ATTACHMENT A

Qualified Residential Treatment Program (QRTP) Application

SC Department of Social Services | Child Welfare Services Division 1535 Confederate Ave., Columbia, SC 29201 Thank you for your interest in becoming designated as a Qualified Residential Treatment Program (QRTP) in South Carolina. Below are the requirements for QRTPs and for the placement of children in QRTPs.

Family First requirements for QRTPs are as follows:

· Utilizes a trauma-informed treatment model that is designated to address the needs, including clinical needs as appropriate, of children with serious emotional or behavioral disorders;

· Have access to registered or licensed nursing staff and other licensed clinical staff who:

· Provide care within the scope of their practice as defined by state law;

· Are on-site according to the treatment model; and

· Are available 24 hours a day and seven days a week. These staff can be contract staff available to be on-site if the child’s needs warrant face-to-face interaction.

· Note: The SC Department of Health and Human Services (DHHS) Managed Care Organization, Select Health provides a 24/7 nursing line, and this will qualify as meeting this criterion for nursing care for Medicaid eligible youth.

· Facilitates participation of family members in the child’s treatment program;

· Coordinate with SCDSS and Select Health, the Managed Care Organization for Medicaid-eligible children in foster care to provide after care support dependent on the needs of the child. Coordination of After Care support services may be provided via Case Management Services through Select Health for Medicaid-eligible children.

· For non-Medicaid eligible children and youth, the provider must coordinate with SCDSS around the provision of After Care Services.

· Accredited by at least one of the following:

· The Commission on Accreditation of Rehabilitation Facilities,

· Joint Commission on Accreditation of Healthcare Organizations,

· Council on Accreditation,

· The Teaching Family Association, or

· Educational Assessment Guidelines Leading toward Excellence (EAGLE)

The placement requirements for children in a QRTP are as follows and determination of whether the child/youth meets these requirements is the responsibility of the placing agency (DSS):

· Within 30 days of a youth being placed in a qualified residential treatment program, an assessment must be performed by a “qualified individual” to determine if a QRTP is the best fit for the child. In South Carolina, the “qualified individual” assessments will be performed by the SCDSS Therapeutic Services Coordinator (TSC).

· Within 60 days of a foster youth’s placement in a QRTP, a court review must take place to approve or disapprove the placement in a QRTP setting. The Court will consider the 30-day assessment and determine whether the needs of the youth can be met through placement in a foster family home or if a QRTP will provide the most effective and appropriate level of care for the youth.

· If a youth in foster care 13 years of age or older has been placed in a QRTP for 12 consecutive months or 18 non-consecutive months, the QRTP placement must be reviewed by the SCDSS State Director.

· If a child in foster care 12 years of age or younger has been placed in a QRTP for 6 consecutive months, the QRTP placement must be reviewed by the SCDSS State Director.

This application contains additional detailed information on QRTP requirements for facilities as well as the steps needed to obtain and maintain the QRTP designation. This designation is in addition to the already established state licensing regulations through the South Carolina Department of Social Services (SCDSS) Division of Licensing. The QRTP designation is dependent upon a program being properly licensed. Although the designation may be denied or revoked for issues related to a license, the inverse does not apply. The issuance, denial, or revocation of a QRTP designation does not affect a program’s license unless the licensing requirements require a program be certified as QRTP. However, if issues related to licensure are noted during the QRTP certification or monitoring process, they may be reported to the licensing authority. If notified of a licensing related issue, it will be the licensing authority’s responsibility to determine how to proceed.

The SCDSS is committed to helping interested programs receive a designation as a QRTP and will partner with programs prior to the application and submitting a bid (e.g., consultation meetings) to provide support.

Complete applications must be sent electronically with your On-Line Bidding documents.

APPLICATION PROCESS

Submission and Review Process

SCDSS will initiate an initial review of the application after the bid closes. Following initial review of the application, the applicant will receive an email acknowledging SCDSS’ receipt of the application, which will include notification of any missing documents or needed clarification. Further review of application will not proceed until the additional information has been submitted. If additional requested information or clarification is not received within 30 days of request by SCDSS, the application will be considered abandoned.

