Form M-6A-UF Form M-6A-UF Unlicensed Facility Monitoring Notes

Updated: 04/22/2022 OMB 0970-0564 [valid through MM/DD/2026]

Unlicensed Facility (UF) Quarterly Health and Safety Monitoring Notes

_____________ Monitoring Trip

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

Directions: Each section of the Pre-Monitoring Review of this document must fully be completed by UC Monitors. UC Monitors have the option to complete the Monitoring Plan Based on Pre-monitoring Review, Monitoring Activities and Exit Meeting sections of this document or use external tools to document these activities. UC Monitors are required to upload the Monitoring Notes Template and other tools used into the S:\ Drive monitoring reports folder.

Pre-Monitoring Review

Grant application/cooperative agreements

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

• 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:

Quarterly/Annual Report

(See GrantSolutions or S:\ drive)

• Read the last Quarterly/Annual Report

• Recent capacity expansion

• Recent new employees or equipment

• Issues identified

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

Follow up notes:

Care Provider’s website (if applicable)

(Use the internet)

• UC pictures included?

• Shelter address included?

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

Follow up notes:

Review SIR Report populated in the UC Portal

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

• Review recent SIRs (e.g. past 3 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 UC 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:

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:

UC 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):

  • An 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:

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?

• Does the evacuation plan include a list of agencies and individuals to notify in the event of an evacuation, including ORR contacts, DHS, and local law enforcement (UC MAP Section 3.3.4)?

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)

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

• Are meals prepared with sensitivity to cultural and special dietary needs?

• 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 UCs that are represented by attorneys (i.e. that have a G-28 on file (SVG attachment)

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

• Notify the CFS that if a child has a G-28 and indicates that he/she wants to be interviewed with his/her attorney, that we will not interview the child. If the child has a G-28 and does not want his/her attorney present, we can proceed with the interview.

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:

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

(Request from care provider.)

Use UC Case File Checklist

Follow up notes:

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 meet with during monitoring trip?

• Does the agenda need to be adjusted?

• Additional questions for Entrance Meeting/Care Provider PD

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

• List of case files to potentially review on-site

• Possible UC to interview

• Additional questions for UC interviews

• Possible staff to interview

• Additional questions for staff interviews

• Questions/additional questions for stakeholders

• List of personnel files to potentially review on-site

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

• Other issues to address

Monitoring Activities

Entrance Meeting

Introductions and Background on the UC Monitoring Team:

• Do introductions.

• Explain your role/role of the monitoring team i.e. to conduct quarterly monitoring visits to unlicensed facilities to ensure compliance with 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:

  • UC provided with a safe and appropriate environment.

  • UC provided with client-focused care to maximize UC’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 UC, 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 promptly upon return to DC office

To accomplish these goals:

• Tour facilities to assess the adequacy of meeting UC 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 UC

• 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:

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

• Staff Roster (with staff title and start date)

• Education/Academic Schedule

• Weekly/Daily/Monthly UC Activity Schedule

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

Directions for UC Monitors: Completing the Onsite Monitoring notes sections below is optional, as long as the review of standard activities is completed and saved somewhere in the monitoring visit folder.

Facility Walkthrough

(On-Site Monitoring Checklist)

General Findings:

UC Case Files to Request

Additional Questions resulted from UC 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 for PSA Compliance Manager

Additional questions for Interpreter

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

Observe UC Activities

(See the On-Site Monitoring Checklist)

General Findings:

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

(See the On-Site Monitoring Checklist)

General Findings:

Exit Meeting

Positives

Items to improve

Next Steps

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

Thanks for your hospitality.

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