pennsy' lva nia CERTIFICATE OF COMPLIANCE DEPARTMENT OF HUMAN SERVICES This certificate is hereby granted to DAUPHIN COUNTY COMMISSIONERS To operate DAUPHIN COUNTY CHILDREN AND yourHt | SERVICES Located at Restrictions: ‘This certificate Is granted in accordance with the Public Welfare Code cf 1967, P_L. 31, as amended, and Regulations: ‘55 Pa.Code Chapter 3130: Administration of County Children with Services and Program R and shall remain in effect from uly 24. 201 unless sooner revoked for non-compliance with applicable laws and regulations. No: 316631 unti! January 24,COMMONWEALTH OF PENNSYLVANIA (DEPARTMENT OF PUBLIC WELFARE AUG 2 0 2015 VIA CERTIFIED MAIL Mr, Joseph Dougher, Interim Administrator Dauphin County Social Services for Children & Youth 1001 North Sixth Street Harrisburg, Pennsylvania 17102-1726 Dear Mr. Dougher: The Department of Human Services (Department) conducted inspections of Dauphin County Social Services for Children and Youth, 1001 North Sixth Street, Harrisburg, Pennsylvania, 17102-1726, on March 27, March 31, April 1, April 6 and April 10, 2015, for the purpose of conducting an annual inspection. The enclosed Licensing Inspection Summary (LIS) documents include details of the violations of the regulations at 55 Pa. Code Chapters 3130, 3490 and 3700 found during this inspection. Many of the areas of noncompliance were previously cited during inspections of Dauphin County Social Services for Children and Youth conducted by the Department on March 10, March 16, March 20, March 27 and May 2, 2015 for the purpose of investigating complaints. The regulatory violations found preclude the Department from granting Dauphin County Social Services for Children and Youth a regular Certificate of Compliance. Failure to comply with the applicable regulations, as specified in detail in the enclosed LIS documents, is the basis for the revocation of your regular Certificate of Compliance and issuance of a first provisional Certificate of nce (62 P.S. § 1008; 55 Pa, Code §20.54 (a)). The Department will issue Dauphin County Social Services for Children and Youth a first provisional Certificate of Compliance (Certificate #316631) for the time period from July 24, 2015 through January 24, 2016 (see 55 Pa. Code §§20.54 (a); 20.71(a){2). You may appeal the refusal to renew your Certificate of Compliance and the issuance of a first provisional Certificate of Compliance by filing a written petition within 30 days of service of this letter (see 55 Pa, Code §3130.82). Your petition should indicate the reasons for the appeal, being as specific as possible as to the areas of disagreement. Any appeal must be filed with: Department of Human Services Bureau of Hearings and Appeals Director Post Office Box 2675 Harrisburg, Pennsylvania 17105 OFFICE OF CHILDREN, YOUTH & FAMILIES PO BOX 2675 | HARAISAURG, PA 7120 |717-787.4736 | Fax 717.787 04%4 | wren dpw statepautsMr. Joseph Dougher Your appeal must be received by the Bureau of Hearings and Appeals within 30 days of service of this letter. If you appeal, please also send a copy of your appeal letter to Ms. Gabrielle Williams, Regional Director for the Central Region Office of Children, Youth and Families, Hilltop Building #52, 3 Gingko Drive, Second Floor, Harrisburg, Pennsylvania, 17110. If you do not choose to appeal, the decision of the Department will become final 31 days from service of this letter. The Department has worked closely with you and your staff to identify areas of needed improvement and to provide technical assistance. We stand ready to continue to provide oversight and support to Dauphin County throughout this process as required by the Commonwealth Public Welfare Code, We look forward to continuing to work with you and would be happy to address any questions you may have. Sincerely, Cathy A. Utz Deputy Secretary Enclosures ¢: The Honorable Jeffrey T. Haste, Chairman, Dauphin County Commissioners The Honorable Mike Pries, Dauphin County Commissioner The Honorable George Hartwick, III, Dauphin County Commissioner Ms, Gabrielle Williams, Director, Central Region Office of Children, Youth & FamiliesDAUPHIN COUNTY CHILDREN AND YOUTH AGENCY ANNUAL SURVEY AND EVALUATION SUMMARY NAME OF AGENCYIFACILITY: TELEPHONE: | OCYF REGIONAL STAFF APPROVAL DATE Dauphin County Social Services for Children and Youth 717-780-7200 | | ‘ADDRESS COUNTY. ] i 1001 N. 6" St, Harrisburg PA 17722 Sauphin oe INSPECTED BY. INSPECTION DATES: | Desiree Weisser, Mike Yakum, Frank Adame, Mark Schrode, March 27,31, April | | 7 Michael Beckstein, Colleen Smith, Faith Biough. Kim Deibler 1,6&10,2015 | superveor: an A 124-18 INTIAL RENEWAL" | GOMPLANT | UNANNOUNCED RANDOM 7 A nsPecrion | INSPECTION INSPECTION SAMPLE ql - - eerraee il 734-15 XX I | cutting-edge practice. They are part of the Human Services Block Grant, which gives the county local decision-making authority over grant funds that were ‘The Department Human Services, Office of Children, Youth and Families, Central Region, conducted the annual licensing inspection of Dauphin County Social Services for Children and Youth (DCSSCY) on March 27, 31, April 1, 6 and 10, 2015 by means of a random sample record review, interviews with administrative, ‘supervisory and casework staff, internal policy/procedures review, personnel record review and agency fiscal documentation review. In additica, site visits to four ‘agency resource/kinship resource homes were conducted. During the visit the resource families spoke positively of the agency. They feel supported and usually get timely responses from the caseworkers. These families are strong advocates for the children in thelr care ‘The case sample was drawn from cases assigned to all program units and casework functions within the agency. The following records were reviewed: 20 of 988 Child Protective Ser-ice records; 30 of 1,961 General Protective Services Intake records, including 10 “Once & Done" records; 20 of 296 Ongoing/in-home Services records, 10 of 319 Placement recorcs: 43 agency Rocource Family Home records, including 37 new resource homes 4 0f 82 Adoption records; anc | 169 personnel records, including 24 new employees. A "Once & Done" as defined by Dauphin County Children and Youth is a referral that was determined, following one contact, to be without merit and not accepted for further investigation. DCSSCY is a public child welfare agency serving a diverse population of approximately 27 1,000 residents in 2 3" class county. They have a history of embracing previously specifically allocated and they are part of the Child Welfare Demonstration Project which expands the use of Fedeval IV-E funds beyond placement services, DCSSCY chose to participate in a Quality Services Review (QSR) in Round One of the Continued Quality Improvement Process. Their first QSR was completed in 2012 and their second QSR was completed in 2014. Their next QSR is currently scheduled for 2016. In March 2014, DCSSCY completed an internal restructure of their agency. This restructure was completed because the agency identified that there was a need to work more efficientiy towards accomplishing their mission while maximizing resources and continually improving the level of services provided to families. With the _| 1implemented changes, individual program units were eliminated and 8 Teams were implemented that consisted of two supervisors, nine caseworkers, one practice ‘coach end one clerical support staff. The expectation was that all caseworkers would provide services to families from Intake to case closure to ensure continuity of services. While some caseworkers and supervisors embraced this challenging new structure, many did not. In the past year, the overall level of services with the children, families and service provicers has declined ‘There was a significant increase in -he turnover rate this past year with 28 staff leaving. Included in those 28 staff was; 1 Administrative staff, 3 clerical support staff, 2 Fiscal staff, 1 case aide, 1 legal staff and 20 caseworkers. New staff, most of whom had some type of child welfare experience, were hired fairly quickly due to the county's move to @ merit based hiring system. The county chose to change the'r hiring practices to attract more experienced applicants who had knowledge, experience and an understanding of the population of children and families with whom the county worked. ‘The restructuring, turnover rate and increase in referrals, due in part to the amendments made to the Child Protective Services Law, are additionally concerning given the areas of concern noted during the licensing review which included: ‘+ Procedures surrounding screen-outs and information/reterrai reports; ©The process cf assuring the safety of all children; and ‘+ Family engagement, ‘Some citations listed below are repeat citations from prior issued Licensing Inspection Summaries, Despite plans of corrections being developed by the county, tepeat areas of non-compliance were seen in the following service areas: CPS, GPS intake, In-Home Services, and Placement spectically related to Safety, ‘Supervision, Family Service Planning and Risk Assessment. All case specific regulatory referenaes contained within the License and Inspection Summary do not contain specific identifying demographic data due to statutory prohibitions relating to confidentiality. ‘SUMMARY OF AGENCY PRACTICES. Practice Area! Sally Resesarnert and “The records reviewed shoved fcandtentpracices sounding The @Surance of say of al chiaren iva amy home oral Monterng sence areas. As noted Belew nthe ction seston, the folowing areas of concer ecaring Safety assesoment and Montorng oud GSR incicator: Satety from Exposure Missing olate Safety Assessments; Threats of Harm All children in household not listed on the Safety Assessment; Children not seen within required timeframes prior to case closure; Children listed as “Safe” when they were “Unsafe”, and Missing or late supervisor signatures on the Safety Assessment QSR Indicator: Safety from Risk to SeHOthers DCSSCY has an established Safety Court Hearing process to ensure that al families are afforded the opportunity of aue process regarding safety planning. Practice area: Casework Visitation with Family | The records reviewed showed inconsistent contadl with fanilies and chikdren by DCSSCY caseworkers_In some Instances, children andior families were not visited for several months while the case was open for services or the child was in placement. It QSR Indicator: Planning for Transitions and __| was further noted through case documentation that during the visits with familes, the Family Service Plan was not being reviewed Life Agjustments and updated regularly. Case documentation demonstrated that caseworkers spoke with children (ifage-appropriate) individually during home and school visits. QSR Indicator: Parent/Caregiver FunctoningPractice Area: Fostering Connections ACivios ‘SR Indicator: Parent Caregiver Funcioning SR Indicator, Role and Voice ‘QSR indicator: Engagement QSR Indicator: Teaming ‘While Kinship care is explored for all children, it was noted that relatives are not consistently being nollied ofa chidss placement within the required tmeframes. While DCSSCY is responsible for notifying kinship resources for every child placed in an out-of- home setting, the agency hes begun using a private provider to help facilitate family findng efforts and relative notifications. DCSSCY also decited to contract with a private provider to complete all resource home stucles, including kinship care applicants, While the home studies are completed by the contracted provider, OCSSCY maintains tre final approvalidisapproval status ofthe fami, ‘Anumber of the children reviewed were living with relatives or kin and many were in placement with siblings, Practice Area: Shared Case Responsitiity Activities DCSSCY has fully implemented the SCR bulletin. Family Group Decision aking (FGDM) was available to JPO fora number ‘years prior tothe issue of the bulletin. One statfis assigned to SOR referrals and assessments, Of the cases sampled during the licensing inspection. none were Shared Case Responsibility cases, JPO and CYS staff have open and consistent communication regarding shared cases. Bractice Area: Family Engagement Practices QSR Indicator. Physical Health QSR Indicator. Emotional Well-Being QSR Indicator: Early Leaming and Development QSR Indicator Engagement Efforts QSR Indicator. Role and Voice QSR Indicator. Teaming With the restructuring of the agency, the agency's Family Engagement program was expanded and al Family Group Conferance (FGO) services are now provided through the DCSSCY. FGC's are offered to all families that are active, and conducted for every Youth facing a transition out of placement. Efforts are made to locate and involve non-resident parents, particularly absent or luninvolved fathers. During the licensure year, a total of 968 family engagement type meetings were held which included 89 Family Group Conferencing meetings, 158 Family Engagement meetings, 15 Blended Perspecive meetings and 125 Pre-court meetings. While the agency has a dedicated team to faciitate engagement-type meetings, the every-day practice of family engagement by caseworkers and supervisors has not been occurring consistently within the past year. Dauphin County human services agencies have developed a Cross-System Policy and rocedure which requires monthly team meetings for families/children who have involvement with multiple systems. In case records reviewed, there was clear documentation that monthly team meetings are occurring. The family’s goals and prograss are discussed along with future steps and plans. \With the exception ofthe citations listed below, all other requirements for medical and dental care for children in placement were ‘met. Records showed consistent follow-through for medical and dental treatment when needed. Additionally, parents are invited lo pattiipete fn dildien's neuica appointments. Practice Area: Family Service Planning QSR Indicator: Assessment and Understanding QSR Indicator: Long-Term View QSR Indicator: Child/Youth and Family Planning Process. QSR Indicator: Planning for Transitions and Life Agjustiments QSR Indicator: Intervention Adequacy and Resource Availabilty QSR Indicator: Maintaining Family Relationships Family Service Plans (FSP) and FSP reviews were reviewed in a number of sanice areas and revealed inconsistent practices, AS noted below in the citations area, the following areas of concem include: ‘+ Missing, late andlor incomplete FSP and FSPR; reviews ‘Parents not involved in the development or review of the FSP: + Copies of the FSP or FSP reviews were either not provided or were provided late to the parents; and ‘+ Missing of late supervisor signatures on the FSP. MCI numbers are searched, cleared or generated, at the point of intake and included in the electronic case fle, The workers review the MCI history so that involvement with other systems can be reviewed Inthe past year, 31 youth aged out of care. Ofthese 31 youth ‘+ South decided to stay in foster care past their 18" birthday but 1 of those youth left @ week after her birthday and her whereabouts are now