SCDSS will initiate a thorough review of the application once all required documentation has been received and the application is determined to be complete.

Designation Period

Designations of QRTPs will be issued for a 2-year period from contract award. After approval, program will be reviewed during the licensing renewal schedule to affirm it still meets the QRTP requirements.

Designation Renewal

QRTPs must submit a renewal application 60 day prior to the expiration date of their current designation (two years following initial approval). Failure to submit renewal applications in a timely manner may lead to a gap in the QRTP’s designation status, which could affect funding for services provided during that time period. Recertification approvals may only be backdated to the date the renewal application is received if the application is not submitted within 30 days of the certification expiration date.

SOUTH CAROLINA DEPARTMENT OF SOCIAL SERVICES

INITIAL PROVIDER APPLICATION FOR

QUALIFIED RESIDENTIAL TREATMENT PROGRAM (QRTP) IN SOUTH CAROLINA

Instructions:

After an initial consultation meeting, complete this application in its entirety, as appropriate.

Type or print legibly using permanent blue or black ink and retain a copy for your records.

Review the application carefully to ensure it is complete before submitting.

Return the completed application and all required attachments through the On-Line Bidding process.

APPLICATION AGREEMENT*

*This section and the following section must be completed for each licensed program providers would like designated as a QRTP.

In making this application, I agree that:

□ I am in receipt of and have read the laws applicable to the type of program for which I am making application.

□ I understand that representatives of SCDSS are authorized to investigate all aspects of program operations, to inspect the facility and record, and to make any investigations necessary concerning the circumstances surrounding this application.

□ I understand that if the program is designated as a QRTP, the Department’s representatives can make announced and unannounced visits to investigate complaints received and to determine continuing compliance.

□ I will notify SCDSS within 1 business day of any violations issued by a governmental regulatory agency to the program and any issues that could adversely affect the program meeting QRTP requirements.

□ I am aware that it is a misdemeanor for any person to interfere with an authorized agent of the Director in the discharge of his duties, make false or untrue reports with respect to the operation of the facility, engage in the operation of a facility without first obtaining a license, or serve more persons than the maximum capacity stipulated on the license.

I hereby attest that the information contained in this application, including the attachments, are truthful and correct under penalty of perjury. Falsification of application information is grounds for denial or revocation of a QRTP designation. An application may be withdrawn at any time the applicant so desires.

This application must be signed by an individual legally responsible for the operation of the residential facility for children, or, if the facility is to be operated by a board/governing body, by an officer of the board/governing body, preferably the chair. If the facility is to be operated by a governmental entity, the person employed by that government to operate the facility (i.e., director, facility head) may sign the application.

Signature of Applicant(s) Date

PROGRAM INFORMATION

(Information provided here will NOT update your license record. Contact your licensing authority regarding updating any licensing information.)

Fax Number

QRTP Capacity Number of Total Beds: ____________ Female: ________________________ Male: ____________________________

LICENSE INFORMATION

REQUIRED ATTACHMENTS

(Refer to the information on the referenced pages in the “Document Instructions” section for more information about the required documentation)

PART 2: DOCUMENT INSTRUCTIONS

GENERAL INSTRUCTION FOR SUBMITTING DOCUMENTATION

Whenever possible, submit procedures marked with the section abbreviation and bullet number versus a description of how the program meets a requirement (e.g., Page 4 of a Trauma Training manual would be flagged with a GL1 if that page explained how agency leadership communicates its support of a trauma-informed approach to services).

Some forms of documentation may need to be a narrative or pictures (e.g., pictures flagged with a PE1 might sufficiently show how a program’s environment promotes a sense of safety and calming).

Documentation must be submitted for each section, but not necessarily for each bullet within the section. However, the likelihood of meeting the QRTP requirements for that section increases if documentation is submitted for each bullet.

TRAUMA INFORMED MODEL (SECTION 1)

FFPSA Requirement: The program has a trauma-informed treatment model that is designed to address the needs, including clinical needs as appropriate, of children with serious emotional or behavioral disorders or disturbances.

