Form M-6B Remote Monitoring Notes

Updated: 09/15/2020 OMB 0970-#### [valid through MM/DD/YYYY]

_____________ Remote Monitoring Notes

Grant #:		Capacity
Program Director		Address
PO		FFS
CFS		ORR Medical
PSA		GDIT CC

Pre-Monitoring Review

Grant application/cooperative agreements

(See GrantSolutions for Grant Information. See S:\ Drive or ask PO for Cooperative Agreement)

• Grant Budget Period and Expiration date:

• Is the Cooperative Agreement current?

Follow up notes:

Past monitoring trip reports or corrective actions issued by PO/FFS

(See S:\ drive)

• Dates of past monitoring trips:

• Findings/Corrective Actions from monitoring trip reports and/or PO/FFS:

Follow up notes:

Past OIG Reports

(See https://oig.hhs.gov/reports-and-publications/featured-topics/uac/)

• Dates of OIG visits:

• Findings/Corrective Actions from visit:

Follow up notes:

Quarterly/Annual Report

(See GrantSolutions or S:\ drive)

• Read the last two Quarterly/Annual Reports

• Recent capacity expansion

• Recent new employees or equipment

• Issues identified

• Stated services provided to UAC (e.g. vocational)

Follow up notes:

Current approved Fiscal Year Budget

(See S:\ drive or ask PO)

• Review budget narrative to get familiar with staff and their proposed roles/responsibilities

• Staff ratio in line with positions described in organizational chart?

• Supplies/equipment approved in the budget that monitor should see during walkthrough?

Follow up notes:

Key Position Approved by PO?

(See S:\ drive)

• Review the organizational chart/staff list to identify staff in key positions (PD, APD, Lead Clinician, Lead Case Manager, all clinicians, and PSA Compliance Manager) at program

• Check S:\ drive to see if the key positions have been approved by the PO? If not, follow-up with the assigned PO.

Follow up notes:

Care Provider’s website (if applicable)

(Use the internet)

• UAC pictures included?

• Shelter address included?

• UAC information (if included) accurate and in-line with public information on ORR’s website?

Follow up notes:

Review SIR Report populated in the UAC Portal

(Check UAC Portal for recent SIRs by changing search dropdown to “Event” and typing in program’s name.)

• Review recent SIRs (e.g. past 6 months):

1. Identify notable SIRs (e.g. abuse allegation on-site, medical emergency, etc.) to follow-up on, as applicable; and

2. To potentially select a case file(s) to request from the program.

Follow up notes:

Review of completed Site Visit Guide (SVG)

(Request from care provider)

• Identify personnel assigned to coordination of services duties such as coordination of UAC transportation, education, primary medical provider, etc.

• Legal Service Provider:

• Discrepancy between procedures mentioned and ORR P&P:

• Understanding challenges posed by care provider

• Identifying potential issues outside the norm

• Follow up questions for Care Provider

• Add items to facility walkthrough

Follow up notes:

List of Documents that have been Referred to the PO or PSA for Clearance (if not included under Program Management Question 1)

• Review the list to confirm that the below have been submitted/cleared by ORR. If not, consult with the PO.

1. Zero Tolerance Policy

2. Staff Reporting Policies and Procedures

3. Coordinated Response and Sexual Abuse

4. Attorney Client Visitation Rules

Follow up notes:

Program’s Staffing Plan (if not explained in the SVG under Child Protection Question 1)

• Does the staffing plan meet the ORR minimum requirements for client to staff ratio requirements?

Follow up notes:

UAC Orientation Packet

• Are all ORR required Orientation topics covered?

• Is the information in line with ORR policies and procedures?

• Is it child friendly?

Follow up notes:

Behavior Management Plan (if not explained in the SVG under Intake and Orientation Services Question 2)

• Review the Behavior Management Plan. Does the behavior management plan meet the Flores requirements i.e. “Program rules and discipline standards shall be formulated with consideration for the range of ages and maturity in the program and shall be culturally sensitive to the needs of alien minors. Minors shall not be subjected to corporal punishment, humiliation, mental abuse, or punitive interference with the daily functions of living, such as eating or sleeping. Any sanctions employed shall not: (1) adversely affect either a minor's health, or physical or psychological well-being; or (2) deny minors regular meals, sufficient sleep, exercise, medical care, correspondence privileges, or legal assistance”?

Follow up notes:

Background Checks for Staff, Volunteers, and Contractors (SVG attachment)

• Review the entire list to ensure that staff, volunteers, and contractors are receiving the ORR required background checks (ORR Guide 4.3.3):

  • A FBI fingerprint check of national and state criminal history repositories;

  • A child protective services check with the staff’s State(s) of U.S. residence for the last five years; and

  • Background investigation updates at a minimum of every five years of the staff/contractor/volunteer’s start date or last background investigation update.

• Have you identified any background discrepancies to discuss with the program?

• Are there specific files you plan to pull on-site?

Follow up notes:

Educational Assessment Tools

• Does the program have an educational assessment tool that enables them to assess the UAC’s educational level?