unknown; ‘+ 3 youth exited care while in a subsidized permanent legal custodianship living arrangement where they remain; + 3youth exited care while attending and residing on campus at a four-year college: + 3youth exited care when they reached their 21" birthday:QSR Indicator: Tracking and Adjustment ‘+28 youth had an identified life connection upon their exit fom care; * 28 youth had a residence upon exiting care. Of the remaining 3 youth, 2 were incarcerated in adult prison at the time of their 18” birthday and + youth's whereabouts are unknown, ‘+ 18 youth had a source of income, 14 youth had no source of income but were in living arrangements that provided for theirbasic needs. One youth's whereabouts were unknown, | Practice Area’ Parmanericy Aces SR indicator: Steblty | QSR Indicator: Living Arrangement | Q8R indicator Permanency SR Indicator: Academic Status SR Indicator: Pathway to Independence QSR Indicator: Parent and Caregiver Functioning QSR Indicator: Efforts to Timely Permanence OCSSCY utilizes farily preseivalion/reunifcation services regulary to help plan for chikren's ransiions to rehum home, Family Group Conferencing is used prior to a placement episode, if possible, to explore alternate resources and at time of reunification to Identity supports for the birth family. The county has increased SWAN services, including child profiles, chid preparation and child-specific recruitment for children in care. Services are provided regardless of the cle’ plan to retum home, live permanenty with a relative, be adopted or eave care to lve on their own. While the number of placements is stil considerably lower than fve years ago, DCSSCY has seen a 19% increase in placement numbers in the past year Atthe time of a child's placement, printed information is provided to each parent describing the time lines and requirements of ASFA, promoting ful disclosure throughout the placement. Policy has changed over the past year, 60 that at present every child in ‘utor home care is reviewed by the court every three months, The county uses Bethany’s Safe Families program, in which parents voluntarily place children temporarily with volunteer families ‘when there is not dependency, but short-term placement needs, e.g, when a parent is hospitalized. AAtthe time of licensing, 19 of the 254 children in placement have @ goal of Anether Planned Permanent Living Arrangement. Of those 19 children: 3 youth are in a residential placement: 2 ate in group homes; 2 are living with a parent; 8 are in non-kinship foster care homes: 2 are in supervised independent living setting 1 is in a juvenile probation placement setting; and 1 is in a pre-adoptive placement setting. ‘Transition planning is completed using Family Finding and FGC to maximize the number of potential life connections and supports for the youth. The independent living program includes an active after-care component; effors are made to put more emphasis on hhousing that s stable and long-term, as well as viable employment oppartunites, Older youth are strongly encouraged 10 remain, in foster care after they reach age 18, Practice Area: Placement Settings QSR Indicator: Living Arrangement ‘The Teast restrictive placement setting is sought for each child, and Child Pemanency Plans document the reason for the seting ‘where the child resides. “A number ofthe children reviewed were living with relatives or kin, DCSSCY coordinates and transports children as needed in order to have them remain in their home school uniess fis not in the child's best interest. ‘The following chapters 3380, 3700, 313), 3480, CPSL and Chapter 20 were reviewed curing the annual lensing review. Based on violalcn with regard to chaplers 3460, 3130, ‘and 3700, the Department of Public Weare, Ofice of Children, Youth and Families is issuing the following cations which require a plan of comection, REGULATORY FINDINGS REQUIRING PLAN OF CORRECTIONTEER S/CORRECTION REGUIRED 4TREQUIRED | 5 PROVIDERS PLAN OF & STATUS OF cobEe ; a = | CORRECTION | CORRECTIONOR RESPONSE —_| CORRECTION cuaprer | ue : So ponte g i '3490.58(@) | in 1 of 20 CPS intake Case Files, | When investigating a repor of suspected | immediately and the alleged perpetrater was not | child abuse, the county agency must | ongoing A fs provided with oral notfication of _| ensure that oral notication is provided to feed i 7 the report prior to the CPS. alleged perpetrators within the mandated 4 a interview, timeframe. 7 ‘A pian should be developed to assure Vag |p? ye that this mandates berg met. ‘The plan j | should state the staf postion/person that Airy is responsibe for he review and enforsement ofthis pocy with taf. 349055 (aNB)_| 18 Zof20 GPS intake Case Files, | When investigang a repod of suspected | amedlaely and there was no incicaten that the | child abuse, the county agency must | ongoing safety ofthe vcim child and other | ensure the safety ofl enidren Inthe chisten in te nome was ensured | Romo where the suspected end abuse | immediately ceourred immediately it cannot be determined ffom the repor whethor oF \ not emergency protective custody s needed ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. 450.55 (@) | In 1 of 20 GPS Intake Case Files, | When investigating a repor of suspected | Immediately and there was no writen child abuse, tne agency shall recorain | ongomg documentation of the alaged \witing the facts obtained as.a result of \ perpetrators interview. the interviews conducted, ‘A plan should be developed to assure \ that this mandate is being met. The plan should state the staff postion/person that is responsible for the review and enforcement ofthis policy with staf. ‘349055 () | In 1 of 20 CPS Intake Case Files, | When investigating a repor of suspected | immediately and pictures documenting the child or | child abuse in which a child has ‘ongoing Injuries were not found, sustained a visible injury, the agency shall, whenever possible and ‘appropriate, take, cause to be taken or ‘obtain color photographs of the injury A plan should be developed to assure that this mandate is being met. The plan | should state the staff postion/berson thatTs responsible for the review and enforcement ofthis policy with staf 3490.58 (@)__| in 3 of 20 CPS Intake Case Files, | When investigating a report of suspected | Immediately and ‘medical evidence or consultation | child abuse involving mental injury, ‘ongoing ‘was not obtained or cocumented | sexual abuse or exploitation or serious in the case fie. physical neglect, the agency shall, whenever appropriate, obtain medical evidence or expert consultation, or both ‘The agenoy shall maintain a record of medical evidence andior expert ‘coneuitation obtained during the investigation. A plan should be developed to assure that this mandate is being met. The plan should state the staff postioniperson that is responsible for the review and enforcement ofthis policy with staf. ‘3490.59 (@) | Despite the county stbmittinga | When the agency determines that a Case | inmediately and Plan of correction to address this | is Unfounded, indicated or Founded and | engoing Issue, 1 of the cases 2elow was | accepts the family for services, a Family ‘out of compliance follawing the | Service Plan shall be developed and jmplementation of thet pian. implemented. In2 of 20 CPS Intake Case Files, | The Departmant recommends that the a Family Service Plan was not | county re-evaluate and revise the ‘completed when the famiiy was | previously submitted plan of correction to accepted for services. assure compliance with this mandate, ABO) | In 1 of 20 CPS Intake Gave Files, | The county agendy supervisor shal Tinmediately and a supenisor did not sign a review each report of suspected child | engoing ‘completed Risk Assessment. abuse which is under investigation on a regular and ongoing basis to ensure that In 4 of 20 CPS Intake Case Files, | the level of services are consistent with 2 supervisor signed acompleted ° | the level of risk to the chile, to determine Risk Assessment outside of the _| the safety of the child and the progress, required timeframe. Caseworker | made toward reaching a status, signed RA on 5/20/14; Supervisor | determination signed RA on 3/80/16. ‘plan should be developed to assure ‘that this mandate is being met. The plan should state the staff postion/person that is responsible fer the review and enforcement ofthis policy with stat. '$490.321 ()__| in 7 of 20 CPS Intake Case Files, | The agency shail rate each factor and | linmediately and ‘isk was not assessed for al ofthe | shall provide documentation in the record | ongoing coildten resicing inthe farily home. to support the identified level of risk and ‘to assure the chils's safety.A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf S4O0527 FY Th 620 OPS Intake Case Files, a Risk Assessment wes. ‘completed outside ofthe requires ‘timeframe at the conclusion of an investigation. Assessment closed (on 7/10/14, Closing Fisk ‘completed 817/14. The agency shall ensure that periodie assessments of risk shall be completed by the county agency at all required intervals. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff positon/person that is responsible fer the review and enforcement ofthis policy with staf. immediately and ergoing 349061) In 13 of 20 GPS Intake Case Files, supervisory reviews of the cases were completed outside of the required timeframe, In 1 of 20 CPS Intake Case Files, supervisory reviews cfthe case. were not completed. “The agency supervisor shall review each report of suspected child abuse which is under investigation on a regular and ‘ongoing basis to ensure that the fevel of services are consistent with the level of risk to the child, to determine the safely of the child and the progress made toward reaching a status determination, ‘The supervisor shall maintain a log of these reviews which, at a minimum, shall include an entry at 10-calendar day intervals during the investigation period. ‘A plan should be developed to assure al this rnaridate is belng met, The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf inmediately and engoing 348055 and 3130.24 (b) as itrelates to Act 126 In 1 0120 GPS Intake Case Files, there was no documented photograph of the chid in the record. When investigating a repor of suspected child abuse in which & child has sustained visible injury, the county agency shall, whenever possible and ‘appropriate, take, cause to be taken or obtain color photographs ofthe injury, ‘The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. Act 126 of 2006 amended the CPSL to include the requirement that photographs cof all children in the household must be taken as part ofthe investigation to censure all children are properly identified, Tinmediately and ‘ongoingAll photographs should remain in the case file and updated annually when a case has been accepted for services. ‘Aplan should be developed to assure ‘hat this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf ‘Bi8087 ©) Despite the county eubmiting a plan of correction to address this Issue, both of the cases below were out of compliance following the implementation ofthat plan. In 1 of 20 CPS intake Case Files, ‘the Family Service Pan was developed on 11/284, the parent signatures were rece'ved on 42/22/14 and 122/18 In 1 0f 20 CPS intake Case Files, the Family Service Plan was not signed by the parents nor wes. there decumestation that the agency attempted to get the parents signatures. "The agency shall ensure thatthe parent cr legal guardian shall be givan the ‘opportunity to sign the service pian, The ‘agency shall inform the parent or legel guardian that signing the plan constitutes agreement with the service plan. ‘The Department recommends that the ‘county re-evaluate and revise the Previously submitted plan of correction to ‘assure compliance with this mandate. Tmmediatoly and ‘ongoing BS06T ‘Despite the county submiting a plan of conection to adcress Tis issue, 1 of the cases betow was out of compliance folowing the implementation of thet plan. In 4 of 20 CPS Intake Case Files, there was no indication that the parents were provided with the ‘opportunity to partciate in the development of the Family Service Pian. “The agency shall ensure that family members, including the chicren, their representatives and service providers, the opportunity to participate in the development and amendment of the service plan ifthe opportunity does not jeopardize the chitd’s safety. The ‘method by which these opportunities are provided shall be recorded in the plan, ‘The Department recommends that the ‘county re-evaluate and revise the previously submitted plan of correction to ‘assure compliance with this mandate, Immediately and ‘ongoing B1a02 Tn? of 20 GPS Intake Case Files, ‘not all chiidren in the family household were listed on the. Safety Assessment, “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations, ‘The Safety Assessment and Management Process requires that Immediately and engoingthe safety of all children who reside in the household be assured and ‘documented on the Safety Assessment worksheet ‘plan should be developed to assure that this mandate is being met. The plan ‘should state the staff position/person that is responsible for te review and ‘enforcement ofthis policy with staf 33027 In 5 of 20 CPS Intake Case Files, there were one or mere Safety Assessments that were signed by the supervisor beyond the required time frame. The sive ois sal metre Bat Te ageryic operated im conoriy ana tools Fede! Sate an eea Sates orinenes ar eputans | Te Sey Atsosonent ne | Matagoret Proce tous ht he | caseworker completes and signs the | Scty ecesemenrmtin'2 Roos ane ie Qpentorwiie oa ‘Aplan should be developed to assure ‘that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. Immediately and ‘ongoing ‘313027 @) Th 7 of 20 OPS Intake Case Files, the Safety Plan was not signed by the patty responsible for the Safety end monitoring ofthe plan. “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires thal ve Satety Pian be signed by all parties. ‘A plan should be developed to ascure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. Tmmediataly and ‘ongoing 348027 Tn 1 of 20 GPS Intake Gas0 Files, the closing Safety Assessment ‘was completed, but the children had not been seen in ever 30 days. The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local Statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the children must be seen within 30 days of completing a conctuding safety assessment A plan should be developed to assure. Immediately and ‘engoingThat this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement of this policy with staft. B1a0aT Tn2 of 20 GPS Intake Case Files, a Safety Assessmen: was not Completed prior to case closure. “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State end local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that @ Safety Assessment be completed within 30 days ofthe date of case closure. