Updated: 03/10/2022 OMB 0970-0654[valid through MM/DD/2026]
_____________ Unlicensed Facility (UF) Quarterly Health and Safety Visit LTFC Monitoring Trip1
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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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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Past OIG Reports |
(See https://oig.hhs.gov/reports-and-publications/featured-topics/uac/)
Follow up notes:
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Quarterly/Annual Report |
(See GrantSolutions or S:\ drive)
Follow up notes:
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Current approved Fiscal Year Budget |
(See S:\ drive or ask PO)
Follow up notes:
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Key Position Approved by PO? |
(See 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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List of Documents that have been Referred to the PO or PSA for Clearance (if not included under Program Management Question 1) |
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 |
Follow up notes:
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Personnel/Foster parent 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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3. Quality assurance procedures and internal monitoring resources (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. Current State License (SVG attachment) |
Follow up notes:
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7. State licensing requirements and recent state licensing inspection and/or CPS reports (SVG attachment) |
Follow up notes:
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8. Two recent vehicle inspection (SVG attachment) |
Follow up notes:
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9. 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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10. List of trainings all personnel and foster parents receive annually and how they correspond to ORR trainings (SVG attachment) |
Potential Reference: Personnel and Foster Parent File Checklists.
Follow up notes:
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11. List of Current foster parents, addresses of foster homes, capacity of each foster home, languages spoken by foster parents, and list of UC placed in each foster home. (SVG attachment) |
Use the list to establish various selections to which foster home to visit and UC to interview, Follow up notes:
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12. Foster Home Information |
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Review UC Case Files (including the electronic case file documents in the ORR database) |
(Request from care provider.) Use LTFC UC Case File Checklist Follow up notes:
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Consult with program PO, FFS, CFS, Medical Coordinator Specialist, and PSA Coordinator |
(Request from ORR Federal/Contractor staff)
PO:
FFS:
CFS:
Medical Coordinator Specialist:
PSA Coordinator:
ORR Management (if applicable):
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Legal Service Provider |
Follow up notes: |
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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Facility Walkthrough |
(On-Site Monitoring Checklist) General Findings: |
UC Case Files to Request |
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Possible UC to Interview |
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Additional Questions for 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/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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Foster Parent Files to Review |
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Foster Homes to Visit |
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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. |
1 Unlicensed Facility Quarterly Health and Safety Visits are performed for long-term group homes. ORR does not operate unlicensed long-term foster care or transitional foster care programs.
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 | 2023-12-17 |