Compliance Rating Partial Compliance. Discussion Each incident report is reviewed by the Shift Commander. These reviews should critique staff performance in preventing, anticipating, or intervening in the incident. Feedback surrounding the use of de-escalation techniques, staffing ratios and posts, supervision strategies, maintaining security, conflict resolution, environmental hazards, policy and procedures will help to improve staff skill and knowledge and may lead to a decline in youth violence over time. Across the 45 incident reports reviewed, all of the reviewing shift commanders at least attempted to critique the incident—no longer are they simply summarizing the event as they were at the time of the previous Monitors’ Report. However, as a whole, the shift commander reviews are not as adept as they need to be in order to function as an effective strategy to combat youth violence. Over half of the reviews were inadequate in that: ▪ Conclusions are made without foundation (e.g., “good de-escalation” when the narrative made no mention of any staff action other than physical restraint); ▪ Obvious issues are not raised (e.g., the event occurred when the unit was not staffed according to required ratios); ▪ Key pieces of information (e.g. the number and locations of each staff assigned to the unit) are simply noted as “missing” which would preclude a meaningful analysis of the event; and ▪ Inconsistencies across staff witness statements are largely ignored. If these reviews are to be helpful to staff, they must identify the specific decisions made or actions taken that either promoted or compromised youth and staff safety so that staff can refine their responses when next placed in a similar situation. During the current monitoring period, the Group Life Managers took over the auditing function from the Assistant Superintendents. By design, these audits should not only verify the completeness of the incident reporting package, but should also comment on the quality of the staff’s responses to each portion of the incident report and confirm that all of the sources of information hang together without contradiction. In contrast to the last monitoring period, most of the audits were timely, occurring within a few days of the event itself. Most of the audits were well-done, although some missed some of the substantive issues raised in the shift commander discussion above. The major problem however is a lack of responsiveness from staff who were required to undertake some sort of corrective actio...
Compliance Rating Partial Compliance. Discussion Behavior Management Program The development and implementation of an effective behavior management program is an area in which very little progress has been made since the inception of the Agreement. It is also one of the key strategies needed to reduce youth violence and to address some of the behavioral issues that challenge the academic program at BCJJC (as discussed in the “Special Education” section of this report). Its full implementation is an essential step for coming into compliance with this Agreement over the next 12 months. During the previous monitoring period, the BCJJC adopted an earnings-based behavior management program. Prior to implementing the new program, all staff and youth were provided written and verbal guidance on how the new system would operate. When interviewed, both youth and staff could explain how both the new and the old systems worked. At the end of the previous monitoring period, use of the system had just gotten underway. In March, 2008, the facility administration felt that the system was not achieving its objectives and decided to change the program from an earning-based program to a point deduction-based program. Rather than beginning the day with zero points and earning points for engaging in prosocial behavior, youth instead begin the day with 100 points and lose them if they violate the various facility rules. Although it may have been possible to implement the deduction-based system in a manner that could have fulfilled the requirements of this provision, the new system was not well-conceptualized nor was it well- articulated to staff or youth. When interviewed, both groups had a difficult time explaining how the system worked and how points were deducted or how they could be used to purchase incentives. Perhaps most notably, the new system involved a major conceptual change (and one which is not well-supported in behavior modification research) that appeared to be moving in the opposite direction of the facility’s behavioral health program that seeks to teach adaptive behaviors. As a result, the program was changed again toward the end of the current monitoring period in late April 2008. The basic structure of the current behavior management program is solid—youth are able to earn up to 100 points per day and as points accumulate, youth are promoted to a higher level that comes with greater privileges. The range of privileges and incentives available through the program are meaningful to youth—they wan...