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that | responsible for the review and enforcement ofthis policy with staf Tamediately and ‘ongoing BsaeT in 1 of20 CPS Intake Case Files, 1 child was determned to be "safe", however a Safety Plan was stil developed and feund in the fi. “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local Statutes, ordinances and regulations. ‘The Safety Assessment and ‘Management Process requires that the etermination of safe" does not result in the need for a safety plan. ‘Aplan should be developed to assure that this mandate is being met. The plan should state the staff position/person that Is responsible for me review ana enforcement ofthis policy with staff Tamediately and ongoing SEROZSE ey Tn 7 20 GPS Intakes Files, the assessment was completed ‘outside of the required timeframe, Referral date: 5/8/14, assessment closing date: 8728/14 “The agency shall complate an assessment within 60 calendar days to determine whether or not the child an ‘amily should be accepted for general protective services, be referred to another agency for services or close the case. ‘Aplan should be developed to assure ‘that this mandate is being met. The plan should state the staff position/person that is responsible forthe review and enforcement of this policy with staff Immediately and ‘ongoing BROS Tn 1 of 20 GPS Intake Files, 2 Visit tothe child's home was not completes. “The agency shall ee the chid and vist the child's home during the assessment Period, The home visits shall occur as ‘often as necessary to complete the immediately and ‘ongoing 10‘assessment and insure the Safety ofthe child. There shall be at least one home visit. ‘Aplan should be developed to assure that this mandate is being met, The plan should state the staff positionfperson that is responsible for the review and enforcement of this poicy with staf 3490734 (B) | In 2 of20 GPS Intake Files. there | The agency shall rovise written notice | Immediately and 02) was no documentation thatthe | tothe parents and the primary person | ongoing family was notifed in writing ofthe | who is responsible for the care of the f { agency's decision to accept or not | child ofthe county agency's decision to bu ‘accep! for services. ‘2ocept or not accept the farily for general protective services within 7 I; Zalendar days of making the decision. : j Du ‘A plan should be developed to assure | \ that this mandate is being met. ‘The plan i should stato the staff postion/person thet | | is responsible forthe review and | ! enforcement ofthis poicy with staft | 3490235 () | 19 1 0f 20 GPS Intake Files, 8 | The agency shall develop a femily Tamediatey and Family Service Pian vas not | servee plan 2s requred by 3130.81 _| ongoing | ‘completed within the required | (relating to family service plans) for each | timeframe. Date opened for family accepted for general protective | services: 5/21/14, dae ofintial | services within 60 days of date of FSP: o/igita acceptance. | ‘Alan should be developed to assure ! that tis randate is belng met. The plan i | should state the staff positon/person that | is responsible for the review and { | enforcement ofthis policy with staff | '3490.322 (@_ | In 1 0f20 GPS Intake Files, tere | The county agency shal assure that he | Tnmedalely and was no documentation thata | level of activty, in person contacts with | ongoing | ‘supervisor signed a completed Risk Assessment the child, overs'ght, supervision and services for the child and family are consistent with the level of isk as determined by the county agency. ‘Supervisors shall review these risk ‘assessments and sign off to ensure ‘appropriate services are being provided ‘plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement of this poicy with staff3490527 in 1 of 20 GPS intake Files, there was no documentation within the Risk Assessment that discussed ‘and supported the ratings for each factor. The agency shail rate each factor in subsection (e) and shall provide documentation in the record to suppor the identified level of risk and to assure the child's safety. A plan should be developed to assure ‘that this mandate is being met. The plan should state the staff posttion/person thet 's responsible for the review and enforcement ofthis policy with staf Immediately and ‘ongoing Ba00 SAT NT in? of 20 GPS Intake Files, there ‘was no documentation that 2 Risk Assessment was completed at the ‘conclusion of the assessment period. In2 of 20 GPS Intake Files, a Risk Assessment was completed at the conclusion of the assessment period but twas ‘completed outside of he required timeframe. In one case the assessment closed on 21614, Risk assessment dated: 326/16, In the second case, the assessment wert over the mandated 60 timeframe making the closing risk assessment late as wal, ‘The agency shall ensure that periodic assessments of risk be completed, including at the conclusion of the Intake investigation which may not exceed 60 calendar days. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that Js responsible for the review and enforcement ofthis policy with staf Tramediately and ‘ongoing BBO SAN) Ta ¥ of 20 GPS Intake Files, one oF more supervisory reviews were completed outside of he required timeframe, In 4 of 20 GPS Intake Files, there ‘was no indication that any supervisory reviews were completed. There sill be supevision oF caseworkers and other direct service staff to ensure the following: Ongoing ‘support and direction for the case activities of supervised statt A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review ane enforcement of this policy with staf Tamedlaiely and ‘ongoing S802 182 0f 20 GPS Intake Files, © wes documented that ll children were seen but not all children were listed on the Safety Assessment. The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the safety ofall chileren who reside in the household be assured and immediately and ‘ongoing 12documented on the Safely Assessment worksheet, ‘Aplan should be developed to assure that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement ofthis poicy with staf 318021 (6) | Despite the county submiting @ | The executive offcers shall ensure that | Wamedately and lan of corection to address this | the agency is operated in conformity with | ongoing i issue, the cases below were out of | applicable Federal, State and local - ‘compliance folowing the lattes, ordinances and regulations ke implementation of that pian. ‘The Safety Assessment and Hei CF Management Process requires that the Jn 1 0f20 GPS Intake Files, there | caseworker completes and signs the aie were one or more Salty safety assessment within 72 hours, and i Ble 5 Assessments that were not signed | the eunervsor within 10 days. | by a supervisor | ‘The Department recommends that the | tn 1 of 20 GPS intake Files, there | county e-evaluate and revise the | wore one or more Safety previously submitted plan of correction to | j ‘Assessments that were signed by | assure compliance with this mancate. | 2 supervisor outside ofthe | required timeframe | In2 of 20 GPS intake Files, there | | were one or more Salty ‘Assessments that were signed by | | 2 caseworker outside ofthe | required timeframe. 1 SiS) [nT of 20 GPS intake Files, he | The execuive offcers shal ensure that 1 closing Safety Assessment was | the agency is operated in conformity wth | ongoing | completed, but the children had | applicable Federal, State and local ' ‘rot been seen in over 30 days. | statutes, ordinances and cegulations. | | ‘The Safety Assessment and | Management Process requires that the | | chikiren be seen within 20 days of competing a concluding safety assessment A plan should be developed to assure | } that this mandate s being met. The plan \ should state the staff positon/person that \ is responsibe forthe review and \ enforcement of his policy with staf. | ‘313027 | ih T6F20GPS Intake Files, he | The executive offcors shall ensure that | Vimedately and T t preliminary Safety Assessment | the agency is operated in conformity with | ongoing 13Was completed outsice ofthe sequired timeframe, Date of Referral: 12/18/16 Date of Visit 12/19/14 Date of SAW: 12/23/14 ‘applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the ‘caseworker completes and signs the Safety Assessment within 72 hours. ‘Aplan should be developed to assure that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement of this policy with staf S4S0252 Tn 2 of 10 "Once and Done™ Case Files, the child was not ‘seen within the assigned response tie, Referral came to agency on 6/24/14 and was giver a five day response time, Childwas seen 6/30/14, one day past the ‘assigned response tine. “The agency shall see the child immediately if emergency protective custody has been taken, 's nesded or iit cannot be determined from the report whether or not emergency protective custody is needed. Otherwise, the county agency shall prorize the response time for an assessment to assute that children who are most at risk receive an assessment first. ‘Appian should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible forthe review and enforcement ofthis policy with staf immediately and ‘ongoing BS027 By Tit of 10 “Once and Done™ Case Files, the preliminary Safety Assessment was completed Outside of the required timeframe. ‘The preliminary safety assessment worksheet was ‘completed on 1/16/16. Home visit was not completed urtl 1/22/15 which is outside of the 72 hour period. Child was visited at school ‘0 safety was assessed without ‘seeing home, caretaker, or other family members, “The executive officers shail ensure that the agency is operated in conformity with ‘epplicable Federal, State and local | statutes, ordinances and regulations, ‘The Safety Assessment and Management Process requires that the caseworker completes and signs the Safety Assessment within 72 hours. ‘Applan should be developed to assure that this mandate is being met. The plan ‘should state the staff position/person that is responsible for he review and enforcement of this policy with stat Tinmediately and ‘ongoing FIAT Tn of 20 in-Home Case Files, there was no documentation of the race of the parents and the race of the child was neorect. ‘The agency must ensure that the family cease record includes accurate and ‘completed information related to names, race, sex and date of birth of each family member. ‘A plan should be developed to assure Immediately and ‘ongoing 14That this mandate is being mat. The plan should state the staff postion/person that is responsible for the review and enforcement of this policy with staf 318021 (Das itretates to Act 126 Tn6 of 201n-Home Case Files, there was no documented photograph of the chld in the record “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘Act 126 of 2006 amended the CPSL to include the requirement that photographs of al children in the househo'd be taken to ensure al children are property identified. All photographs should remain in the case fle and updated annually when a case has been accepted for services. ‘Aplan should be developed to assure ‘that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement of this policy with stat. Immediately ana ongoing A802) Th 1 of 20 in Home Case Files, | there was no documentation that {2 supervisor signed ¢ completed Risk Assessment, In 7 of 20 In-Home Case Files, ‘the supervisor reviewed and signed the Risk Assessment vulside of the required tmetrame, ‘RA date: 63/14 Sup sig: 118/15 2) RA Date: 11/25/14 Supsig: vans 3) RADate: 10214 Sup sig: 4115 4) RA Date: 127/18 Sup sig: 4115 5) RADate: 11/24/14 Sup Sig: 4/15 6) RADate: 9/174 Sup Sig: 3/31/15 7) RA Date: 21415 Sup Sig: 3/31/15 “The county agency shall assure that the level of activity, in person contacts with the chid, oversight, supervision and ‘services for the child and family are ‘consistent withthe level of risk as determined by the county agency. Supervisors shall review these risk assessments and sign off to ensure. ‘appropnate services are being provided A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsibie for the review and enforcement of this policy with staf. Immediately and ongoing 3400521 WH) In of 20 in-Home Case Files, there was no indication that | periodic Risk Assessments were Periodic assessments of risk shall be ‘completed by the county agency as required by regulations. inmediately and ergoing 15‘completed. {n 1 of 20 In-Home Case Files, a periodic Risk Assessment was completed late. GPS Assessment closed on 11/19/44. Closing Risk completed on 2/9/15 In of 20 In-Home Case Files, there was no Indication that a Risk ‘Assessment was conpleted within 30 days of case closure, ‘Aplin should be developed to assure ‘that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement of this policy with staff, ‘BTB08t (a) Despite the county submiting @ plan of correction to address this Issue, 6 of the cases below were ‘ut of compliance folowing the Implementation of that plan. In6 of 20 InHome Case Files, ‘there was no indicaton that a Family Service Pian was, completed. Despite the county submiting a plan of correction to address this Issue, 2 of the cases below were cout of eompitance folowing the implementation of that plan, In of 20 In-tome Case Files, Family Services Plans were ‘completed outside of the required timeframe. 1. Date of Acceptance: 6/4/14 Date of FSP: 1128/14 2. Date of Acceptance: nner Date of FSP: 244/15 3. Date of Acceptance: ana Date of FSP: 1/18/15 "The agency shall pregare, within 60 days of accepting a family for service, a “wcitten family service plan for each family receiving services through the county agency. ‘The Department recommends thet the county re-evaluate and revise the previously submitted plan of correction to assure compliance with this mandate, Immediately and ‘ongoing sa08T © nT of 20 In-Home Case Files, the Family Service Plan was signed by a supervisor outside of the required timeframe, 1) FSP date: 1/9/18 ‘Sup Sig: 4/1/15 2) FSP date: 1072/4 ‘The agency shall ensure that he Service plan is signed by the county agency sat! person responsible for management of the case. The parent or legal guarcian shall be given the opportunity fo sign the service pian. The agency shal infor the parent of legal quarcian that sizing Immediately and ‘ongoing 16Sup Sig: 471716 3) FSP date: 112715 Sup Sig: 4/1/15 4) FSP date: 11/415 Sup Sig: 11/2015 5) FSP date: 10/2014 Sup Sig: 4/1/15. 6) FSP date: 13/'5 ‘Sup Sig: 1/16/15 7) FSP date: 40/"4 Sup sig: 4/15/14 In 1 of 20 In-Home Case Files, the Family Service Pan was signed by a caseworker cutside of the required timeframe, 1) FSP: 1/9/15 cWeig: 415 In 1 of 20 In-Home Case Files, the Family Service Pian was not signed by any particisants. Despite the county sabmitting a plan of correction to address this issue, all of the cases below were ‘out of compliance folowing the implementation of that plan. In 4 0f 20 tn-Home Case Files, ‘there was no indication that the parents signed or were given the ‘opportunity to sign tre Family Service Plan. In 2 of 20 In-Home Case Files, the Family Service Flan was not signed by the child and parents timely. 