Form ACR

OMB Approval: 0930-0169

Expiration Date: XX-XX-XXXX

The ADVISORY COUNCIL REPORT (ACR) Section of the ANNUAL PAIMI PROGRAM PERFORMANCE REPORT (PPR)
STATE	FISCAL YEAR

The Advisory Council Report (ACR) section of the annual PAIMI Program Performance Report (PPR) is due by January 1. The ACR is an independent assessment by the PAIMI Advisory

Council (PAC) of their state P&A system’s PAIMI Program operations. The ACR must be signed

and dated by the PAC Chairperson.

The annual ACR must be submitted electronically via the PAIMI Electronic Reporting System (PERS). The PAC Chairperson’s signature page must be uploaded, as an attachment into the PERS. PAIMI Electronic Reporting System (PERS): http://ppr.paimippr.com/

For ACR assistance, please contact the PAIMI Program Coordinator:

Karen S. Armstrong, MSSW, JD at [email protected]

or 1 (240) 276 -1741

Please read and follow the instructions in each section and use the attached glossary in to complete the form.

Public reporting burden for the ACR section of the annual PAIMI PPR is estimated to

average 10 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); CBHSQ, Room 2-1057; 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).

The ACR Section of the ANNUAL PAIMI PPR
TABLE of CONTENTS
SECTION	TITLE	PAGE
A.	GENERAL INFORMATION	3
B.	PAIMI ADVISORY COUNCIL (PAC) MEMBERSHIP	4
C.	PAC ETHNICITY/DIVERSITY	6
D.	GENDER	6
E.	GOVERNING BOARD INFORMATION	7
F.	PAC ACTIVITIES	8
G.	PAC ASSESSMENT OF PAIMI PROGRAM OPERATIONS	13
H.	GRIEVANCE PROCEDURES	15
GLOSSARY		17

The ACR Section of the Annual PAIMI PPR
SECTION A. GENERAL INFORMATION
Fiscal Year:
State:
Name of P&A system:
PAC Report Prepared By: Provide the name [Print First, Middle and Last Name] Title of the preparer Phone Number:
Name of PAC Chair: [Print First, Middle and Last Name] Provide updated contact information if the PAC Chair is different than the person listed on the most recent PAIMI Application.
Telephone Number
E- Mail Address:
Date Submitted:
By signing this document, the Chair certifies that this report reflects the consensus of the PAC members.

SECTION B. The PAIMI ADVISORY COUNCIL (PAC)
*Under Primary ID, select ONLY ONE (1) primary identity for each PAC member position [B.1.b. - B.1.h.] that is mandated per the PAIMI Act & Rules).				Primary Identification
B.1.a. The TOTAL number of seats on the PAC.				Total
B.1.b. Individuals who are recipients/former recipients (R/FR) of mental health services.
B.1.c. Family members of individuals who are recipients/former recipients (R/FR) of mental health services.
At least one (1) PAC member shall be a B.1.d.
B.1.d. Family members of a minor child or youth (under 18 years old) who has received or is receiving mental health services.
B.1.e. Mental health service providers.
B.1.f. Mental health professionals.
B.1.g. Attorneys.
B.1.h. Individuals from the public knowledgeable about mental illness.
B.1.i. Others (please identify by position held).
B.1.j. Vacancies as of 9/30. [Identify each vacant position & the date it was vacated].
B.1.k. TOTAL number of PAC members serving on 9/30.				Total
B.1.l. Number of PAC members who are either CR/FR of MH services or family members of these individuals (count each PAC member only once).
B.1.m. Percentage of PAC members who are either CR/FR of MH services or family members of these individuals [B.1. k. divided by B.1.l.]
B. 2. REPRESENTATION OF THE PAC CHAIRPERSON
B.2. Is the PAC Chair an individual who has received or is receiving mental health services, or a family member of an individual who has received or is receiving mental health services?					Yes	No
B. 3. PAC TERMS of Appointment
B.3.a. Term of Appointment (Number of years)
B.3.b. Maximum Number of Terms a Member May Serve
B.3.c. Frequency of Meetings
B.3.d. Number of Meetings Held in the FY [3 is the mandated minimum].
B.3. e. Number (%Average) of PAC members present at Meeting.
SECTION C. PAC ETHNICITY & RACIAL DIVERSITY
Please refer to the GLOSSARY for definitions. The following information is self-reported or self-identified and uses two separate questions. The data on race and ethnicity are collected SEPARATELY; provision shall be made to report the number of respondents in each category who are Hispanic or Latino. Collection of greater detail is encouraged; however, any collection that uses more detail shall be organized in such a way, that the additional information can be aggregated into these minimum categories for data on race and ethnicity.
C. A. ETHNICITY			Number of PAC Members
C. A. 1. Hispanic or Latino
C. A. 2. Not of Hispanic Origin
(Add C.A.1 & C.A.2., the total should be the same as the one listed in B.1.k. (members serving as of 9/30).			Total
C. B. RACE
C. B. 1. American Indian or Alaska Native
C. B. 2. Asian
C. B. 3. Black or African American
C. B. 4. Native Hawaiian/Other Pacific Islander
C. B. 5. White
C. B. 6. Two or More Races
C. B. 7. = C.B.1 through C.B.6.			Total
Members may select as many racial identifications as they want.
C. C.1. Total Number of PAC member vacancies on September 30.			Total PAC Vacancies

