Attachment J-8 Monthly Program Activity Report.pdf

Attachment J-8: Monthly Program Activity Report

Contractor Name: _______________________________Contract Number:_________________

Program Address: ______________________________________________________________

Treatment Modality: ___________________________________________________________

Submitted By: _____________________________ Telephone Number:___________________

PERFORMANCE TARGETS

For the Month of __________________ Year___________

Instructions: Please complete the numbers and names required for the below tables. Attach additional pages if necessary.

TABLE 1 (Non- RSC Cases)

A. Total Number of active cases at the end of the previous month

B. Total Scheduled Placements No Shows Actual Admissions

C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended

Total number of active cases at the end of the month

TABLE 2 (Non-RSC Cases):

Please include the names and PDID numbers of individuals for each category

ADMITTED NO-SHOWS SUCCESSFUL

COMPLETIONS

UNSUCCESSFUL

COMPLETIONS

(Please attach discharge reports for each name listed below)

TABLE 3 (RSC Cases)

A. Total Number of active cases at the end of the previous month

B. Total Scheduled Placements No Shows Actual Admissions

C. Total Discharges Successful Program Completions (Number and Percentage) Unsuccessful Program Completions Discharge for non-compliance Dropout against clinical advice Absconded Rearrested/remanded Medical/hospitalized Administrative Supervision period ended

Total number of active cases at the end of the month

TABLE 4 (RSC Cases):

Please include the names and PDID numbers of individuals for each category

ADMITTED NO-SHOWS SUCCESSFUL

COMPLETIONS

UNSUCCESSFUL

COMPLETIONS

(Please attach discharge reports for each name listed below)

TABLE 5: Monthly CSOSA Contract Staff Changes

New Hires Name

(Please attach the medical clearance, resumes, licenses and certifications)

Position Title Hire Date

Security Clearance Submission Date

Resignations or Terminations

Position Title Separation Date

TABLE 6: Unusual Incidents Please attach copies of all incident reports (via secured email method) to this monthly report.

A. Total Number of unusual incident reports for the month: ______________ Date of incident Date report was submitted to

CSOSA

B. Type(s) of unusual incidents for the month.

Death, serious illness, injury or incapacitation Physical, sexual or verbal abuse of an Patient by staff or others Fire Theft Destruction of loss of property, or sudden/serious problems in the facility

Patient criminal charges, arrest, or incarceration Infestations or outbreak of communicable disease Inappropriate relationships/fraternization between an Patient and contract staff

Chronic complaints from Patient’s families or Patients themselves

Monthly Physical Plant Issues (Provide narrative, describing all serious facility maintenance problems):