1) FSP: 7/04 Signed: 9/17/16 2) FSP: 116H5 Signed: 331/18 the plan constitutes agreement with the service plan. ‘The Department recommends that the ‘county re-evaluate and revise the previously submitted plan of correction to ‘assure compliance with this mandate, was OM @ Despite the county submitting a plan of correction toaddress this issue, all ofthe cases below were ‘out of compliance folowing the “The agency shall ensure that family ‘members, including the children, their representatives and service providers, | the opportunity to participate in the Immediately and ‘ongoinginipiementation of that plan, In4 of 20 In-Home Case Files, there was no indication that the Parents were provided withthe ‘opportunity fo participate in the development of the Family ‘Service Pian, “evelopment and amendment ofthe service plan ifthe opportunity does not jeopardize the child's safety. The ‘method by which these opportunities are provided shail be recorded in the plan. ‘The Department recommends that the ‘county re-evaluate and revise the previously submitted plan of correction to assure compliance with this mandate, 313061 © Despite the county submitting a plan of correction to address this Issue, 4 ofthe 8 cases below ware out of compliance folowing the implementation of thet plan. In 5 of 20 In-Home Caso Files, there was no indication that a copy of the Family Service Plan ‘was provided to the parents. Despite the county submitting a plan of correction to edress this issue, the case below was out of ‘compliance following the implementation of thet plan. In 1 0f 20 In-Home Case Files, a ‘copy of the Family Service Pian ‘was not sent to the parents in a timely manner. Case closed 2/26/15, records indicate FSP was maled atter ‘ease closure, ‘The agency shall ensure that famiy members, their legal counsel, other representatives and agencies or facilities providing services to the child and family are provided with a copy of the service pian, including service pian amendments ‘and results of reviews when the ‘amendments or reviews change the previously agreed upon plan. ‘The Department recommends that the ‘county re-evaluate and revise the Previously submitted plan of correction to ‘assure compliance with this mandate. | Tamediataly and ‘ongoing 313065) In of 20 In-Home Case Files, there was no indication that a Family Service Plan Review was ‘completed. In 4 0f 20 In-Home Case Files, the Family Service Plan Review was completed outsice of the required timeframe. Inia family service pan: 7/18/14 Family service plan review: 4/3/15 “The agency shall ensure that a review oF the service plan occurs atleast every sx months. ‘plan should be developed to assure that this mandate is being met, The plan should state the staff posiion/person that Is responsible for the review and enforcement ofthis policy with staf, Tmmediately and engoing B1S0SaA) In6 of 20 in-Home Case Files, ‘there was no indication that “There shall be supenision of caseworkers and other direct service Tnmedately and ‘engoing 18‘upanisory reviews were completed monthly. “talfto ensure the folowing: Ongoing ‘support and direction for the case activites of supervised staft. ‘Aplan should be developed to assure that this mandate is being met. The pian should state the staff position/person that 's responsible for the review and enforcement ofthis policy with staf 3450235 a0 Th 3 of 20 In-Home Case Files, there was no indication that the farily was visited once every 50 days. ‘When a case has been accepted for services, the county agency shall monitor the safety of the child and assure that contacts ere made with the child, parents and service providers. The contacts may occur either directly by a county agency ‘worker or through purchase of service. by phone or in person but face-to-face contacts with the parent and the child shall occur as often as necessary for the protection of the child but at least as fften as once a month for 6 months or case closure when the child is placed out (of the home ors in a setting in which the eed for general protective services was ‘established ‘Aplan should be developed to assure ‘hat this mandate is being met. The pian should state the staff position/person that is responsibie for the review and forcement of this policy with staf. immediately and ‘ongoing | 3480232 (6) Tim 2 of 20 In-Home Case Files, the GPS assessmert was not completed within the required timeframe. Date of Referral: S714 Acceptance date: 83/14 Date of Referral: 1017/14 Acceptance date: 1'7/15 “The agency shall complete an ‘assessment within 60 calendar days to determine wether or not the child and family should be accepted for general protective services, be referred to another agency for services or cose the case. ‘A plan should be developed to assure that this mandate is being met. The plan ‘should state the staff positioniperson that is responsible for the review ang enforcement of this poticy with stat. Immediately and ongoing ) 3490.234 in of 20 In-Home Case Files, ‘there was no docurrentation that the family was noted in witing of the agency's decision to accept or not accept for services. “The agency shall provide written notice to the parents and the primary person who is responsible for the care of the child of the county agency's decision to accept or not accept the family for Immediately and ongoing 19General protecive servioss within 7 Calendar days of making the decision, ‘Aplan should be developed to assure that this mandate is being met. The plan ‘should state the staff postion/person that is responsible for the review and enforcement ofthis polcy with staf 373021 Tn? of 20 In-Home Case Files, safety threats were identified but there were no protecive capacities documented for the caregivers. In 1 of 20 In-Home Case Files, a safety threat was identified but ‘the protective capaciies documented were fora different safety threat, The executive officers shall ensure that the agency 's operated in conformity with applicable Federal, State and local Statutes, ordinances and regulations. ‘The Safety Assessment and ‘Management Process requires that each Safety threat be documented with 2 corresponding protective capacity. ‘plan should be developed to assure that this mandate is being met, The plan should state the staff position/person that is responsible for he review ang enforcement ofthis policy with staf Immediately and ‘ongoing Bist2T in6 of 201m Home Case Files, there was no indication that Safety Assessments were completed In 4 of 20 In-Home Case Files, there was no indication that the losing Safety Assessment was ‘completed at the conclusion of the GPS Intake assessnent, In 3 of 20 In-Home Case Files, the closing Safety Assessment ‘was completed outside of the required timeframe a: the conclusion of the GPS Intake assessment. 1) Date of Acceptance: inert Closing SAW: 127/16 2) Date of Acceptance: 10/1/14 Closing SAW: 11/1/14 9) Date closed: 3/26/15 Closing SAW: 2710/15, The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that a Safety Assessment be completed at Specified intervals, ‘Aplan should be developed to assure that this mandate is being met, The plan should state the staff position/person that is responsible for the review and enforcement of this policy with staf Tmmediataly and ‘ongoing gee eae BB037 WY Tn 0f 20 In-Home Case Files, a Safety Assessmentwas ‘completed without the parents ‘The executive offcers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes. ordinances and regulations. immediately and ‘engoing 20Int of 20 In-Home Case Files, a Safety Assessment was, completed without al children being seen. ‘Tho Safely Assesement and Management Process requires that all children and adult caretakers be seen and assessed for safety. ‘Applan should be developed to assure that this mandate is being met. The plan ‘should state the staff posttion/person that is responsible for the review and tenforoement of this policy with staf 3180270) Tn 7 of B0tn-Home Case Files, the Safety Analysis cuestions on the safety assessment worksheet were net completed, despite threats being present “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the Safety Analysis section be completed if safety threals are present. plan should be developed to assure ‘that this mandate is being met. The plan should state the staff position/persor that is responsible for the review and enforcement of this policy with stat. Immediately and ‘ongoing BBO STE) Despite the county albmiting @ plan of correction to address this Issue, 6 of the 7 cases below were out of compliance folowing the Implementation of that pian. In 7 of 20 In-Home Ca0e Fileo, ‘there were one or more Satety ‘Assessments that ware signed by the supervisor outside of the required timeframe. 1)” SAW date: 1020/14 Sup Sig: 11/712'14 2) SAW date: 1/19/15 Sup Sig: 4/1/15 3) SAW date: oat Sup Sig: 3226/15 4) SAW date: 1/0/15 Sup Sig: 27225 5) SAW date: 5/23/14 ‘Sup Sig: 6/10/-4 6) SAW date: 2/13/15 Sup Sig: 2126/°5 7) SAW date: 210/15 Sup Sig: 3/26/'5 “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the safety eaeeaamont workchest be eigned by the caseworker at the time of the completion of the Safety Assessment and within 10 days of completion by the supervisor. ‘The Department recommends that the county re-evaluate and revise the previously submited pian of comection to assure compliance with this mandate. immediately and ongoingDespite the county submitting a plan of correction fo address this Issue, both of the cases below were out of compliance following the implementation ofthat pian. In 2 of 20 In-Home Case Files, there was no indication that one or more Safety Assessments were signed by a supervisor. Despite the county sabmitting a plan of correction to address this Iscue, all 4 of the cases below were out of comaliarce following the implementation cf that pian In 4 of 20 In-Home Case Files, ‘there were one or more Safety Assessments that were signed by the caseworker outsde of the required timeframe. 1) SAW date: 1/3415 GWesig cate: 1119/15 2) SAW date: 113/15 Wig date: 41/18 3) SAW date: 9/4/14 CW sig date: 326/15 4) SAW date: 2/10/15 (CW sig date: 328/15 027 @) Th'7 of20 In-Home Case Files, the closing Safety Assessment ‘was completed, but the children had not been seen in over 30, cays. The executive officers shall ensure that the agency is operated in conformity with ‘applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the children be seen within 30 days of completing a concluding safety ‘assessment ‘Aplan should be developed to assure that this mandate is being met. The plan should state the staff position/person that js responsible for the review and enforcement ofthis policy with staf Tmmediately and ‘ongoing 318027 18320 In-Home Case Files, the child was “unsate" and in “The executive officers shall ensure that the agency is operated in conformity with Immediately and ‘ongoingplacsment but was arsesced a6 "safe" on the Safety Assessment. ‘applicable Federal, State and local statutes, ordinances and regulations. “The Safety Assessment and Management Process determination of “safe” would not lead to a child being in placement. Chilcren in placement are “unsafe™ ‘plan should be developed to assure that this mandate is being met Guidance on the determinations of “safe, "unsafe" and “cafe with a plan" ‘should be provided to staff, The pian should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. 318021 (bas itrolates to Act 128 in 1 of 10 Placement Gave Files, ‘there was no documented photograph of the chil in the record “The executive officers shall ensure That the agency is operated in conformity with ‘applicable Federal, State and local statutes, ordinances and regulations, ‘Act 128 of 2008 amended the CPSL to include the requirement that photographs ofall children in the household must be taken as par ofthe investigation to ‘ensure ail children are property identified Al photographs should remain in the cease file and updated annually when @ ‘case has been accepted for services. ‘Appian should be developed to assure Uhal Us mandate Is being met, ‘The plan should state the staff positioniperson that is responsible forthe review and enforcement ofthis policy with staf. Tnmedately and ‘ongoing 33043 (10) inf of 10 Placement Gaso Files, there was ne indication that educational records were received for the child or that they were requested. The agency shall ensure that a family case record includes educational reports ‘and records for each child in placement. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff posttion/person thet is responsible for the review and enforcement of this policy with staf. Thimediately and ‘ongoing 313061 (a) Tin 4 of 10 Placement Gace Files, there was no indication that a Family Service Plan was completed, “The agency shall prepare, within 60 days of acvepting a family for service, a \wrtten family service plan for each family receiving services through the county agency. Tinmediately and ‘ongoing 23“Tplan should be developed to assure ‘that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement ofthis policy with stat 313081 © @ in 1 of 10 Placement Case Files, there were no service objectives Identified in the FSP ‘or one of the parents. ‘The agency shall ensure that the service plan be a discrete part of the family case Feoord and ehall include the service ‘objectives for the family, identifying changes needed to protect children in the family in need of protection from abuse, neglect and exploitation and to prevent their placement. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff posttion/person that is responsible for he review and enforcement of this policy with staft. Tmmediately and ‘ongoing HaOeT WO © InZ of 70 Placement Case Files, the Family Service Pan was signed by a supervisor outside of the requited timeframe. 1) FSP cate: 7/304 ‘Sup sig: 3/30/15 2) FSP date: 174 Sup sig: 11/20/14 In of 10 Placement Case Files, there was no indication that the pparonte cignod or were given the ‘opportunity to sign tre Family Service Pian. “The agency shal ensure that the service plan Is signed by the county agency staff person responsible for management of the case, The parent or legal guardian shall be given the opportunty to sign the ‘service plan, The agency shall inform the parent or legal guardian that signing the plan constitutes agreement with the service pian. ‘A plan should be developed to assure that thie mandate is being met The plan ‘should stale the staff position/person that is responsible for the review and enforcement ofthis policy with staf Immediately and cengoing sa08T HM © TW 4 of 10 Placement Case Files, ‘there was no indication that the parents were provided with the ‘opportunity to participate in the development of the Family Service Pian. “The agency shall ensure that family members, including the chléren, their representatives and service providers, ‘the opportunity to participate in the development and amendment of the service plan ifthe opportunity does not jeopardize the child's safety. The ‘method by which these opportunities are provided shall be recorded in the pian, A plan should be developed to assure that this mandate is being met. The plan ‘should state the staff posion/person that is responsible forthe review and enforcement ofthis policy with staf Trmediataly and ongoing 2433061 e) Th 1 of 10 Placement Case Files, ‘there was no indication that a copy of the Family Service Plan ‘was provided to a parent. The agency shall ensure tral family members, their legal counsel, other representatives and agencies or facilities providing services to the child and family are provided with a copy of the service plan, including service plan amendments ‘and results of reviews wher the ‘amendments or reviews change the previously agreed upon plan. Aplan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. Immediately and ‘ongoing 33081) Th of 10 Placement Gase Files, there was no indication that 2 Child Permanency Pan was completed. In 1 of 10 Placement Case Files, the Chid Permaneney Plan was completed outside of the required timeframe. Placement date: 8/7/14 Date of CPP: 1/23/15 The agency shail ensure that the sence plan be a discrete part ofthe farlly case Fecord and shall include Placement ‘Amendments as required by 3130.87 (felating to placement planning) A plan should be developed to assure: that this mandate is being met. The pian should state the statt postion/person that is responsible for the review and enforcement ofthis policy with staf Immediately and ongoing 313061 © Tn 3 of 10 Placement Case Files, there was ne Indication that the parents were given the ‘opportunity to sign the Chile Permaneney Plan. In2 of 10 Placement Case Files, the Child Permanency Plan was signed by a supervisor outside of the requited timeframe. ‘DCPP date: 2/8/14 Sup sig: 1/5/14 2)CPP date: 11/7/18 Supsig: 11/19/14 In 1 of 10 Placement Case Files, the Child Permanency Plan was signed by the caseworker outside of the required timetrame. 