SECTION D. GENDER of PAC Members
D.1 MALE	D.2 FEMALE
D.3. TOTAL

SECTION E. GOVERNING BOARD INFORMATION
E. 1. FOR STATE-OPERATED P&A SYSTEMS ONLY:
E.1.a. Is this a State-operated P&A system?	Yes	No
E.1.b. Does this State-operated system have a Governing Board/Authority authorized by State statute? If the answer is NO, proceed to Section F.	Yes	No
E.1.c. If the answer to item E.1.b. is YES, does the PAC Chair sit on the Governing Board/Authority as a full voting member?	Yes	No
E.1.d. If the answer to item E.1.c. is no, briefly explain (e.g., State statute determines Governing Board/Authority composition, etc.).
E.2. For PRIVATE, Not-for Profit P&A SYSTEMS only
E. 2.a. Does the P&A system have a multi-member Governing Board?	Yes	No
If you answered YES to E.2.a., please answer the questions E.2.b. 1. - 3.
E.2.b.1. Number of Governing Board members.	Total
E.2.b.2. Is the PAC Chair a full voting member of the Governing Board?	Yes	No
E.2.b.3. If you answered No to E.2.b.2., than explain why the PAC Chair is not a full voting member of the Governing Board as mandated by the PAIMI Rules at 42 CFR 51.22(b)(3).
E.2.b.4. Do any other PAC members hold seats on the Governing Board? If Yes, how many seats? ____	Yes	No

SECTION F. PAC ACTIVITIES [See, PAIMI Act - 42 U.S.C. 10805(7)]
F.1. Are P&A program staff invited to attend PAC meetings?	Yes	No
F.1.a. Did any of the invited program staff attend?	Yes	No
F.2.a. If the answer to F.1. is Yes, please identify the positions of staff (e.g., PAIMI Coordinator, Mental health advocate, etc.) usually invited to attend.
F.2.b. If the answer to F.1.a. is Yes, please identify the positions of the program staff in attendance (e.g., one advocate, one attorney) and their role at the meetings, e.g., information sharing, etc.
F.2.c. If the answer to F.1. is No, you MAY provide a brief explanation.
F. 3. a. Were governing board members, excluding the PAC Chair, invited to PAC meetings?	Yes	No
F.3.b. If you answered Yes to F.3.a., which governing board members were invited, for what purpose (e.g., informational, etc.) and did they attend?
F.3.c. Did any of the invited governing board members attend?	Yes	No
F.4. Did the PAC work jointly with the governing board to develop the annual PAIMI priorities? [42 CFR 51.23(a) (2)].	Yes	No*
F.4.a. If Yes, Briefly describe these joint activities.