Compliance Rating Partial Compliance. Assessment, as with other services, needs to have clear standards regarding timeliness for that service. For example, a CSED Waiver assessment versus a CMCR assessment would have different timeliness standards to access assessment. Specific timeliness standards and related oversight and monitoring are not available for all services. Chapter 502, the CSED manual, notes that “The BMS contracts with a MECA to determine initial and re-determination eligibility of prospective and active persons and to recruit and train licensed clinicians to participate in the Independent Evaluator Network (IEN). The ASO and the MECA work together to process initial applications and re-determination packets.” The Achieving Safety, Permanency and Well Being For West Virginia’s Children, A Knowledge and Skills-Based Curriculum includes information that children must be independently evaluated but does not include timeliness for the assessment itself. The State of West Virginia Department of Health and Human Resources (DHHR) Bureau for Behavioral Health (BBH) Pathway to Children’s Mental Health Services Phase 1 Reference Guide notes that for the CSED Waiver, “KEPRO will then review the application, contact the child, family, BSS worker, or other legal guardian to complete the Child and Adolescent Functional Assessment Scale (CAFAS) within an approximate three-business-day period, and notify BBH at xxxxxxxxxxxxxxxxxxxx@xx.xxx within three business days whether the individual will be further evaluated for the CSED Waiver, based on the CAFAS score. If the CAFAS score is 90 or above, KEPRO will assign an evaluator to complete the CSED Waiver evaluation process to determine eligibility, which typically takes 21-45 days.” The CMCRS Draft Manual notes that “MCRS services will be provided up to eight weeks; will take place in family homes, schools, group care, and other settings that are natural to the youth and family; and will include such services as: crisis intervention, crisis assessment, the development of a crisis plan which will include presumptive eligibility for crisis services (i.e., the family and youth determine whether it is a crisis), engagement, de-escalation, assessment, planning, and the coordination of supports and other services as needed” [emphasis added]. The Children’s Crisis and Referral Line Data Update January – December 2021 notes that as of January 2022, “staff are trained to incorporate the Assessment Pathway screening into calls when appropriate to help indiv...
Compliance Rating Partial Compliance. Explanation: Chapter 503 includes, as part of ACT’s purpose, “[t]o reduce psychiatric hospitalization for members with serious and persistent mental illnesses; to provide an established clinical relationship with the member and his or her natural support system to promote continuity of care; to improve successful integration into the larger community through non-traditional approaches to broadening a member’s social support base; to ensure that the member’s basic needs for sustaining community living are addressed, promoting acquisition of independent levels of adult living skills whenever possible.” Service elements include “[s]ustained effort to engage the member in treatment, medication education and prompting, and skill development activities to facilitate more integrated and successful community living; comprehensive and appropriate assessment of medical, environmental and social needs; maintenance of on-going involvement with the member during stays in environments such as inpatient care, convalescent care facilities, community care hospitals, or rehabilitation centers to assist in transition back to a community placement; assistance with securing necessities (e.g., food, income, safe and stable housing, medical and dental care, other social, educational, vocational, and recreational services); facilitation of maintenance of living arrangements during periods of institutional care; and collaboration with family/personal support network.” [Emphasis added] The KEPRO Assertive Community Treatment Behavioral Health Retrospective Review Tool includes Question 15 “Does the documentation indicate efforts to link the member to natural supports/activities/services in the community including providing support to those primary support networks?” Although the State provided information on retrospective reviews, we did not receive scores for existing providers to verify the number of providers who received a 3 (“100% of the documentation meets this standard”), 2 (“99% to 75% of the documentation meets this standard”), 1 (“74% to 50% of the documentation meets this standard”), or 0 (“under 50% of the documentation meets this standard) in measures related to service to prevent crisis and promote stability. The SME notes that KEPRO conducts these retrospective reviews, but the SME did not receive any documentation regarding how the State uses these reviews and fidelity assessment scores to ensure that services are provided in the most integrated setting and what ste...