4)CPP Date: 4/8/14 CW sige 55/14. "The agency shall ensure that the service plan is signed by the county agency staff person responsible for management of the case. The parent or legai guardian ‘hall be given the opportunity te sign the service plan, The agency shall infor ‘the parent or legal guardian that signing the plan constitutes agreement with the service plan A plan should be developed to assure. that this mandate is being met. The plan ‘should state the staff positioniperson that is responsible for the review and enforcement of this policy with staff. nmediately and ongoing Ha08 Tn 2 of 10 Placement Case Files, there was no indication that the "The agency shall ensure that family members. including the children, their Tamediately and ongoing 25Parents were given te ‘opportunity to partcizate in the development of the Child Permanency Plan, Tepresentatives and service providers, the opportunity to participate in the development and amendment of the service plan ifthe opportunity does not jeopardize the chik's safety. The ‘method by which these opportunities are provided shall be recorded in the plan. Aplan should be developed to assure ‘that this mandate is being met. The p'an should state the staff position/person that is responsible for the review and enforcement of this policy with staf. 313061 (@) Th 7 of 10 Placement Gaze Files, there was no indication that the parent was provided with a copy of the Child's Permanency Plan. “The agency shall ensure that family members, their legal counsel, other representatives and agencies or facilities providing services to the child and family are provided with a copy of the service plan, including service plan amendments ‘and results of reviews when the amendments or reviews change the previously agreed upon plan. ‘Aplan should be developed to assure ‘hat this mandate is being met The pian should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. mmediataly and ongoing BASS 4) Tn 1 of 10 Placemert Gase Files, there was ne indication that a review of the Family Service Plan was completed In 1 0f 10 Placement Case Files, the review of the Fanily Service Plan was completed outside of the required timeframe, Initial FSP: 4/9/14 FSP review. 11/7/14 ‘The agency shall review service plans at Teast every six months, except as provided in aubsection 2120.62 (b). Aplan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. Immediately and cengoing Hse) Tn t of 10 Placement Case Files, the review of the Criid Permaneney Plan was completed ‘outside of the requited timeframe. Inal CPP: 4/a/ta CPP review: 1177/16 “The agency shal ensure that fa chide in placemert, the county agency shall follow the requirements of 3130.71 (felating to placement reviews). ‘plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that Tnmedately and ‘ongoing 26Ts responsible for the review and enforcement ofthis policy with staf. Bs067 there was no indicaticn that a ‘copy of the Family Service Pian was provided to the court Tn 7 of 10 Placement Case Files, “The agency shall send a copy ofthe family service plan, as amended in ‘compliance wit this section, to the court prior to the intial dispositional hearing unless otherwise directed by the court ‘A plan should be developed to assure that this mandate is being met, The plan should state the staff position/person that 's responsible for the review and enforcement ofthis policy with staf. Immediately and ‘ongoing B1s0S2 BO) Tn of 10 Placement Case Files, there was no indicaticn that monthly supervisory reviews, ‘occurred. In 2 of 10 Placement Case Files, supervisory reviews were ‘completed outside of the required ‘timeframe. There shall be supenvsion of caseworkers and other direct service staff to ensure the following: Ongoing ‘support and directions for the ces2 activites of supervised staff ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff postion/person that is responsiole for the review and enforcement ofthis policy with staf Timediately and ‘ongoing TSO BE oe Th 2 at 10 Placement Case Files, Aotification ofthe visitation plan withthe child was not provided to ‘the chi's parents wihin the required timetrame, The county agency shall, within 24 hours of a child's placement, provide the child's parents with a writen statement Fegarsing the opportunity for visits. ‘Appian should be developed to assure that this mandate is being met, The plan should state the staff postion/person that is responsible forthe review and enforcement of this policy with staf Tinmediately and ‘ongoing Sis027) Fostering Connections to ‘Success and Increasing ‘Adoptions Act ‘of 2008 (Pubic Law 110-351) 102 of 10 Placement Case Files, identified relative resources were not noffied within the required timeframe of their opportunity to bbe part ofthe planning for the child's placement anc provided the opportunity to be a potential caregiver for a child, “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. Fostering Connections requires that due diligence must be exercised to identify all adult relatives within 30 days of a child's placement, notify ther that the child has been or is being removed, and explain to ‘them their options to participate In the care and placement of the child ‘Appian should be developed to assure Tnmediately and ‘ongoing 27That this mandate is boing met. The plan should state the staff position/person that fs responsibie for the review and ‘enforcement ofthis policy with staf 3490827 0D Th 1 of 10 Placoment Case Files, there was no documentation in the record that a Risk Assessment was completed In 4 of 10 Placement Case Files, the Risk Assessment was completed outside ofthe required timeframe. Case accepted: 11/7'14 GPS closing RA: 128/14 "The county agency shall assure that @ Risk Assessment is completed as often as necessary to assure the child's safety ‘and when the circumstances change within the child's environment. ‘Aplan should be developed to assure ‘that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. immediately and ‘ongoing Bis088 ast relates to the Bulletin 3130- 42.02 in 1 of 10 Placement Case Files, there was no indication that the child grievance procedure had been explained to the child or to the chila’s parent or other responsible party on behalf of chile who is too yourg to understand, at the time of placement In 1 of 10 Placement Case Files, the child grievance procedure was ‘completed outside of the required timeframe. Date of piacement: 3/26/14 Date signed: 4/24/14 ‘The child grievance procedure shall be explained to a child or a chi's parent or other responsibie person (when a child is too young to understand the procedure) as soon as the child is placed in out-of- home care, Aplan should be developed to assure ‘that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement ofthis policy with stat. Immediately and ‘ongoing ‘SISO (p) as itrelates to the Children in Foster Care Act 119 Bulletin 3130- 12-02 Ta 1 of10 Placemert Case Files, ‘there was no indicaton that @ ‘copy ofthe protections and the grievance policy and procedure were provided to the child ‘The executive officers shall ensure that the agency is operated in conformity with ‘applicable Federal, State and local statutes, ordinances and regulations, ‘Act 119 mandates that a copy of the child's protections while in foster care, ‘long with a copy of the agency's Grievance policy and procedure be provided tothe chid at the time of placement. ‘A plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement of this poticy with staff Tmmediataly and ongoing EEO} Despite the county submiting a “The county agency shall ensure that a Immediately and 28plan of correction fo address this issue, the case below was out of compliance following the implementation of that plan In 4 of 10 Placement Case the initial dental examination of the child was completed outside of the required timeframe. Placement date: /7/14 Initial dental: 11/24ris. Child, 3 years of age or older, receives a dental appraisal by a Ecensed dentist within 60 days of admission, unless the child has had an appraisal within the previous 6 months and the results of the appraisal are available. ‘The Department recommends that the ‘county re-evaluate and revise the previously submitted plan of correction to assure compliance with this mandate, ‘ongoing 37005T in { of 10 Placement Case Files, the updated dental examination of the child was completed outside of the requited timeframe. Dental exam: 5/1/14, no record of Updated dental exam following that vist. The county agency shall ensure that after the intial cental examination of children 3 years of age or older, ongoing dental examinations must occur at least once every 9 months while in placement, Aplan should be developed to assure ‘hat this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf Tmedately and ‘ongoing 318027) Tn 7 of 10 Placement Case Files, there was one Sefety Assessment that was signed by the supervisor Outside of the required timeframe. SAW date: 8/5/14 Sup Sig: 8/26/14 “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and regulations. ‘The Safety Assessment and Management Process requires that the safety assessment worksheet be signed by the caseworker at ne tme ot the Completion of the Safety Assessment and within 10 days of completion by the ‘supenisor ‘plan should be developed to assure ‘that this mandate is being met. The plan should state the staff position/person that is responsible for the review and enforcement ofthis policy with staf. Tramediately and ‘ongoing 3180.21) as it relates to the ‘Act 160 Bulletin 2400- 05.01 in of 40 New Foster Family Case Files, the resource family registration application was not ‘submitted to the Rescurce Family Registry within the required 30 days of their approval disapproval, In 1 of 40 Now Foster Family Case Files, there was no “The executive officers shall ensure that the agency is operated in conformity with applicable Federal, State and local statutes, ordinances and reguistions. ‘Act 160 requires that the county agency provide documentation in the file that the resource parents were registered with the Resource Family Registry within 30 days of theit approvalidisaporoval. Act Tinmediately and cengoing 29indication that the recource family registry was updated when the resource family was closed. 160 also requires that the Resource Family Registry include date and reason for any closure of a resource family home. Aplan should be developed to assure that this mandate is being met. The plan ‘should state the staff position/person that is responsible for the review and ‘enforcement of this policy with staf. 370058 [aS of 40 New Foster Farily | Case Files, tere was no | ndicaton that the recource ferly ras provided vith infomation regarding he cd placed inher home, "The agency shall ensure that foster families are provided with information from the case record which is necessary 10 protect the child’s health and safety and to assist in the chile's successtul accomplishment of necessary educational, developmental or remedial skis, ‘A plan should be developed to assure that this mandate is being met. The plan shoul state the staff posttion/person that is responsible for the review and enforcement ofthis policy with staf. immediately and ‘ongoing ‘B1S0.27(0) as itrelates to the ‘Children in Foster Care het 140, Bulletin 3130- 12-02 Tn2 of 40 New Foster File Case Files, there was no indication that the resource family was provided with a copy of the protections for children in foster care atthe time of their approval The executive officers shall ensure that the agency is cperated in conformity with applicable Federal, State and local statutes, ordinances and regulations. Act 119 mandates that the resouice family the childs placed with be provided with a copy of the protection for children in foster care document, ‘plan should be developed to assure that this mandate is being met. The plan should state the staff position/person that is responsible for the review and ‘enforcement ofthis policy with staffs responsible for the review and enforcement ofthis policy with staf Tnmediately and ongoing S700 68 Tht of 8 Tenured Foster Family Case Files, there wes no date of completion listed on the annual reevaluation document. “The agency shall visit and inspect ‘annually each foster family to determine continued compliance with the requirements of 3700.62 (relating to ‘foster parent requirements; foster child discipline, punishment and control poicy; assessment of foster parent capability: immediately and ongoing 30Toster parent training, foster family residence and safety requirements). Aplan should be developed to assure that this mandate is being met. The plan ‘should state the staff position/person that 's responsible for the review and enforcement ofthis policy with staftis responsible for the review and enforcement ofthis policy with staf. Si05t in 11 of 145 Tenured Staff Files, annual employee performance reviews were completed late. The agency shall ensure that with the exception of the agency administrator, ‘county agency staff hired or reclassified after January 1, 1978, shall be appointed in accordance with a Federally approved merit system of personnel administration ‘Aplan should be developed to assure that this mandate is being met. The plan should state the staff posttion/person that is responsible for the review and enforcement ofthis policy with stat. Tmmedataly and ‘ongoing ‘BB0572 @o In of 145 Tenured Staff Files, there was no indication that a staff completed the minimam hours of annval training, The agency shall ensure that ongoing certification of direct service workers is provided through the completion of a ‘minimum of 20 hours of annual taining ‘Aplan should be developed to assure that this mandate is being met, The plan ‘should state the staff position/person that Js responsible for ne review and enforcement cf this policy with stat. Immediately and ‘ongoing HBOBTO) Pst 634a(01) Int of 24 New Staff Files, there \Was no indication that a Criminal Clearance was ever received for a new empioyee. Staffhired 9/1/14 with a PSP clearance dated 416/13. No updates clearance ever received. Agency immediately ran PSP clearance con date of licensing, In 4 of 24 New Staff Files, the Criminal and Child Abuse Clearance was received more than 30 days after the date of hire. Date of hire: o/1/14 Date of disclosure stetement: eralid “The county agency may net fire a stat? person without frst complying with section 23.1 of the Child Protective Services Law (11 P. 8. § 2223.1) and (Chapter 3490 (relating to protective services) ‘Aplan should be developed to assure that this mandate is being met. The plan ‘should state the staff position/person that is responsible for the review and ‘enforcement ofthis policy with staf Tmmediately and ‘ongoing caDate PSE ORME Date of Child Line: tortarig ‘BiSO ZTE) as | In 1 oF 24 New Stat Files, tere | The exeoulve ofiwers shall ensure that | anedately and ‘See attached response 7 itrelates to | was no indicatfon that a FRI the agency is operated in conformity with | ongoing : \ ‘CPSL 6244(03) | Clearance was ever received fora | applicable Federal, State end local » andAct73.