Follow up notes:

Personnel File Checklists

• Review the personnel file checklists completed by the program’s HR/Training department personnel.

• Based on your review, are there any additional personnel file documents you plan to spot-check while on-site in addition to the one randomly selected case manager’s personnel file?

Follow up notes:

1. Map of facility (SVG attachment)

• Helpful for getting oriented to campus and also to identify if more or less time may be needed for facility walkthrough which may influence the monitoring agenda

2. Emergency Plan (SVG attachment)

• Does the program have a current evacuation plan in place for hurricanes, fires, or other emergencies, as applicable?

Follow up notes:

3. Quality assurance procedures and internal monitoring resources (SVG attachment)

• Do they have formal procedures where a supervisor/lead checks documents for quality assurance and follow up with deficiencies?

• How often do they review UAC case files, and other program documents for compliance?

Follow up notes:

4. Internal Procedures (SVG attachment)

• Code of Conduct – should include employee’s obligations with respect to interactions and interventions with UAC, staff, and external stakeholders. Must include respecting boundaries, zero tolerance for sexual abuse and harassment, not providing legal advice to UAC, therapeutic counseling only if properly licensed and authorized, maintaining professional standards, not discriminating against any person, employing strength-based behavior management approaches, cooperating with official investigations, reporting any criminal or inappropriate conduct, and protecting staff and UAC from retaliation if they disclose or threaten to disclose the existence of an illegal or unsafe practice. (See Cooperative Agreement p. 16-18 for full description and also ORR Guide 4.3.5.)

• Grievances – should include procedures on handling time-sensitive incidents reported as a grievance that involve an immediate threat, include issuing a written decision to a grievance within 5 days of receipt, and that youth may obtain assistance from another youth, care provider staff, family members, or legal representative to prepare a grievance.

• Conflict of Interest – should identify and define conduct that creates a conflict of interest, prohibit employees form having any direct or indirect financial interests in services of the program, require staff to recuse themselves from decision-making if there is a conflict of interest, require staff to disclose conflicts of interest, state that failure to disclose conflicts of interest may result in discipline or termination. (See Cooperative Agreement p. 19 for full description.)

Follow up notes:

5. Recent organizational chart of facility staff and full staff list (SVG attachment)

• Org Chart: Identify lines of communication and authority – helpful when addressing issues at care provider site

• Full staff list: Review staffing ratios. Also may be helpful for identify potential staff to interview and/or whose personnel file you may want to review onsite.

Follow up notes:

6. Education curriculum and weekly class schedule (SVG attachment)

• Ensuring all basic classes per Flores/ORR Guide are covered (Science, SS, Math, Reading, Writing, and PE)

• Ensuring UAC are receiving 6 hours of structured education daily

• Ensuring that there are different level curriculums to address the various UAC educational levels:

Follow up notes:

7. Food services/menus and employee food safety certifications (SVG attachment)

• Are meals prepared in accordance with nutritional guidelines as defined by DOA and State guidelines?

• Are meals prepared with sensitivity to cultural dietary practice when possible?

• Are the employee food safety certifications current?

Follow up notes:

8. Current State License (SVG attachment)

• Who is the state licensing entity?

• What age, total capacity, level of care, etc. is the facility licensed to serve?

• Is the license valid/active?

Follow up notes:

9. State licensing requirements and recent state licensing inspection and/or CPS reports (SVG attachment)

• Is the program in compliance with state licensing?

• When was the last inspection? Were there any corrective actions?

• Have there been any CPS complaints/reports?

• If yes, were the complaints substantiated or unsubstantiated?

Follow up notes:

10. Two recent vehicle inspection (SVG attachment)

• How often does it occur?

• Any deficiencies found? If so, when were they corrected?

Follow up notes:

11. List of UACs that are represented by attorneys (i.e. that have a G-28 on file (SVG attachment)

• Are there any UAC who have a G-28? If so, review the G-28 list with the CFS and go over the UAC Monitoring UAC interviewing guidance with the CFS.

Follow up notes:

12. List of trainings all personnel receive annually and how correspond to ORR trainings (SVG attachment)

Potential Reference: Personnel File Checklist.

• Are the annual trainings in line with ORR required trainings?

Follow up notes:

13. Safety and sanitation certificates and Fire inspection report (SVG attachment)

• Are the safety and sanitation certificates current?

• When was the last fire inspection conducted? Were any violations cited?

Follow up notes:

14. Mosquito Control Inspection (SVG attachment, if applicable)

• When was the last inspection? Were there any deficiencies? If so, when were they corrected?

Follow up notes:

Review UAC Case Files (including the electronic case file documents in the ORR database)

(Request from care provider.)

