD/YYYY)
Agency has written policy and procedures to guide the ED’s evaluation process?		☐Yes	☐No
List documents and exact sections, page, where this information may be found.
Input on ED’s performance evaluation obtained from the following (check all that apply)
All agency employees/staff		☐Yes	☐No
Senior managers		☐Yes	☐No
All board directors		☐Yes	☐No
All PAIMI Advisory Council members		☐Yes	☐No
Stakeholders		☐Yes	☐No
Consumers		☐Yes	☐No
Family members of consumers		☐Yes	☐No
State mental health providers		☐Yes	☐No
Private mental health providers		☐Yes	☐No
Other		☐Yes	☐No

16. PAIMI Advisory Council (PAC)

PAC Chair
Sits on the governing board	☐ Yes	☐No
Appointment date
	MM/DD/YYYY
Other PAC member(s) sit on governing board	☐Yes	☐No
If yes, number serving

17. Staff assigned to the PAIMI Program

	Number of Attorneys	Full-time	Part-time	Male	Female	Number of Advocates	Full-time	Part-time	Male	Female
Ethnicity
Hispanic/Latino (of any race)
Non-Hispanic/ Latino
Race
American Indian/ Alaskan Native
Asian
Black/African American
Native Hawaiian/ Pacific Islander
White
Two or more races
Unknown

Section B: Demographics

1. Age of PAIMI-eligible Individuals Served

Age	Number
0 - 4
5 - 12
13 - 18
19 - 25
26 - 64
65+
Total

2. Sex of PAIMI-eligible Individuals Served

Sex	Number
Female
Male
Unknown/would not disclose
Total

3. Ethnicity and Race of Individuals Served

Ethnicity	Number	PAIMI%	State%
Hispanic/Latino (of any race)
Non-Hispanic/Latino
Ethnicity unknown
Total

Race	Number	PAIMI%	State%
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Two or more races
Race unknown
Total

4. PAIMI-eligible Individuals Served with PAIMI Program Funds

What to Count	Number
1. Number of PAIMI-eligible individuals served with PAIMI program funds, includes any program income resulting from legal actions supported by PAIMI program funds as of October 1 (only cases carried over from previous FY).
2. Number of new PAIMI-eligible individuals served during the FY.
3. Total number of PAIMI-eligible individuals served during this FY (add lines 4.1 and 4.2).
Total number of PAIMI-eligible individuals who requested program related advocacy services ,but were not served within 30-days of initial contact because of:
insufficient PAIMI program resources
non-priority areas.
5. Individuals served as of September 30 (carry over to next FY; This should equal ≤ item 3 above).

5. Living Arrangements of PAIMI-eligible Individuals at Intake

Living Arrangement	Number
Community residential home for children/youth up to age 18 yrs.
Community residential home for adults
Non-medical community-based residential facility for children/youth
Foster care
Nursing homes, including skilled nursing facilities
Intermediate care facilities
Public general hospitals including emergency rooms
Private general hospitals including emergency rooms
Public institution
Private institution
Psychiatric hospitals (public/private)
a. public/state b. private
Jails
a. municipal/city b. county c. other
State prison
Federal detention center
Federal prison
Veterans administration hospital
Other federal facility
Homeless
Independent (in the community & PAIMI-eligible)
a. within 90-days post-discharge from a facility
b. after 90-days of discharge
Parental or other family home & PAIMI-eligible
a. within 90-days post-discharge
b. after 90-days of discharge
Unknown
Total

Section C: Complaints/Problems of PAIMI-eligible Individuals

1. Areas of Alleged Abuse

Number of complaints/problems (Make every effort to report within the following categories)	Number from Closed Cases only		Outcomes
	Total		A		B		C		D
a. Inappropriate or excessive medication
b. Inappropriate or excessive
Physical restraint
Chemical restraint
Mechanical restraint
Seclusion
c. Involuntary medication
d. Involuntary electrical convulsive therapy
e. Involuntary aversive behavioral therapy
f. Involuntary sterilization
g. Failure to provide appropriate mental health treatment
h. Failure to provide needed medical treatment
Physical assault
Serious injuries related to the use of seclusion and restraint.
Serious injuries not related to seclusion and restraint.
Patient on patient
Staff/caretaker
Facility resident
j. Sexual assault
Staff/caretaker
Patient/facility resident
k. Threats of retaliation or verbal abuse by facility staff
l. Coercion
m. Financial exploitation
n. Suspicious death
o. Other - Specify type of complaint (describe on a separate sheet) - [This number should be ≤1 percent of abuse complaints total].
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)).

2. Abuse Complaints Disposition

For total closed cases listed in Table C.1., provide the number of abuse complaints/problems for each disposition category.
Total number of abuse complaints/problem addressed from closed cases.
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 resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.