— | new employee. Statutes, orcinances and reguiatons. \n Bulletin 3490- | Date of hire: a/2trt4 Tne county agency may not hire a staff \W 0803 Date of terminaton: 8720/18, No v FBI clearance ever setained for this stat In of 24 New Stat" Files, the FBI Clearance was “eccived more than 90 days atter ihe date of hive, Date of hire: et/34 Date of disciceure satoment: sara Date of FBI clearance: 10/17/16 ‘person without frst compiying with Seciion 23.1 of the Chid Protective Senvices Law (11 P. $. § 2225-1) and (Chapter 2490 (relating fe protective services) Aplan should be developed to assure tat this mandate fe being met. Tae pian | shel tte he sat poston peor thet | Svessenabieorthe even era enforcement of this poley with staf uss ‘SiGADIRE OF Le GAL EXT NEPRERE NATIVE A etity ResReseaTV= Wet Covi TE GoLUK 6 SGN GN THE GONATURE LNG SENS SORBENT TO NOUR CIGNA OFFICE DE SBOAB Ten e SCION AND ORE AL ces asco Z GH B45 TATED ae 32DAUPHIN COUNTY SOCIAL SERVICES FOR CHILDREN AND YOUTH PROVIDERS PLAN OF CORRECTION ANNUAL LICENSING REVIEW June 30, 2015 CPS INVESTIGATIONS ORAL NOTIFICATION: 3490.58(a) In 1 of 20 CPS intake case files, the alleged perpetrator was not provided with oral notification of the report prior to the CPS interview Regulatory requirements under this section were reviewed at the June 19, 2015 CPS group supervision and Northern Dauphin Group Supervision. Ail Supervisory and Casework staff will be reminded of the regulatory requirements which will occur at the supervisory-administration and all-staff meeting on July 9, 2015. The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will review all requirements utilizing the CPS checklist which specifies the date oral notification was provided to the subjects of the report. Discipline will be provided for any infraction. ‘SAFETY OF THE VICTIM/OTHER CHILDREt 3490.55(2)(b) In 2 OF 20 CPS intake files, there was no indication that the safety of the victim child and « peg other children in the home was ensured immediately pried Teri Upon assignment of the case for investigation, the victim child will be seen immediately and/or within YUL) 2 24 hours. A subsequent assessment of the victim child’s siblings will be done within 24 to 72 hours. (Both will be conducted in conjunction with the completion of the Safety Assessment, Regulatory requirements under this section were reviewed at the June 19, 2015 CPS group supervision and Northern Dauphin Group Supervision. Ali Supervisory and Casework staff will be reminded of the regulatory requirements which will occur at the supervisory-administration and all-staff meeting on July 9, 2015. This requirement will be monitored through the completion of the safety assessment which addresses timeliness and safety of child/siblings being seen. The Supervisor/Director will meet with the ‘caseworker no less than one time every 10 days and will review all requirements utilizing the CPS checklist which specifies the date in which the child and siblings were seen. Discipline will be provided for any infraction. ), WRITTEN DOCUMENTATION OF ALLEGED PERPETRATOR'S INTERVIEW: 3490.55(e) In 1 of 20 CPS intake case files, there was no written documentation of the alleged perpetrator’s interview Rbauatory Tequirements under this section were reviewed at the June 19, 2015 CPS group supervision and Northern Dauphin Group Supervision. All Supervisory and Casework staff will be reminded of theregulatory requirements which will occur at the supervisory-administration and allstaff meeting on Luly 9, 2015. The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will review the dictation policy which has been revised to reflect the required input of dictation into CAPS, The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will review all requirements to include case note documentation in CAPS, Discipline will be provided for any infraction, PICTURES DOCUMENTING INJURIES: 3490.55(f) and 3130.21{b) as it relates to Act 126 In 1 of 20 CPS intake files, pictures documenting the child or Injuries were not found Regulatory requirements under this section and ACT 126 were reviewed at the June 19, 2015 CPS group supervision and Northern Dauphin Group Supervision. All Supervisory and Casework staff will be reminded of the regulatory requirements. The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will review face identifying photographs as well as photographs identifying the injury or lack thereof, Should subjects of the report refuse to allow photographs of the child to be taken, the Child Photograph Denial Form will be completed and entered into case documentation. Discipline will be provided for any infraction. MEDICAL EVIDENCE/CONSULTATION 3490.55 (g) In 3 of 20 CPS intake case files, medical evidence or consultation was not obtained or Ks documented in the case file. Through the course of Individual supervision or group supervision, direction surrounding the necessity for medical consultation will occur and a determination will be made and documented in case dictation. The Agency has worked with Hershey Medical Center to develop a protocol. Further meetings are placed to finalize this protocol (See attached DRAFT of Hershey Medical Center Child Protection Protocol). The caseworker will be required to obtain all medical documentation/records pertinent to the allegations or medical concerns/needs of the child. These records will be maintained in case record. ‘The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will review all requirements utilizing the CPS checklist (See attached CPS Checklist). Discipline will be provided for any infraction. GPS ASSESSMENTS TIMEFRAMI 3.490.232 (e) In 1 of 20 GPS intake files, the assessment was completed outside of the required timeframe.In 2 of 20 In-Home case files, the GPS assessment was not completed within the required timeframe, ‘The Supervisors/Directors and Caseworkers will be reminded of the 60 day maximum timeframe for which to complete an assessment. This will occur on July 9, 2015 during a staff meeting. The Supervisor/Director will meet with the caseworker no less than one time every 10 days and will monitor the 60 day time frame to ensure compliance. The caseworker will review thelr caseload and the number of days a case is pending through CAPS weekly. The caseworker will have cases submitted to thelr supervisor for review no later than 55 days. Discipline will be provided for any infraction. HOME VISIT: 3490,232 (g) In 1 of 20 GPS intake files, a visit to the child’s home was not completed. ‘The requirement that a visit s made to the child’s home as part of the GPS assessment will be reiterated to Agency staff at the supervisory-administration and all-staff meetings on July 9, 2015. Compliance will be monitored by supervisors during weekly supervision. Discipline will be provided for any resulting. infraction. 5490. 235(g) _, In 3 of 20 In-Home case files, there was no indication that the family was visited every ppg 20a. The requirement that a home visit must be conducted at least every 30 days for each family receiving in- home services will be reiterated to Agency staff at the supervisory-administration and all-staff meetings on July 9, 2025. Compliance will be monitored by supervisors during weekly supervision. Discipline wil be provided for any resulting infraction, WRITTEN NOTIFICATION: 3490.234 (b) (1-2) In 2. of 20 GPS intake files, there was no documentation that the family was notified in writing of the Agency's decision to accept or not accept for services In 1 of 20 In-Home case files, there was no documentation that the family was notified in writing of the Agency's decision to accept or not accept for services F/Director will meet with the caseworker no less than one time every 10 days and will review all requirements utilizing the GPS checklist which specifies the date in which Agency determination letters were completed and mailed to parents/caretakers. Discipline will be provided for any infraction.ONCE AND DONE 3490.232(c) 3130.21 (b) The Agency will no longer utlize this category. Three outcomes willbe used forall referrals~SCREENED OUT, INFORMATION AND REFERRAL, or ACCEPTED TO ASSESSMENT. The areas of non-compliance will rho longer be a matter of concern as any face-to-face contact with a family will be considered an / “assessment” following regulatory guidelines and timeframes. This information will be shared with supervisors and staff at the supervisory-administration and all-staff meetings on July 9, 2015. (SUPERVISORY REVIEW jo) There is a comprehensive corrective action plan for supervisory review following the list of citations in (each category—CPS, GPS, In-Home and Placement. In 13 of 20 CPS intake case files, supervisory reviews of the cases were completed outside of the timeframe In 1 of 20 CPS intake case files, supervisory reviews of the case were not completed In 7 of 20 GPS intake case files, one or more supervisory reviews were completed outside of the required timeframe. {/ tof 20 GPS intake case files, there was no indication that any supervisory reviews gi” were completed UIE /°'3130.32(a)(2) In 6 of 20 In-Home case files, there was no indication that supervisory reviews were KV completed monthly 3130.32(a)(2) In 1 of 10 Placement case files, there was no indication that monthly supervisory A reviews occurred. In 2 of 10 Placement case files, supervisory reviews were completed outside of the required timeframes. Supervisors were previously expected to provide oversight of the cases assigned to their unit within regulatory timeframes. The requirements that this be done was solidified on March 24, 2015. All supervisory staff were directed to complete 10-day supervisory reviews of all CPS and GPS assessments at the supervisory meeting on March 24, 2015. Additionally, the mandate that supervisory staff enter documentation in the CAPS system each time a 10-day supervisory review is completed was articulated at this time, As a back-up to CAPS system, a spreadsheet has been created for supervisors to track casesthat have been assigned to thelr individual units, Through this spreadsheet, supervisors are able to document the dates of supervisory reviews. Supervisors are required to review and update this spreadsheet on a daily basis, The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements, reviewing the spreadsheet on a weekly basis to ensure for compliance. Additionally, the requirement that regular supervision be provided to all ongoing casework staff on a weekiy basis was articulated to supervisors at the supervisory/administration meeting on July 9, 2015. Ongoing supervision is to be documented in the case record. Any infractions will be disciplined REQUIRED DOCUMENTATION IN CASE RECORDS RACE OF PARENTS/CHILDREN: 3130.43 (b)(3)_In 1 of 20 In-Home case files, there was no documentation of the race of the parents and the race of the child was incorrect. During an all staff meeting on July 9, 2025 staff will be reminded of the requirement to obtain accurate Identifying information which includes names, race, sex, date of birth and social security numbers for each family member. Supervisors and Quality Assurance staff will monitor during file reviews. Infractions will be disciplined. PHOTOGRAPHS OF CHILD: 3130.21(b) Asit relates to Act 126 In 6 of 20 tr-tiome case In 1 of 10 Placement case files, there wes no documented photo of the child in the , there was no documented photo of the child in the record. record. Regulatory requirements under this section and ACT 126 will be reviewed July 9, 2015 all staff meeting. Staff will be reminded of the requirement to obtain identifying photographs for all children as well as the outlined timeframes stated in the regulations for ongoing cases. Supervisors and Quality Assurance staff will monitor during file reviews. Infractions will be disciplined. FAMILY SERVICE PLANS There is a comprehensive corrective action plan for Family Service Plans following the list of citations in each category—-CPS, GPS, In-Home and Placement. COMPLETION WITHIN TIMEFRAMES: 3490.61(a) In 2 of 20 CPS intake case files, FSP was not completed when family was accepted for , services 3490.235 {b) In 1 of 20 GPS intake files, a FSP was not completed within the required timeframe.67) 3230.63 hol gHP ( expel) bt is nee \’ 3130.61{a) a Bp cof 3130.63(0) 43130.63(a) (1-4) In 6 of 20 In-Home case files, there was no indication that an FSP was completed In 3 of 20 In-Home case files, FSPs were completed outside of the required timeframe Jn 3 of 20 In-Home case files, there was no indication that a FSPR was completed In 1 of 20 In-Home case files, the FSPR was completed outside of the required timeframe In 1 of 10 Placement case files, there was no indication that an FSP was completed. In 1 of 20 Placement case file, there was no indication that a review of the FSP was completed. In 1 of 10 Placement case files, the review of the FSP was completed outside of the required timeframe yp#"| PARENTAL SIGNATURES: ~ rs 3130.61 (c) uve dja oof PF S130.610b)17) yi In 4 of 20 CPS intake case files, the FSP was developed on 11/28/14 and the parental signatures were received on 12/22/14 and 1/22/15 In 1 of 20 CP intake case files, the FSP was not signed by the parent nor was th documentation that the agency attempted to obtain parents’ signatures In 1 of 20 in-Home case files, the FSP was not signed by any participants In 4 of 20 in-Home case files, there was no indication that the parents signed or were given the opportunity to sign the FSP In 2 of 20 In-Home case files, the FSP was not signed by the child and parents in a timely manner In 3 of 10 Piacement case files, there was no indication that the parents signed or were given the