The Substance Abuse and Mental Health Services Administration (SAMHSA) trauma framework states that, in a trauma informed approach, all people at all levels of the program have a basic realization about trauma and understand how trauma can affect families, groups, organizations and communities as well as individuals. People in the program are also able to recognize the signs of trauma. The program responds by applying principles of a trauma-informed approach to all areas of functioning. The trauma informed approach seeks to resist re-traumatization of clients as well as staff. SAMHSA describes 10 domains, which provide a framework for implementation of a trauma informed approach.

Provide documentation for each of the 10 domains listed below to demonstrate how the program provides a trauma informed model to the children and families they serve. Documentation must be submitted for each section, but not necessarily for each bullet within the section. Likelihood of meeting the QRTP requirements increases for each section where documentation is submitted for each bullet.

Governance and Leadership: The leadership and governance of the organization support and invest in implementing and sustaining a trauma-informed approach; there is an identified point of responsibility within the organization to lead and oversee this work; and there is inclusion of the peer voice. A champion of this approach is often needed to initiate a change process.

GL1. How does agency leadership communicate it support and guidance for implementing a trauma-informed approach?

GL2. How do the program’s mission statement, and/or written policies and procedures include a commitment to providing trauma-informed services and supports?

GL3. How do leadership and governance structures demonstrate support for the voice and participation of people using their services who have trauma histories?

Policy: There are written policies and protocols establishing a trauma-informed approach as an essential part of the organizational mission. Organizational procedures and cross program protocols, including working with community-based agencies, reflect trauma-informed principles. This approach must be “hard-wired” into practices and procedures of the organization, not solely relying on training workshops or a well-intentioned leader.

PO1. How do the program’s written policies and procedures include a focus on trauma and issues of safety and confidentiality?

PO2. How do the program’s written policies and procedures recognize the pervasiveness of trauma in the lives of people using services, and express a commitment to reducing re-traumatization and promoting well-being and recovery?

PO3. How do the program’s staffing policies demonstrate a commitment to staff training on providing services and supports that are culturally relevant and trauma-informed as part of staff orientation and in-service training?

PO4. How do human resources policies address the impact of collaborating with people who have experienced trauma?

PO5. What policies and procedures are in place for including trauma survivors/people receiving services and peer supports in meaningful and significant roles in program planning, governance, policymaking, services, and evaluation?

Physical Environment of the Organization: The organization ensures that the physical environment promotes a sense of safety and collaboration. Staff working in the program and individuals being served must experience the setting as safe, inviting, and not a risk to their physical or psychological safety. The physical setting also supports the collaborative aspect of a trauma informed approach through openness, transparency, and shared spaces.

PE1. How does the physical environment promote a sense of safety, calming, and de-escalation for clients and staff?

PE2. In what ways to staff members recognize and address aspects of the physical environment that may be re-traumatizing, and work with people on developing strategies to deal with this?

PE3. How has the program provided space that both staff and people receiving services can use to practice self-care?

PE4. How has the program developed mechanisms to address gender-related physical and emotional safety concerns (e.g., gender-specific spaces and activities).

Engagement and involvement of people in recovery, trauma survivors, people receiving services, and family members receiving services: These groups have significant involvement, voice, and meaningful choice at all levels and in all areas of organizational functioning (e.g., program design, implementation, service delivery, quality assurance, cultural competence, access to trauma-informed peer support, workforce development, and evaluation).

EI1. How do people with lived experience can provide feedback to the organization on quality improvement processes for better engagement and services?

EI2. How do staff members keep people fully informed of rules, procedures, activities, and schedules, while being mindful that people who are frightened or overwhelmed may have a difficulty processing information?

EI3. How is transparency and trust among staff and clients promoted?

EI4. What strategies are used to reduce the sense of power differentials among staff and clients:

EI5. How do staff members help people to identify strategies that contribute to feeling comforted and empowered?

Cross sector collaboration: Collaboration across sectors is built on a shared understanding of trauma and principles of a trauma-informed approach. While a trauma focus may not be the stated mission of various service sectors, understanding how awareness of trauma can help or hinder achievement of an organization’s mission is a critical aspect of building collaborations. People with significant trauma histories often present with a complexity of needs, crossing various service sectors. Even if a mental health clinician is trauma-informed, a referral to a trauma insensitive program could then undermine the progress of the individual.