3. Areas of Alleged Neglect

[failure to provide for appropriate . . .] - Number of complaints/problems:	Number from Closed Cases only	Outcomes
	Total	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. Inadequate care (e.g., personal hygiene, clothing, food, shelter)
g. Physical plant or environmental safety
h. Personal safety issues (unsecured access to facility, resident rooms, patient to patient abuse)
i. Other [Describe and make every effort to report within the above categories].
Total

4. Neglect Complaints Disposition

For total closed cases listed in Table C.3., provide the numbers of neglect complaints or problem areas for each disposition category.
Total number of Neglect complaints/problem addressed from closed cases.
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/problems resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.
e. Other indicators of success or outcomes that resulted from P&A involvement.

5. Areas of Alleged Rights Violations

Number of Complaints/Problems	Number from Closed Cases only	Outcomes
		A	B	C	D
	Total
a. Right to an individualized, written treatment or service plan.
A written discharge plan, including a description of mental health services needed upon discharge from such program or facility
c. The right to ongoing participation, appropriate to such person’s capabilities, in the planning of mental health services (including the right to participate in the development and periodic revision of the plan).
d. Denial of financial benefits/entitlements (e.g., SSI, SSDI, Insurance).
e. Guardianship/conservator problems
f. Denial of rights protection information or legal assistance
g. Denial of privacy rights (e.g., congregation, telephone calls, receiving mail)
h. Denial of recreational opportunities (e.g., grounds access, television, and smoking)
i. Denial of visitors
j. Denial of access to or correction of records
k. Breach of confidentiality of records (e.g., failure to obtain consent before disclosure)
l. Failure to obtain informed consent
m. Advance directives issues
n. Denial of parental/family rights
o. Other [Please, make every effort to report within the above categories].
Total

6. Rights Violations Disposition

For closed cases listed in this Table, provide the number of rights complaints or problem areas for each disposition category.
Total number of rights violation complaints/problems addressed from closed cases.
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 resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.

7. Reasons for Closing Individual Advocacy Case File

	Number
Number of closed cases, which client’s objective was partially or fully met
Other representation found
Individual withdrew complaint
Services were not needed due to client’s death or relocation
P&A withdrew because individual or client would not cooperate
Individual’s case lacked merit
Individual’s issue not favorably resolved
Appeal(s) unsuccessful
Total

8. Intervention Strategies

Outcomes

Abuse

Neglect

Rights Violations

Strategy

Total

A

B

C

D

A

B

C

D

E

A

B

C

D

1. STA

2. A/NI

3. TA

AR

N/M

LR

Total

1. STA - Short-term assistance

2. A/NI - Abuse/neglect investigations

3. TA - Technical assistance

4. AR - Administrative remedies

5. N/M - Negotiation/mediation

6. L/R - Legal remedies

9. Death Investigation Activities

9.1). The number of deaths reported to the P&A for investigation by the following entities:
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.).
Total
If the information requested in this section was not available please explain.

9.2). All death investigations conducted involving PAIMI-eligible individuals related to the following:
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, (e.g., suicides).
d. Total Number of deaths investigated [Sum of B.9.2. a-c].

9.3). If you reported deaths in categories B.9.2.a., B.9.2.b., or B.9.2.c., please provide the

following information on one 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.

(note – limit text field to 500 words)

10. Intervention on behalf of groups of PAIMI-eligible Individuals

Multiple counts not permitted for lines 1 – 3 and 6.

What to Count	Number
1. Group cases/projects still open at October 1 (carried over from prior FY(s)).
2. New group cases/projects opened during the year.
3. Total group cases/projects worked on during the year (add items1 and 2 above).
4. Total group cases/projects as of September 30 (carry over to next FY).
5. Group cases/projects targeted at serving the following special populations:
a. ethnic
b. racial minorities
c. homeless
d. veteran’s
e. urban
f. rural/frontier
g. elderly/geriatric
Total number of individuals impacted by line 3.

11. Interventions on behalf of groups of PAIMI-eligible Individuals

5. E. Intervention Types	Potential number of Individuals Impacted	Concluded Successfully	Concluded Unsuccessfully	On-going
Group Advocacy non-litigation
Investigations (non-death related)
Facility Monitoring Services
Court Ordered Monitoring
Class Litigation
Legislative & Regulatory Advocacy
Other
Total

Section D. Non-Client Directed Advocacy Activities

1. Individual Information and Referral (I&R).

Provide the number of PAIMI Program I&R services.
Total

2. State Mental Health Planning Activities

3. Education, Public Awareness Activities, and Events

List the number of public awareness activities or events and the number of individuals who received the information [Refer to Glossary].
Number of public awareness activities or events.
Number of education/training activities undertaken.
Number (approximate) of persons trained in 2.

Section E. Grievance Procedures [42 CFR Section 51.25]

Do you have a systemic/program assurance grievance policy, as mandated by 42 CFR 51.25(a) (2)?