opportunity to sign the FSP PARENTAL OPPORTUNITY TO PARTICIPAT joo8913061 (0) In 1 of 20 CPS intake case files, there was no indication that the parents were provided the opportunity to participate in the development of the FSP4° 3130.6x(bK7) (9) 1nd of 20 n-Home case files there was no indication thatthe parents were provided the opportunity to participate in the development of the FSP bet ye 3130.61(b){7) In 4 of 10 Placement case files, there was no indication that the parents were provided with the opportunity to participate in the development of the FSP ‘SUPERVISORY REVIEW/SIGNATURE: ip} 3130.64 (b) (7) In 7 of 20 In-Home case files, the FSP was signed by a supervisor outside of the required timeframe. In 2 of 10 Placernent case files, the FSP was signed by a supervisor outside of the required timeframe. CASEWORKER SIGNATURE: ‘e 3130.61(b)(7) In 1 of 20 In-Home case files, the FSP was signed by a caseworker outside of the () required timeframe gl) COBY PROVIDED TO PARTICIPANTS: 11 843130.61(b)(7) In 5 of 20 In-Home case files, there was no indication that a copy of the FSP was provided to the parents 24 3130.61(b)(7) Sepa? ee) In 1 of 20 In-Home case files, a copy of the FPS was not sent to the parents ina timely Owk manner sep hh) 3130.61(0K7) ity? (@) In 1 of 10 Placement case files, there was no indication that a copy of the FSP was provided to @ parent 3130.67(c)__ In 1 of 10 Placement case files, there was no indication that a copy of the FSP was provide to the court ‘SERVICE OBJECTIVES: 3130.61(b)(3) In 1 of 10 Placement case files, there were no service objectives identified in the FSP for one of the parents. At the staff meeting on April 1, 2015, the requirement that Family Service Plans will be completed within the timeframes identified in regulations—within 60 days of acceptance for in-home cases andwithin 30 days of the date of placement—was restated to supervisors and casework staff. In addition to assuring for timely completion, supervisors will also assure that caseworkers are using the CANS and FAST assessment tools to ensure that the challenges that brought the family to the Agency's attention are being addressed and that these goals/objectives are clearly articulated in the Family Service Plan document for each identified family member. ‘The Agency has been actively including family members in case planning and will ensure this occurs in all cases. Generally, caseworkers meet with families in their homes to discuss areas of concern and begin to develop consensus around a plan of action to alleviate these concerns, An increased effort has been made to utilize available family engegement strategies, namely, Family Group Conferencing, in the development of FSPs and FSPRs. Once the FSP/FSPR is developed, caseworkers discuss the family’s progress on completing the goals and objectives during regularly scheduled home visits, reviewing and re-evaluating the use of supportive services with the goal of safe case closure, In addition to review with the family, the family’s progress and the appropriateness of the goals and objectives are reviewed by the supervisor and caseworker during regularly scheduled supervision. A formal review of these documents occurs at three and six month intervals. ‘At the supervisory-administration meeting and staff meeting on July 9, 2015, supervisors and casework staff will be reminded of the requirement to involve mothers, fathers and al children over age 14 In the process and to clearly document this involvement in both the case record and on the FSP document. ‘Through Quality Assurance Reviews as well as supervisory record review, Agency will also ensure that the signed documents are maintained in the case record. While DHS regulations 3130.60 and 3130.63, do not specify a timeframe in which the FSP/FSPR document must be signed, supervisory and casework staff will be directed to obtain the signatures of family members within 10 days of the compietion of the FSP/ESPR. Although caseworkers were always expected to ensure that all parties were provided a copy of the completed FSP/FSPR documents, this requirement will be restated at the supervisory-administration meeting and staff meeting on July 9, 205. Staff will also be reminded of the importance of recording the date this action occurred on the FSP/FSPR. Additionally, both supervisors and caseworkers will be reminded of the need to review progress on the Identified goals during each visit with the family and to document the efforts made toward achieving these goals in the case record via CAPS. In cases In which the court is involved with a family, the FSP/FSPR is attached to court documents presented to the court for permanency review hearings. These documents are also provided to the parents and the parents’ attorneys. Supervisors will hold their staff accountable to these requirements during regularly scheduled supervision. Directors will monitor compliance on @ monthly basis. Discipline will be provided for any resulting infraction. Quality Assurance staff will also monitor compliance with this directive during case reviews. Presently, there is a Program Specialist assigned to conduct quality assurance reviews of ‘Agency case files. Two casework level staff are scheduled to be added to the component on or aboutAugust 3, 2015. A statistical analyst will be added in August 2015. By September 2015, the Agency should have a fully operational Quality Assurance Unit led by @ Quality Assurance Manager. CHILD PERMANENCY PLAN There is a comprehensive corrective action plan for Child Permanency Plans following the list of citations In each category. ,.o? COMPLETION WITHIN TIMEFRAME: off i ff “# 3130.61(b\(6) In 1 of 10 Placement case files, there was no indication that a CPP was completed 4) In 1 of 10 Placement case files, the CPP was completed outside of the req) timeframe 3130.63(b) _In 1 of 10 Placement case files, the CPP was completed outside of the required timeframe J) PARENTAL SIGNATURE: 3130.61(c) in 3 of 10 Placement case files, there was no indication that the parents were given the fait opportunity to sign the CPP SUPERVISORY REVIEW/SIGNATURE: '3130.61(c)__In 2 of 10 Placement case files, the CPP was signed by a supervisor outside of the required timeframe _) CASEWORKER SIGNATURE: upf2°)3130,61(c)__ In 1 of 10 Placement case files, the CPP was signed by the caseworker outside of the shales required timeframe agit he 4. f5~ "PARENTAL OPPORTUNITY TO PARTICIPATE: ef] 3130.61(d) m2 oF 10 Placement case files, there was no indication that the parents were given the 2 ‘opportunity to participate in the development of the CPP pppoe a 2» ( ied, COPY PROVIDED To PARTICIPAN indication that the parent was provided a IN|! 3230.61(e) In 1 of 10 Placement case files, there was n copy of the CPP At the staff meeting on July 9, 2015, the requirement that Child Permanency Plans will be completed within the timeframes identified in regulations will be restated to supervisors and casework staff. In addition to assuring for timely completion, supervisors will also assure that caseworkers are using the CANS assessment tool to ensure that the challenges that brought the child or youth to the Agency's10 attention are being addressed and that these goals/objectives are clearly articulated in the Child Permanency Plan document for each identified child in the family. ‘The Agency will actively involve the family in the development of these documents through a family engagement meeting, an office visit or a scheduled home visit with the family. Supervisors will review the completed document and provide their signature according to regulations, The completed CPP document will be provided to the family and parental signatures will be obtained. The date that these actions occurred will be clearly documented on the CPP. Supervisors will hold their staff accountable to these requirements during regularly scheduled supervision. Directors will monitor compliance on a monthly basis. Discipline will be provided for any resulting infraction. Quality Assurance staff will also monitor compliance with this directive during case reviews. As stated previous, by September 2015, the Agency should have a fully operational Quality Assurance Unit. RISK ASSESSMENT There is a comprehensive corrective action plan for Risk Assessment following the list of citations in each category—CPS, GPS, In-Home and Placement. |, COMPLETION WITHIN TIMEFRAMES: “ae 3490.61{a) _In 1 of 20 CPS intake case files, supervisor signed a completed Risk Assessment outside of the required timeframe In 1 of 20 CPS intake case files, Risk Assessment was completed outside of the required timeframe at the conclusion of the investigation plies fi (3490.321 (h) In 2 of 20 GPS intake files, there was no documentation that a Risk Assessment was completed at the conclusion of the assessment period, In 2 OF 20 GPS intake files, a Risk Assessment was completed at the conclusion of the assessment period but it was completed outside of the required timeframe. In 8 of 20 In-Home case files, there was no indication that periodic Risk Assessments were completed | 1 of 20 In-Home case files, a periodic Risk Assessment was completed late In 4 of 20 In-Home case files, there was no indication that a Risk Assessment was ‘completed within 30 days of case closure ow! |, 3490.324(0)G) In 1 of 10 Placement case files, there was no documentation in the record that a Risk 4 Assessment was completedcer In 1 of 10 Placement case files, the Risk Assessment was completed outside of the required timeframe [SUPERVISORY REVIEW/SIGNATURE: 3490.32 (d) In 1 of 20 GPS intake files, there was no documentation that a supervisor signed a completed Risk Assessment In 1 of 20 In-Home case files, there was no documentation that a supervisor signed a completed Risk Assessment In 7 of 20 In-Home case files, the supervisor reviewed and signed the Risk Assessment outside of the required timeframe () SUPPORTING DOCUMENTATION FOR RATING: yo “ 3490.32! (f) In 1 of 20 GPS intake files, there was no documentation within the Risk Assessment that Hanh dlscussed and supported the ratings for each factor. at] ASSESSMENT OF ALL CHILDREN RESIDING IN THE HOME je) 3490.321 (f) In 1 of 20 CPS intake case files, risk was not assessed for all children residing in the home All casework staff have been trained on the utilization of the RISK ASSESSMENT TOOL and the intervals ‘and timeframes in which the tool is to be completed. At the staff meeting on April 1, 2015, the Agency's policies and procedures related to risk assessment were reviewed. Timely completion and the requirement that each factor on the risk assessment tool is rated and supporting documentation entered in the family record were also addressed. Any significant change in risk will be clearly articulated on the case closure risk assessment and the factors that led to this change will be documented in the family record. Supervisors were previously expected to review and approve Safety Assessments completed for cases assigned to thelr unit within regulatory timeframes, The requirement that this be done was solidified on March 24, 2015. At the supervisory meeting on March 24, 2025, all direct service supervisory staff were directed to review all completed safety assessment documents within regulatory timeframes, As a back- up to the CAPS system, a spreadsheet has been created for supervisors to track cases that have been assigned to their individual units. Through this spreadsheet, supervisors are able to document the dates of completion and supervisory review. Supervisors are required to review and update this spreadsheet ona dally basis, The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements, reviewing the spreadsheet on a weekly basis to assure for compliance. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. The spreadsheet is attached for reference. Discipline will be provided for any resulting infraction.2 SAFETY ASSESSMENT There is a comprehensive corrective action plan for Safety Assessment following the list of citations in each category—CPS, GPS, In-Home and Placement. COMPLETION WITHIN TIMEFRAME: 3130.21 (b) In 1 of 20 CPS intake case files, the closing Safety Assessment was completed, but the children had not been seen in over 30 days. * 3130.21 (b) in 2 of 20 CPS intake case files, a Safety Assessment was not completed prior to case closure, {ied 8130.24 (b) In 1 of 20 GPS intake case files, the closing Safety Assessment was completed, but the weed children had not been seen in over 30 days Diout 3130.21(b) In 1 of 20 GPS intake case files, the preliminary Safety Assessment was completed outside of the required timeframe Apap iy 3130.21 (b) In 1.0f 10 “Once and Done” case files, the preliminary Safety Assessment was completed peel pl outside of the required timeframe ® pee aoulis 3130.21(b)__In 6 of 20 In-Home case files, there was no indication that Safety Assessments were completed fcone hcl {9G.3130.21(b) In 1 of 20 In-Home case files, there was no indication that the closing Safety Assessment was completed at the conclusion of the GPS assessment - “ € e 3130.21(b) —_ In 3 of 20 In-Home case files, the closing Safety Assessment was completed outside of oat the required timeframe at the conclusion of the GPS assessment [sz 3130.21(b) In 1 of 20 In-Home case files, the closing Safety Assessment was completed, but the 0 Hy children had not been seen in over 30 days jyyezl) SUPERVISORY REVIEW/SIGNATUR 2 3130.21 (b) In 5 of 20 CPS intake case files, one or more Safety Assessments were signed by the supervisor beyond the required timeframe * 3130.21 (b) In 5 of 20.CPS intake case files, one or more Safety Assessments were signed by the supervisor beyond the required timeframe 3130.21(b) _ In 1 of 20 GPS intake case files, there were one or more Safety Assessments that were not signed by a supervisor wt ff?" 3130.21(b) In 1 of 20 GPS intake case files, there were one or more Safety Assessments that were signed by a supervisor outside of the required timeframe23 peryy vi!" 3130.21(b) In 7 of 20 In-Home case files, there were one or more Safety Assessments that were : signed by the supervisor outside of the required timeframe, 3130.21(b) _In2 of 20 n-Home case files, there was no Indication thet one or more Safety Assessments were signed by a supervisor. In 1 of 10 Placement case files, there was one Safety Assessment that was signed by the supervisor outside of the required timeframe psossi)), CASEWORKER SIGNATURE: joshi 3130.21(b) In 2 of 20 GPS intake case files, there were one or more Safety Assessments that were : signed by the caseworker outside of the required timeframe spond beck fg@ 3130.21(b) tn 4 of 20 In-Home case files, there were one or more Safety Assessments that were : signed by the caseworker outside of the required timeframe /,) CORRECT RATING: 3130.21 (b) In 1 of 20 CPS intake case files, the child was determined to be “safe”, however a Safety Pian was stil developed je /°3130.24(b) In 2 of 20 In-Home case files, safety threats were identified but there were no protective a capacities documented for the caregivers. [-(i#)) 3130.24(b) In 1.0f 20 In-Home case filles, a safety threat was identified