SECTION F. PAC ACTIVITIES [See, PAIMI Act - 42 U.S.C. 10805(7)]
F.4. b. If No, PAC’s affiliated with private, non-profit P&A systems must provide a brief explanation.
F.5. Did PAC members attend any in-state or out-of- state trainings or educational presentations related to PAIMI Program activities? [42 CFR 51.27 - payments for PAC and Governing board/authority members by a State P&A system are optional].
F.5.a. In-State Trainings/Educational Activities.			Yes	No
If Yes, list each activity by number and provide a brief description of PAC involvement, e.g., Activity 1 – Attendance at local NAMI training.
F.5.b. Out of State Trainings/Educational Activities.			Yes	No
If yes, list each activity by number and provide a brief description of PAC involvement, e.g., Activity 1 – Attendance at NDRN annual conference.
F.6. Does the P&A system have established written policies and procedures for reimbursing PAC members for expenses that takes into account the needs of the individual council members, available resources and applicable restrictions on use of grant funds, including the restrictions cited in and the restrictions in 51.31(e) and 51.6(e)? [See, 42 CFR 51.23 (d) (1)].
F.6.a.1. Yes	F.6.a.2. No*	F.6.a.3. Don’t Know.*
F.6.b. Brief explanation needed for F.6.a.2. or F.6.a.3. responses].

SECTION F. PAC ACTIVITIES [See, PAIMI Act - 42 U.S.C. 10805(7)]
F.7. If the answer to F.6. was Yes, were PAC members reimbursed for expenses incurred for PAIMI Program related activities, consistent with the P&A system’s policies and procedures.
F.7.a.	1.Yes		2. No*			3. Don’t Know*
F.7.b. *Brief explanation required for either F.7.a. 2. No or F.7.a. 3. Don’t Know responses.
F. 8. REIMBURSEMENT OF EXPENSES – If PAC member expenses were reimbursed, please complete the following chart. [42 CFR 51.23(d) (1)]. Under the Activity column, list the activity by the number used in above F.5.a. – In-State or F.5.b. – Out-of State. Example: F.5.b. Out of State activity # 1, – 5 PAC members attended the NDRN annual meeting, 2 members reimbursed by the P&A; 2 self paid, 1 NDRN scholarship.
a. ACTIVITY		b. # ATTENDING		c. P&A	d. SELF		e. OTHER

SECTION F. PAC ACTIVITIES [See PAIMI Act at 10805(7)]
F.9. Did the P&A system provide the PAC with reports, materials, & fiscal data to enable review of the following: [42 CFR 51.23(c)].
F.9.a. Existing program policies, priorities, and performance outcomes.	Yes	No*
F.9.b. If Yes, were the submissions (of P&A system documents referenced in F.9.a.) made at least annually and (shall) report expenditures for the past two (2) FISCAL YEARS?	Yes	No*
*F.9.c. If the answer to F.9. a. or F.9.b. is ‘No”, a brief explanation is required.]
F.9.d. If you answered Yes in F.9.a., did the P&A system documents referenced also INCLUDE THE PROJECTED EXPENSES FOR THE NEXT FISCAL YEAR (FY) IDENTIFIED BY BUDGET CATEGORY, e.g. salary & wages, contracts for services, administrative expenses, including, the amount allotted for training of the PAC, the governing board and staff?	Yes	No*
F.9.d.1. If No*, a brief explanation is required].

SECTION F. PAC ACTIVITIES [See, PAIMI Act at 10805(7)]
F.9.e. The PAIMI Rules 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 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 representatives of such individuals with disabilities. [42 CFR at 51.24(b)].
F.9.e. Does the P&A have procedures established for public comment?
F.9.e. 1. Yes	F.9.e. 2. No*	F.9.e.3. Don’t Know*
F.9.e.4. *Brief explanation required for F.9.e.2. No or F.9.e.3.Don’t know responses.
F.9.f. Was the PAC provided a copy of these procedures?
F.9.f.1. Yes	F.9.f.2. No*	F.9.f.3. Don’t Know*
F.9.f.4. *Brief explanation required for F.9.f.2. No or F.9.f.3.Don’t know responses.