Use UAC Case File Checklist

Follow up notes:

Consult with program PO, FFS, CFS, Medical Coordinator Specialist, and Intakes

(Request from ORR Federal/Contractor staff)

• Recent emergency SIRs

• Potential issues to research

• Key personnel recently approved by PO

• Name of specific personnel/ UAC to meet

• Specific case files to review

• FFS/CFS reports

PO:

FFS:

CFS:

Medical Coordinator Specialist:

Intakes:

PSA:

ORR Management (if applicable):

Legal Service Provider Interview

• Were there any issues/concerns raised by the LSP?

Follow up notes:

GDIT Case Coordinator Interview

• Were there any issues/concerns raised by the Case Coordinator(s)?

Follow up notes:

Monitoring Plan based on pre-monitoring review

• Any additional stakeholders (GDIT CC, LSP, State Licensing, public school principal, etc.) to schedule a conference meeting during remote monitoring?

• Does the agenda need to be adjusted?

• Additional questions for Entrance Meeting/Care Provider PD

• Additional items to look for during facility virtual walkthrough (Document: On-Site Monitoring Checklist)

• List of case files to potentially review

• Possible UAC to interview

• Additional questions for UAC interviews

• Possible staff to interview

• Additional questions for staff interviews

• Questions/additional questions for stakeholders

• List of personnel files to potentially review virtually

• List of documents to potentially review (Document: On-Site Monitoring Checklist)

• Other issues to address

Remote Monitoring Activities

Entrance Meeting

Introductions and Background on the UAC Monitoring Team:

• Do introductions.

• Explain your role/role of the monitoring team i.e. to conduct a comprehensive review of a program, no less than every two years to ensure compliance with all ORR requirements.

Primary Goals:

• Look at compliance with governing statutes, ORR policies and procedures, regulations and cooperative agreement in meeting program performance goals with a focus on ensuring that:

  • UAC provided with a safe and appropriate environment.

  • UAC provided with client-focused care to maximize UAC’s opportunities for success both while in care and upon release.

This visit is not a ‘gotcha’, but rather we are here to work with you to strengthen the program and services for UAC, if needed.

Secondary Goals:

• Assist programs to understand what their responsibilities are

• Identify areas where technical assistance may be helpful

• Identify successful and innovative program implementation/administration techniques.

• Answer Grantee’s questions or provide answers as soon as possible

To accomplish these goals:

• Tour facilities to assess the adequacy of meeting UAC needs

• Review records (if any personnel file documents maintained separately, need them all when reviewing personnel files i.e. I-9), participant files, and other relevant records to ensure administrative compliance

• Interview UAC

• Conduct interviews with service provider staff, participants and employers to obtain information about program administration, operations, and quality of service provided

• Conduct monitoring review

• Conduct exit conference after completion of the review. This conference should cover at least a discussion of the following: General findings. Process and schedule for formal report including the mechanism for Grantee feedback.

Request the following documents:

• UAC Roster with UAC Admission date, assigned CM and Clinician

• Staff Roster (with staff title and start date)

• Education/Academic Schedule

• Weekly/Daily/Monthly UAC Activity Schedule

Also ask relevant questions for Care Provider PD selected as a result of pre-monitoring review

Remote Facility Walkthrough

( Monitoring Checklist)

General Findings:

UAC Case Files to Request

Additional Questions resulted from UAC Interviews

Staff to Interview

Additional questions for Youth Care Workers

• Do staff/case managers demonstrate a general understanding of all ORR/UCP P&P?

Additional questions regarding Educational Services

• Do staff/case managers demonstrate a general understanding of all ORR/UCP P&P?

Additional questions for Case Management

• Do staff/case managers demonstrate a general understanding of all ORR/UCP P&P?

Additional questions for Clinician

• Do staff/case managers demonstrate a general understanding of all ORR/UCP P&P?

Additional questions/topics for Lead Clinician

Additional questions/topics for Lead Case Manager:

Additional questions for Program Management:

Issues/Concerns raised by Care Provider

Interviews with Field Staff, GDIT CC, Stakeholders, etc.

Personnel Files to Review

Additional items to review/research in relation to personnel files

• Do the pre-service training requirements meet State and ORR/UCP policy? How many hours?

Observe UAC Activities

(See the Remote Walkthrough Monitoring Checklist)

General Findings:

Additional Documents to Request /Items to follow-up on:

(See the Remote Walkthrough Monitoring Checklist)

General Findings:

Exit Meeting

Positives

Items to improve

Next Steps

Part One:

The Provisional Formal Report should be finalized within 30 business days. It will mainly include all the information presented during this meeting. The care provider will have 30 business days to respond with a comprehensive corrective action plan. This corrective action plan should be sent to your assigned PO, who will follow-up with the program and provide any further technical assistance. Please copy the UAC monitor(s) and FFS/CFS on your response.

Part Two:

The Close-Out Final Report will be determined when ORR staff has an opportunity to go on-site and compete all pending activities resulted from remote monitoring. At that time, a final report will be issued closing out the monitoring visit.

Thanks for your hospitality.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR Monitoring Team staff to compile comprehensive notes and information related to biennial monitoring visits. Public reporting burden for this collection of information is estimated to average 12 hours per response (if the site visit is performed by a contractor monitor), including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.