but the protective capacities documented were for a different safety threat In 1 of 20 In-Home case files, the Safety Analysis questions on the safety assessment worksheet were not completed, despite threats being present pid ye J01'3130.21(b) In 3 of 20 In-Home case files, the child was “unsafe” and in placement but was assessed as “safe” on the Safety Assessment p(y! AULCHILDREN IN HOUSEHOLD aSsesseD/usTE fey 3130.21 (b) In 2 of 20 CPS intake case files, not all of the children in the family household were listed wall on the Safety Assessment probes sd f° PH%3130.21(6) In 2 oF 20 GPS intake case files, It was documented that al ofthe children were seen but ferry age not all of the children were listed on the Safety Assessment "T3159 211b) in oF 20 n-Home case files, a Safety Assessment was completed without the parents het being seen pens 3130.22(b) _In 1 of 20 In-Home case files, a Safety Assessment was completed without the children i being seen4 The Agency recognizes the Importance and role of safety assessments in the case process. All casework staff have been trained in the utilization of SAFETY ASSESSMENT TOOL and the intervals and timeframes in which the tool Is to be completed. The need for accuracy on each individual document as well as consistency between documents was articulated. A written copy of the policy regarding safety assessments will redistributed to all direct service staff on August 6, 2015. ‘ Shpervisors were previously expected to review and approve Safety Assessments completed for cases assigned to their unit within regulatory timeframes. The requirements that this be done was solidified ‘on March 24, 2015. At the supervisory meeting on March 24, 2015, all direct service supervisory staff were reminded and directed to review all completed safety assessment documents within regulatory timeframes. Subsequent discussions occurred at supervisory-administration and staff meetings on April 4, 2025, May 7, 2015 and June 4, 2015. Supervisors are to pay particular attention to the safety determinations ~"safe”, “safe with a plan” and “unsafe” assuring that the resulting plan corresponds to the determination, Asa back-up to the CAPS system, a spreadsheet has been created for supervisors to track cases that have been assigned to their individual units. Through this spreadsheet, supervisors are able to document the dates of completion for Safety Assessments as well as monitor the due dates of future assessments, Supervisors are required to review and update this spreadsheet on a daily basis. The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements, reviewing the spreadsheet on a weekly basis to ensure for compliance, Any infractions will be disciplined. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. p SAFETY PLAN WLP copie! 3230.21 (b) 1 0f 20 CPS intake case files, the Safety Plan was not signed by the party responsible for yo the safety and monitoring of the plan Supervisors and casework staff will be reminded of the importance of having all parties responsible for assuring for children’s safety to document their agreement by placing their signature on the Safety Plan. Supervisors will assure for the accuracy and completion of each individual document during their regulatory review of the document, prior to placing their signature on the document. Supervisors will hold their staff accountable to these requirements during regularly scheduled supervision. Directors will monitor compliance on a monthly basis. Discipline will be provided for any resulting infraction. Quality Assurance staff will also monitor compliance with this directive during case reviews. As stated previous, : by September 2025, the Agency should have a fully operational Quality Assurance Unit. Any infractions will be disciplined, VISITATION PLANS -3130.68(f) (2)(2) 12 of 20 Placement case files, notification of the visitation plan with the child ‘was not provided to the child’s parent within the required timeframe. At the supervisory-administration and all-staff meetings on July 9, 2015, the requirements of developing 2 visitation plan with parents whose child are in out-of-home care, and providing a copy of the plan to15, parents will be reiterated. Supervisors will review these requirements during weekly supervision with caseworkers, The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements. Any infractions will be disciplined. Additionally, the Quality ‘Assurance Unit will monitor compliance with this directive during case reviews. FOSTERING CONNECTIONS 3130.21 (b) In 2 of 10 Placement case files, identified relative resources were not notified as within the required timeframe of their opportunity to be part of the planning for the child's placement and provided the opportunity to be a potential caregiver fora child, ‘At the supervisory-administration and all-staff meetings on July 9, 2015, the requirements of the Fostering Connections to Success and Increasing Adoptions Act of 2008 will be reiterated, stressing the importance of identifying and engaging relatives from the point of referral throughout a family’s involvement with the Agency. A genogram accompanies each new referral that Is provided to a caseworker for assessment. The requirement that the caseworker continues to expand this genogram, through ongoing conversations with parents and family members and the use of search engines such as ACCURINT, to identify and document potential resources prior to out-of-home placement will be stressed. The requirement to involve these family members in planning will also be addressed. Supervisors will review these requirements during weekly supervision with caseworkers. The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements. Any infractions will be disciplined. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. GRIEVANCE POLICY AND PROCEDURE FOR CHILDREN IN FOSTER CARE 3130.88 Asit relates to Act 119. In 1 of 10 Placement case files, there was no indication that the child grievance policy procedure had been explained to the child/parent/caregiver. 3130.88 As itrelates to Act 119 In 1 of 10 Placement case files, the child grievance procedure was completed outside of the required timeframe. 3130.21(b) Asit relates to Act 119 In 1 of 10 Placement case files, there was no indication that a copy of the protections and the grievance policy and procedure were provided to the child ‘At the supervisory-administration and all-staff meetings on July 9, 2015, the requirements of providing age-appropriate children, parents and other responsible parties with the Child Grievance Policy and Procedure will be reiterated, The completion of this requirement is to be documented on the PLACEMENT CHECKLIST (see attached) which can also serve as a reminder to both the caseworker and' 16 supervisor. Supervisors will review these requirements during weekly supervision with caseworkers. Signatures of both the supervisor and the caseworker are also required on the completed PLACEMENT CHECKLIST. The Directors of Social Service will hold the supervisory staff under thelr oversight accountable to these requirements. Any infractions will be disciplined. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. EDUCATIONAL RECORDS 3130.43(c) (10) In 1 of 10 Placement case files, there was no indication that educational records were \s received for the child or that they were requested, ‘At the Agency's staff meeting on April 1, 2015, the requirement to obtain information from any agency involved with the family was discussed. The need to obtain educational records for all children in placement will be reiterated to supervisors and staff at the supervisory-administration and staff meetings on July 9, 2015. The completion of this requirement is to be documented on the PLACEMENT CHECKLIST (see attached) which can also serve as a reminder to both the caseworker and supervisor. Signatures of both the supervisor and the caseworker are also required on the completed PLACEMENT CHECKLIST. The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements. Any infractions will be disciplined. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. yo DENTAL CARE In 1 of 10 Placement case files, the initial dental examination of the child was completed i outside of the required timeframe. nye" 3700.51(e) In 1 of 10 Placement case files, the updated dental examination of the child was completed outside of the required timeframe. ‘At the supervisory-administration and all-staff meetings on July 9, 2015, the requirements of following the required timeframes for assuring for dental examinations for children in out-of-home care will be reiterated. Supervisors will review these requirements during weekly supervision with caseworkers. The Directors of Social Service will hold the supervisory staff under their oversight accountable to these requirements. Any infractions will be disciplined. Additionally, the Quality Assurance Unit will monitor compliance with this directive during case reviews. |) FOSTER CARE 3130.21(b] |, Asitrelates tor "Act 160 In 3 of 40 New Foster Family Case Files, the resource family registration application was not submitted to the Resource Family Registry within the required 30 days of their approval/disapproval.4 7 3130.21(b) Asit relates to ‘Act 160 In 1 of 40 New Foster Family Case Files, there was no indication that the resource family registry was updated when the resource family was closed, ‘The Foster Care Program Manager will assure that all registrations and updates are made to the Family Resource Registry within the 30 day timeframe, Although the initial study is completed by Families United Network the Foster Care Program Manager will review the file upon completion of the home study and submission to Dauphin County Children and Youth for final approval. The staff of Families United will submit a family registry for FUN and the Foster Care Program Manager will submit a final registry for Dauphin County to the Resource Registry. The Foster Care Program Manager will assure that both of these tasks are completed and a copy of the documents will be maintained in the Agency file. ‘This procedure will be followed for all families opening as a foster parent as well as all updates and closings. In 5 of 40 New Foster Family Case Files, there was no indication that the resource family was provided with information regarding the child placed in their home. Dauphin County CYS caseworkers and supervisors will complete the Placement Request Form (please see attached form) and submit it to the on call worker with Families United Network, The referring/on- call worker will then discuss all of the information contained in the Placement Request Form with the potential foster parent/resource family. Upon accepting the child for placement, @ copy of the Placement Request Form will be provided to the resource family. The resource family will then another copy acknowledging that they received the Placement Request Form and were informed of all factors relating to the child. Additionally, caseworkers and supervisors will complete the Placement Request Form and review it with all identified kinship resources agreeing to accept the child into their home to assure they are aware of all factors relating to the child. The signed documents will be placed into the foster parent record. Should additional information become available regarding the child, an updated Placement Request Form will be completed by the family’s caseworker, provided to the resource family and appropriate signatures obtained to document that the Information was shared. The signed documents will be placed into the foster parent record. vee) s130.21(b) Asit relates to > Act 119 In 2 of 40 New Foster File Case Files, there was no indication that the resource family was provided with a copy of the protections for children in foster care at the time of their approval. The Foster Care Program Manager will instruct and assure that all staff working on completing foster home profiles through Families United Network are aware of this regulation on July 21, 2015. Upon completion of the home study and review of the final documents, the Foster Care Program Manager will18 ensure that all documents were completed and are part of the file, The Foster Care Program Manager will utilize the existing foster parent tracking sheet to document all forms received. 3700.69, In 1 of 6 Tenured Foster Family Case Files, there was no date of completion listed on the | annual reevaluation document. Upon receipt of the reevaluation tool the Foster Care Program Manager will assure that all dates are filled in properly. The Families United worker will be instructed to ensure that they complete the form and put all necessary dates properly on the form, The Foster Care Program Manager will provide this direction to the supervisor of the Families United Program on July 21, 2015. PERSONNEL 3130.51(a) Dauphin County now operates under a state approved merit hire system that requires te annual performance reviews for employees. Annual performance reviews will be ‘completed on time for each employee who is not on probationary status. The Agency Administrative Assistant will maintain a spreadsheet tracking the due dates for all staff performance reviews. Three months prior to the required completion date, the Administrative Assistant will send a notice via email to the person responsible for completion of the performance review. if a performance review is late the person responsible for the review will required to attend a pre-disciplinary conference to ‘answer why the annual review was not conducted. If the response does not satisfactorily answer why the review was late the staff person will have a disciplinary letter placed in his or her personnel file and this may have an impact on their annual review if t occurs more than once. 3.490.312 (d) (8) (i) j ‘There is no reasonable excuse for any Dauphin County Social Services for Children and Youth staff member not to have at least 20 hours of required annual training. The Quality Assurance Unit will be responsible for assuring compliance with staff training, The QA Unit will maintain a spreadsheet for all direct service workers noting training type, hours and dates of attendance. Information regarding training will be provided to supervisors on a quarterly basis to assure that all direct service staff has obtained the 20 hours of required training hours per year. 3130.54 (c) CPSL 6344(b)(1), 3130.21(b) CPSL 6344 (b3) and act 73 bulletin 3490-08-03 (/ Ih compliance with the noted subsection of the CPSL, the Agency will permit the provisional hire of applicants on a provisional basis for a single period not to exceed 90 days from the initial start date provided the prospective employee has provided copies of their clearance requests to the Administrative Assistant, and has sworn in writing that they are not disqualified from employment under 6344{c}. If hire provisionally, said19 employee will not be permitted to work alone with children and will be required to work In the immediate vicinity of a permanent employee. This requirement will be in place as of 6/30/15. See three attached policies—B0100, 80110 and 80120.