CS1. Is there a system of communication in place with other partner agencies collaborating with the individual receiving services for making trauma-informed decisions?

CS2. Are collaborative partners trauma-informed?

CS3. How does the organization identify community providers and referral agencies that have experience delivering evidence-based trauma services?

CS4. What mechanisms are in place to promote cross-sector training on trauma informed approaches?

Screening, Assessment and Treatment Services: Practitioners use and are trained in the interventions based on the best and available empirical evidence and science, are culturally appropriate, and reflect principles of a trauma-informed approach. Trauma screening and assessment are an essential part of the work. Trauma-specific interventions are acceptable, effective, and available for individuals and families seeking services. When trauma-specific interventions are not available within the organization, there is a trusted, effective referral system in place that facilitates connecting individuals with appropriate trauma treatment.

SA1. Is an individual’s own definition of emotional safety included in treatment plans?

SA2. Is timely trauma-informed screening and assessment available and accessible to individuals receiving services?

SA3. Does the organization have the capacity to provide trauma-specific treatment or refer to appropriate trauma-specific services?

SA4. How are peer supports integrated into the service delivery approach?

SA5. How does the program address gender-based needs in the context of trauma screening, assessment, and treatment? For instance, are gender-specific trauma services and supports available for both men and women?

SA6. Do staff members talk with people about the range of trauma reactions and work to minimize feelings of fear or shame and to increase self-understanding?

SA7. How are these trauma-specific practices incorporated into the organization’s ongoing operations?

Training and Workforce Development: Ongoing training on trauma and peer support are essential. The organization’s human resource system incorporates trauma-informed principles in hiring, supervision, staff evaluation; procedures are in place to support staff with trauma histories and/or those experiencing significant secondary traumatic stress or vicarious trauma, resulting from exposure to and collaborating with individuals with complex trauma.

TW1. How does the program address the emotional stress that can arise when collaborating with individuals who have had traumatic experiences?

TW2. How does the program support training and workforce development for staff to understand and increase their trauma knowledge and interventions?

TW3. How does the organization ensure that all staff (direct care, supervisors, front desk and receptions, support staff, housekeeping and maintenance) receive basic training on trauma, its impact, and strategies for trauma-informed approaches across the program and across personnel functions?

TW4. How does workforce development/staff training address the ways’ identity, culture, community, and oppression can affect a person’s experience of trauma, access to supports and resources, and opportunities for safety?

TW5. How does on-going workforce development/staff training provide staff supports in developing the knowledge and skills to work sensitively and effectively with trauma survivors?

TW6. What types of training and resources are provided to staff and supervisors on incorporating trauma-informed practice and supervision in their work?

TW7. What workforce development strategies are in place to assist staff in collaborating with peer supports and recognizing the value of peer support as integral to the organization’s workforce?

Progress Monitoring and Quality Assurance: There is ongoing assessment, tracking, and monitoring of trauma-informed principles and effective use of evidence-based trauma specific screening, assessments, and treatment.

PM1. Is there a system in place that monitors the program’s progress in being trauma-informed?

PM2. Does the program solicit feedback from both staff and individuals receiving services?

PM3. What strategies and processes does the program use to evaluate whether staff members feel safe and valued at the program?

PM4. How does the program incorporate attention to culture and trauma in program operations and quality improvement processes?

PM5. What mechanisms are in place for information collected to be incorporated into the program’s quality assurance processes and how well do those mechanisms address creating accessible, culturally relevant, trauma-informed services and supports?

Financing: Financing structures are designed to support a trauma-informed approach which includes resources for: staff training on trauma, key principles of trauma-informed approach; development of appropriate and safe facilities; establishment of peer-support; provision of evidence-supported trauma screening, assessment, treatment, and recovery supports; and development of trauma-informed cross-program collaborations.