Compliance Rating Partial Compliance. The West Virginia Wraparound, A Network of Wraparound Facilitation for WV Families discusses the CANS, including that “DHHR is working on a standardized Wraparound care plan template for use by all Wraparound Facilitators.” The same document notes that Xxxxxxxx University provided training and certification for CANS assessors (Xxxxxxxx University CANS Training Opportunities) and Section 2.1 includes language on family voice and choice. The KPI document (Table 2) includes several measures related to CANS assessment but not any data collection, monitoring, or oversight. In addition, to CANS, the State is using the CAFAS tool to determine eligibility for the CSED Waiver. As mentioned in related requirements below, while this provision specifically mentions the CANS, it is the opinion of the SME that any assessment requirements in the Agreement apply to any assessment tool used by DHHR. To fully comply with this requirement, the State will need to provide additional documentation related to both the CAFAS and the CANS, such as West Virginia Wraparound manual and/or other provider manuals, SOPs, training curriculum, bulletins and other transmittals; credentialing /provider requirements; billing and reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to providers and stakeholders that demonstrate how they will use data to monitor quality, and their oversight of training and other contractual requirements. The State will need to include KPIs specific to both assessment tool, including its plans for data collection, monitoring, and oversight. Specific to the CAFAS tool and freedom of choice, training must also reflect the expectation that assessment is provided by a mutually agreed upon individual, such as initial and continuing education; coaching; curricula, competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific as to deliver the services in a manner that is likely to accomplish the Agreement goals. See also Agreement Number 28.
Compliance Rating Partial Compliance. Discussion The DJS’ Suicide Prevention policy is aligned with contemporary standards of care. The policy requires youth to be supervised at different intensities, depending on the level of precaution required. As discussed in III.C-1.v, the practice and documentation of supervision does not always comport with policy. Similarly, while procedures for ensuring the welfare of youth in high-risk settings (i.e., in a locked room by themselves) are established, as discussed in III.C-1.iii, they are not always properly implemented. Clinically, Hope Health staff have developed an effective response strategy for youth displaying or verbalizing self-harming behaviors. Staff are competently trained in developing strategies for youth to address the distress they experience during a suicidal episode. As discussed in the prior Monitors’ Report, environmentally, the DJS rectified all of the deficiencies noted in the DOJ’s findings letter, including fitting the facility with suicide resistant bunks, towel racks, handrails, and Plexiglas barriers. These remedies are still in place.
Compliance Rating Partial Compliance. Chapter 502 notes, as part of Section 502.16.1 that “Members and/or their legal representatives have the right to… Choose who they wish to attend their CFT meetings, in addition to those attendees required by regulations.” A West Virginia Wraparound Manual, marked draft and dated March 9, 2022, notes that “[t]he Wraparound Facilitator leads the Child and Family Team and supports the family in getting connected to the services that best meet the child and family needs in order for the child to remain in the home, or if the child is temporarily in residential services or other out of home placements, to return home as soon as possible…. With support from a team of professionals and natural supports, the family’s ideas and perspectives about what they need and what will be helpful drive all of the work in Wraparound…. The child and family work with the Wraparound Facilitator to build their Wraparound team, which can include the family’s friends and people from the wider community (sometimes called ‘natural supports’), as well as providers of needed services and supports…. The Child and Family Team develops an individualized Wraparound plan of care, puts this plan into action, and works toward the family thriving with its plan after the service ends. The Wraparound plan often includes formal services to build skills and meet child and family needs, community services, and interpersonal support and assistance provided by friends, kin, and other people in the family’s social networks.” To fully comply with this requirement, the State will need to provide additional documentation such as a finalized West Virginia Wraparound manual and/or other provider manuals, SOPs, training curriculum, bulletins and other transmittals; staffing requirements; billing and reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to providers and stakeholders; and evidence of the materials use with Providers, such as meeting minutes with providers, provider quality reviews, feedback from providers on programmatic issues that are later reflected in subsequent versions of provider related materials. The State will need to ensure there is cross-referencing and clarification between Child and Family Teams and MDT, the latter being referred to throughout the West Virginia Department of Health and Human Resources Pathway to Children’s Mental Health Services document. AG...