☐Yes ☐No (If no, please indicate the date that the developed policy is anticipated. __/__/____

The number of grievances filed by PAIMI-eligible clients, including representatives or family members of such individuals receiving services during this fiscal year.
Total

3. 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 [42 CFR Section 1.25(a)(1),(2)]

4. The number of grievances appealed to:
4.a. The governing authority/board
4.b. The Executive Director
Total 4.a. & 4.b.

5. The number of reports sent to the governing board and the advisory board.
Total

6. Please identify all individuals (name & title), responsible for grievance reviews.

Name & title
Name & title
Name & title
Name & title

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?
Number of days

8. Were written responses sent to each grievant? ☐Yes ☐No (if no, explain below).

9. Was client confidentiality protected? ☐Yes ☐No (if no, explain below)

Section F. Other Services and Activities

1. Does the P&A have procedures established for public comment?

a. ☐Yes, (briefly describe how the notice is used to reach persons with mental illness and their families).

b. ☐No, (if no, briefly explain, limit to 500 characters).

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 2.a., b., or c.

3. Do the procedures provide for receipt of the comments in writing or in person?	☐Yes	☐No
3.a. If yes to 3, attach a copy of the agency’s policies/procedures pertaining to public comment.
3.b. If no to 2a, b, c., explain why the agency does not have such procedures in place.

4. Was the public provided an opportunity for public comment?

☐Yes

☐No

5. If you answered yes to 4, briefly describe the activities used to obtain public comment.

6. What formats and languages (as applicable) were used in materials to solicit public comments?

7. If you answered no to 4, briefly explain why the public was not provided an opportunity to comment.

8. List Groups (e.g., states, consumer advocacy, service providers, professional organizations and others, including groups of current and former mental health consumers or family members of such individuals) with whom the PAIMI program coordinated systems, activities and mechanisms [PAIMI Act 42 U.S.C. 10824 (a) (D)].
9. Briefly describe the outreach efforts/activities used to increase the numbers of ethnic and racial minority clients served 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].

10. Did the activities described in 9; result in an increase of ethnic or minorities in the following categories?
a. Staff	☐Yes	☐No
b. Advisory Council	☐Yes	☐No
c. Governing Board	☐Yes	☐No
d. Clients	☐Yes	☐No
If you answer no to any item (10.a-d), please provide a brief explanation, such as 10.a., b., or c. – no vacancies.

11. 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.).

12. 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.).
13. 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.).

14. 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)].

15. Please identify any training & technical assistance requests [42 U.S.C. 10825].

Section G. Actual PAIMI Budget/Expenditures for FY 20_

In this section, provide actual expenditures for the FY. Refer to the PAIMI Application [Appendix C] submitted to SAMHSA/CMHS for the same FY.
PAIMI program personnel – Insert additional rows, as needed.
Position Title	Annual Salary	Percent/Portion of time charged to PAIMI	Costs billed to PAIMI
Subtotal
Vacant Positions
Volunteer Positions
Total

2. Categories

	Cost
Fringe Benefits (PAIMI only)
Travel Expenses (PAIMI only)
Subtotal

3. Equipment - Type (PAIMI only)

	Cost
Subtotal

4. Supplies - Type (PAIMI only)

	Cost
Subtotal

5. Contractual Costs (including, consultants) for PAIMI program only

Position or Entity	Service Provided	Salary/Fee	Fringe Benefit Cost	Travel Expenses	Other Costs
Subtotal

6. Training Costs for PAIMI Program only

Categories	Number of Persons/ Travel Costs	Number of Persons/ Training Costs	Number of Persons/ other Expenses
Staff
Governing Board
PAC Members
Volunteers
Subtotal

7. Other Expenses (PAIMI program only)

	Cost
Litigation
Subtotal

8. Indirect Costs (PAIMI only)

1. Does your P&A have an approved Federal indirect cost rate?	☐Yes	☐No
		Cost
If yes to 8.1, what is the approved rate?
2. Total of all PAIMI program costs listed in G.1 – G.7.		$
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		$
6. Program income (PAIMI only).		$
7. State		$
8. County		$
9. Private		$
10. Other funding sources [identify each source].		$
11. Total PAIMI program resources.		$
Subtotal		$

Section H: Statement of

Priorities (Goals)

1. For each Priority/Objective, please indicate the “Achieved Outcome:

Priority/Goal Description:
Objective:
Target Population:
Expected Target:
Achieved Outcome
Provide an explanation if the target was not achieved:

2. Results narratives of P&A activities and accomplishments related to above priority.

Priority:
Objective:
Target Population:
limited to 500 characters

3. Other qualitative narrative related to the above priority

(Significant activity for which there were no quantifiable results goes here).

Describe any other significant activity related to this goal (500 words maximum)