NOTE: If a detailed budget is available that shows funds allocated to the support of the program being trauma informed, it is preferred that the budget be submitted in addition to any written answers to the questions bulleted below. If a detailed budget or expense report is not available, financial data related to the areas listed above must be provided in some other format or included in the narrative provided.

FI1. How does the program’s budget include funding support for ongoing training on trauma and trauma-informed approaches for staff and leadership development?

FI2. What funding exists for cross-sector training on trauma and trauma-informed approaches?

FI3. What funding exists for peer specialists?

FI4. How does the budget support provision of a safe physical environment?

Evaluation: Measures and evaluation designs used to evaluate service or program implementation and effectiveness reflect an understanding of trauma and appropriate trauma-oriented research instruments.

EV1. How does the program conduct a trauma-informed organizational assessment or have measures or indicators that show their level of trauma-informed approach?

EV2. How does the perspective of people who have experienced trauma inform the program performance beyond consumer satisfaction survey?

EV3. What processes are in place to solicit feedback from people who use services and ensure anonymity and confidentiality?

EV4. What measures or indicators are used to assess the organizational progress in becoming trauma-informed?

REGISTERED OR LICENSED NURSING STAFF AND OTHER LICENSED CLINICAL STAFF (SECTION 2)

FFPSA Requirement: The program has registered or licensed nursing staff and other licensed clinical staff who provide care within the scope of their practice as defined by state law; are onsite according to the treatment model; and are available 24 hours a day and 7 days a week. (Note: This requirement shall not be construed as requiring a program to acquire nursing and behavioral health staff solely through means of a direct employer to employee relationship).

Provide documentation of the following (documentation for each bullet is required for this section):

FACILITATE PARTICIPATION OF FAMILY MEMBERS (SECTION 3)

FFPSA Requirement: To the extent appropriate, and in accordance with the child’s best interests, programs facilitate participation of family members, including siblings, in the child’s treatment program. Programs document how the outreach and participation is made; how family members are integrated into the treatment process for the child, including post discharge; how sibling connections are maintained; and maintains contact information for any known biological family and fictive kin of the child.

Provide documentation of the following (documentation for each bullet is required for this section):

DISCHARGE PLANNING AND FAMILY-BASED AFTER CARE SUPPORT (SECTION 4)

FFPSA Requirement: Programs provide discharge planning and family-based after care support for at least 6 months post discharge.

Provide documentation of the following:

AC1. The provider shall have written criteria for discharge that shall include:

a) Criteria for youth’s completion of the program which are consistent with the facility’s programs and services;

b) Conditions under which a youth may be discharged before completing the program; and

c) Procedures for assisting placing agencies in placing the youth should the facility cease operation AC2. No later than 30 days after discharge a comprehensive discharge summary shall be placed in the youth’s record and sent to the person or agency making the referral. The discharge summary shall review:

a) Services provided to the youth

b) Youth’s progress working toward meeting objectives

c) Youth’s continuing needs, and recommendations for further services

d) Reasons for discharge, and the name of the person to whom the youth was discharged

e) Dates of admission and discharge

f) Date discharge summary prepared and signature of preparing it

g) Documentation that youth, placing agency, and Legally Authorized Representative (LAR) are participants in developing the plan

warranted due to safety risk or potential placement disruption, QRTP is responsible for contacting the legal guardian, immediately.

AC10. Provide documentation of monthly phone calls and any follow up required to legal guardian, monthly by the 10th of the month for activities provided in the previous month.

AC11. Engagement of the Family and Permanency team, monthly for six months, be available for face-to-face meetings, if recommended by the legal guardian. Any other steps as described in the discharge plan and Child and Family Team Meeting (CFTM) for successful transition.

ACCREDITATION AND LICENSING (SECTION 5)

FFPSA Requirement: Programs are licensed to practice within their state and are accredited by any of the following independent, not-for-profit organizations:

· The Commission on Accreditation of Rehabilitation Facilities (CARF)

· The Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

· The Council on Accreditation (COA)

· The Teaching Family Association

· Educational Assessment Guidelines Leading toward Excellence (EAGLE)

Programs should provide the following (documentation for each bullet is required for this section):

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