SECTION F. PAC ACTIVITIES [See, PAIMI Act at 10805(7)]
F.9.g. The PAIMI Rules, at 42 CFR 51. 24(b), mandate that 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. WAS THE PUBLIC PROVIDED AN OPPORTUNITY FOR PUBLIC COMMENT?
F.9.g. 1. Yes#	F.9.g. 2. No*	F.9.g.3. Don’t Know*
F.9.g 4. #If the answer to F.9.g.1. is Yes, briefly describe activities the P&A system used to obtain public comment.
F.9.g. 5. *If the answer to F.9.g.2. is NO, explain why public comment was not obtained.
F.9.g. 6. *If the answer to F.9.g.3. is DON’T KNOW, please explain (e.g., PAC needs training, etc.)
F.10. COMPLETION OF THIS SECTION (F.10 a. –e.) IS OPTIONAL. However, if you choose to respond, please describe in the spaces below any other PAC activities, other than mandated PAC membership meetings.
F.10.a. Briefly describe, governing board or PAC committee work.
F.10.b. Briefly describe any training or educational presentations to either constituency groups or the general public.

SECTION F. PAC ACTIVITIES [See, PAIMI Act – 42 U.S.C.10805(7)]

F.10.d. Briefly describe any special projects (e.g., institutional monitoring).

F.10.e. Briefly describe any other activities, e.g., fund raising, public relations, etc.

SECTION G. PAC ASSESSMENT OF PAIMI PROGRAM OPERATIONS

G.1. Please provide a NARRATIVE SUMMARY of the PAC’S SSESSMENT of the PAIMI priorities (goals) and objectives included in the PPR for this Fiscal Year.

Include in the narrative an assessment of the following items:

G.1.a. The PAIMI Priorities (Goals) and Objectives selected.

G.1.b. The activities conducted towards achieving these priorities (goals) and objectives.

G.1.c. The outcomes.

G.1.d. Examples of individual or systemic cases, applicable legislative activities, and participation in State mental health planning activities.

G.1.e. Any recommendations regarding future priorities (goals) and objectives.

SECTION G. PAC ASSESSMENT OF PAIMI PROGRAM OPERATIONS

G.2. OTHER COMMENTS CONCERNING PAIMI SYSTEM OPERATIONS:

Briefly describe any special initiatives, problem solving techniques, or innovative practices that may help other State P&A systems.

G.3. Please list any training & technical assistance needs identified by the PAC.

SECTION H. GRIEVANCE PROCEDURES [42 CFR Section 51.25]
Pursuant to the PAIMI Rules at 42 CFR 51.25, the P&A systems shall establish procedures to address grievances from: individuals at 42 CFR 51.25(a)(1) – clients or prospective clients . . . ; and systemic complaints at 42 CFR 51.25(a)(2) – individuals who have received or are receiving mental health services in the state, family members or representatives of such individuals . . . .
H.1. Is the PAC aware of and knowledgeable of the above referenced policies and procedures?	Yes	No*
H.1.a. If you answered No to H.1. provide a brief explanation.
H.2. The number of grievances filed by PAIMI-eligible clients, including representatives or family-members of such individuals receiving services during this fiscal year.	Total
H.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
H.4. Add H.2 & H.3 [42 CFR Section 51.25(a)(1),(2)]	Total
H.5. The Number of Grievances Appealed to:
H.5. a. The Governing Board (the PAC Chair of a private, non-profit P&A system should have this information).	Total
H.5.b. The Executive Director	Total
H.5 c. The number of Grievances appealed [H.5.a. + H.5.B = H.5.c.].	Total
H.6. The number of reports sent to the Governing Board AND the PAC (at least one annually) that describe the grievances received, processed, and resolved.	Total

SECTION H. GRIEVANCE PROCEDURES [42 CFR Section 51.25]
H.7. Please identify all individuals, by name & title, responsible for P&A system grievance reviews.
H.8. 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)]		Days
H.9. Were written responses sent to all grievants?	Yes	No*
H.9.a. *If you answered No, to H.9, briefly explain.
H.10. Was client confidentiality protected? ____. If not, explain below. [42 CFR 51.25(B)(6)]	Yes	No*
H.10.a. *If you answered No, to H.10, briefly explain.	Yes	No*

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 an 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 –

The following minimum standards shall be used for all federal administrative reporting and grants reporting or record keeping requirements that include data on race and ethnicity [http://www.whitehouse.gov/omb/fedreg_1997standards/].

CATEGORIES AND DEFINITIONS:

Ethnicity:

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American descent.

Not of Hispanic Origin.

Race:

American Indian or Alaska Native (include tribal affiliation for the Alaska native when possible) - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

Black or African American - A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Respondents have the option of selecting one or more racial designations.

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].