Compliance Rating Partial Compliance. See Agreement Number 32, above. Documents Reviewed: • Aetna Better Health of West Virginia (ABHWV) Partner Provider Investment: Phase I (Dec. 2021) • Aetna Discharge Planning for Providers (Jan. 2022) • CANS Data Plan – Preliminary • Chapter 502 Children with Serious Emotional Disorder Waiver (CSEDW) (July 1, 2021), including Appendix A, Initial Plan of Care and Appendix B, Master Plan of Care • Chapter 503, Licensed Behavioral Health Center (LBHC) Services • Children with Serious Emotional Disturbance Brochure, Approved • Children with Serious Emotional Disorder (CSED) Waiver Discussion during West Virginia Department of Health and Human Resources’ (WVDHHR’s) Monthly Call with the U.S. Department of Justice (DOJ), including Subject Matter Expert (SME) and BerryDunn (December 8, 2021) • Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) (March 6, 2022) • CSED Application Renewal: 2022 Stakeholder Engagement • CSED Flier (Jan. 25, 2022) • CSED Waiver Appendix K • CSED Waiver Enrollment Updated Stats, July 21 to Dec 21 • CSED Waiver FAQs (Feb. 2, 2022) • CSED Waiver Utilization Updates (July 21-Sept. 21) • Draft CSED Trifold Not Approved (March 3, 2022) • Draft Non-CSEDW Wraparound Eligibility • Draft CSED Amendment Eff. July 1, 2022 • KEPRO Scope of Work Level of Care Assessment for Residential Placement Expansion of the Assessment Pathway • Master Plan of Care WV Wraparound Draft (March 11, 2022) • Quality Assessment and Performance Improvement (QAPI) Update (March 10, 2022) • Updated Pathway Process Flow Diagrams (March 11, 2022) • WF Capacity Deployed Across BBH CSED and SAH (March 2022) • Wraparound Fidelity Update (March 7, 2022) • West Virginia Wraparound A Network of Wraparound Facilitation for WV Families (Draft, March 9, 2022) • WF Capacity Deployed Across BBH CSED and SAH (March 2022) • WV Wraparound FAQs (Feb. 22, 2022) WRAPAROUND AGREEMENT REQUIREMENT 12
Compliance Rating Partial Compliance. Chapter 502, Section 502.18, which is specific to the CSED Waiver, describes ten Wraparound principles, including that it is “…community-based. The wraparound team implements service and support strategies that take place in the most inclusive, most responsive, most accessible, and least restrictive settings.” Similar, the SAH notes that the program is design to ensure that youth remain in or return to their community setting whenever safely possible. This language sets an expected standard for services to be provided in home- and community-based settings, which are a proxy for integrated setting. However, while the Continuous Quality Improvement Plan – Proposed Key Performance Indicator (KPI) Tables (Working Document) includes Wraparound indicators (Tables 2 and 7) there are not indicators explicitly related to the delivery of services and supports in the most integrated setting appropriate to meet child and family needs. The Quality Assessment and Performance Improvement (QAPI) Update notes that monthly reviews of CSED Waiver are scheduled to begin in May. The SME anticipates receiving data related to the in the next report cycle. To fully comply with this requirement, the State will need to provide additional documentation such as the finalized West Virginia Wraparound manual and/or other provider manuals, SOPs, training curriculum, bulletins and other transmittals; staffing requirements; billing and reporting requirements; Xxxxxxxx University fidelity monitoring, and any audit and sampling reviews of the master POC or other records; and plans or documentation of conveyance to providers and stakeholders. Training must also reflect the need to provide care in the most integrated setting, including initial and continuing education; coaching; curricula, including seat-time and competency-based requirements; and training evaluation practices to ensure the training is sufficiently robust and specific as to deliver the services in a manner that is likely to accomplish the Agreement goals. See also Agreement Number 26. AGREEMENT REQUIREMENT 26 Aforementioned services will be delivered at times and locations mutually agreed upon by the provider and the child and family (or xxxxxx or kinship care family where applicable) to assist in practicing skill development in the context of daily living.
Compliance Rating Partial Compliance. Description of Monitoring Process The monitoring team reviewed the Camera Surveillance Project: Camera Coverage report submitted by DJJ to the DOJ and the SME on July 13, 2022, and DJJ’s Initial Implementation Plan. The team also conducted a facility site visit on September 7-9, 2022.
