Updated: 04/22/2022 OMB 0970-0564 [valid through MM/DD/2026]
Unlicensed Facility (UF) Quarterly Health and Safety Monitoring Notes
_____________ Monitoring Trip
Grant #: |
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Capacity |
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Program Director |
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Address |
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PO |
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FFS |
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CFS |
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ORR Medical |
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PSA |
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GDIT CC |
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Directions: Each section of the Pre-Monitoring Review of this document must fully be completed by UC Monitors. UC Monitors have the option to complete the Monitoring Plan Based on Pre-monitoring Review, Monitoring Activities and Exit Meeting sections of this document or use external tools to document these activities. UC Monitors are required to upload the Monitoring Notes Template and other tools used into the S:\ Drive monitoring reports folder.
Pre-Monitoring Review |
Grant application/cooperative agreements |
(See GrantSolutions for Grant Information. See S:\ Drive or ask PO for Cooperative Agreement)
Follow up notes:
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Past monitoring trip reports or corrective actions issued by PO/FFS |
(See S:\ drive)
Follow up notes:
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Quarterly/Annual Report |
(See GrantSolutions or S:\ drive)
Follow up notes:
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Care Provider’s website (if applicable) |
(Use the internet)
Follow up notes:
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Review SIR Report populated in the UC Portal |
(Check UC Portal for recent SIRs by changing search dropdown to “Event” and typing in program’s name.)
Follow up notes:
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Review of completed Site Visit Guide (SVG) |
(Request from care provider)
Follow up notes:
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Program’s Staffing Plan (if not explained in the SVG under Child Protection Question 1) |
Follow up notes:
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UC Orientation Packet |
Follow up notes:
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Behavior Management Plan (if not explained in the SVG under Intake and Orientation Services Question 2) |
Follow up notes:
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Background Checks for Staff, Volunteers, and Contractors (SVG attachment) |
Follow up notes:
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Personnel File Checklists |
Follow up notes:
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1. Map of facility (SVG attachment) |
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2. Emergency Plan (SVG attachment) |
Follow up notes:
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4. Internal Procedures (SVG attachment) |
Follow up notes:
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5. Recent organizational chart of facility staff and full staff list (SVG attachment) |
Follow up notes:
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6. Education curriculum and weekly class schedule (SVG attachment) |
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7. Food services/menus and employee food safety certifications (SVG attachment) |
Follow up notes:
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8. Current State License (SVG attachment) |
Follow up notes:
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9. State licensing requirements and recent state licensing inspection and/or CPS reports (SVG attachment) |
Follow up notes:
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10. Two recent vehicle inspection (SVG attachment) |
Follow up notes:
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11. List of UCs that are represented by attorneys (i.e. that have a G-28 on file (SVG attachment) |
Follow up notes:
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12. List of trainings all personnel receive annually and how correspond to ORR trainings (SVG attachment) |
Potential Reference: Personnel File Checklist.
Follow up notes:
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13. Safety and sanitation certificates and Fire inspection report (SVG attachment) |
Follow up notes:
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Review UC Case Files (including the electronic case file documents in the ORR database) |
(Request from care provider.) Use UC Case File Checklist Follow up notes:
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Consult with program PO, FFS, CFS, Medical Coordinator Specialist, and Intakes |
(Request from ORR Federal/Contractor staff)
PO:
FFS:
CFS:
Medical Coordinator Specialist:
Intakes:
PSA:
ORR Management (if applicable):
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Legal Service Provider Interview |
Follow up notes:
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GDIT Case Coordinator Interview |
Follow up notes:
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Monitoring Plan based on pre-monitoring review |
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Monitoring Activities |
Entrance Meeting |
Introductions and Background on the UC Monitoring Team:
Primary Goals:
This visit is not a ‘gotcha’, but rather we are here to work with you to strengthen the program and services for UC, if needed.
Secondary Goals:
To accomplish these goals:
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Request the following documents:
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Also ask relevant questions for Care Provider PD selected as a result of pre-monitoring review
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Directions for UC Monitors: Completing the Onsite Monitoring notes sections below is optional, as long as the review of standard activities is completed and saved somewhere in the monitoring visit folder.
Facility Walkthrough |
(On-Site Monitoring Checklist) General Findings: |
UC Case Files to Request |
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Additional Questions resulted from UC Interviews |
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Staff to Interview |
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Additional questions for Youth Care Workers |
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Additional questions regarding Educational Services |
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Additional questions for Case Management |
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Additional questions for Clinician |
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Additional questions for PSA Compliance Manager |
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Additional questions for Interpreter |
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Additional questions/topics for Lead Clinician |
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Additional questions/topics for Lead Case Manager: |
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Additional questions for Program Management: |
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Issues/Concerns raised by Care Provider |
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Interviews with Field Staff, GDIT CC, Stakeholders, etc. |
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Personnel Files to Review |
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Additional items to review/research in relation to personnel files |
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Observe UC Activities |
(See the On-Site Monitoring Checklist) General Findings: |
Additional Documents to Request /Items to follow-up on: |
(See the On-Site Monitoring Checklist) General Findings: |
Exit Meeting |
Positives |
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Items to improve |
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Next Steps |
Formal Report should be finalized within 30 business days. It will mainly include all the information presented during this meeting. The care provider will have 30 business days to respond with a comprehensive corrective action plan. This corrective action plan should be sent to your assigned PO, who will follow-up with the program and provide any further technical assistance. Please copy the monitor(s) and FFS/CFS on your response. Thanks for your hospitality. |
THE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF
PUBLIC BURDEN: The purpose of this information collection is to
allow ORR contractor monitors to compile comprehensive notes and
information related to the overall functioning and oversight of the
care provider program as part of the pre-monitoring process for
unlicensed facility quarterly site visits. Public reporting burden
for this collection of information is estimated to average 12 hours
per response, including the time for reviewing instructions,
gathering and maintaining the data needed, and reviewing the
collection of information. This is a mandatory collection of
information (Homeland Security Act, 6 U.S.C. 279). An agency may
not conduct or sponsor, and a person is not required to respond to,
a collection of information subject to the requirements of the
Paperwork Reduction Act of 1995, unless it displays a currently
valid OMB control number. If you have any comments on this
collection of information please contact [email protected].
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | DHHS |
File Modified | 0000-00-00 |
File Created | 2023-11-17 |