Exhibit XI One on One Supervision.pdf

Exhibit XI (04/25)

Congregate Care One-On-One Supervision Guidelines

One-on-One supervision is provided to a child to ensure the safety of the child as well as other residents and staff.

Guidelines:

• The One-on-One staff is to provide the one-on-one service for the designated child only and not to any other child during the authorized time.

• One-on-One is a short term approval until the group home is able to demonstrate they are meeting the youths needs with appropriate behavioral health and medical services.

• One-on-One’s are to be utilized for the following reasons including but not limited to: suicidal ideations, sexually maladaptive behaviors, high behaviors, medication and medical concerns, high transition times, DDD

• One-on-One staff is required to be within close enough proximity to watch and hear the child and intervene when behavior or contact is inappropriate.

• One-on-One can only be requested during sleeping hours under extraordinary situations. If approved, the one-on-one staff is required to be positioned in the doorway of the child's bedroom at all times. If the one-on-one staff needs to use the restroom or leave his or her post, the overnight staff is required to temporarily take over the supervision of the child until the one-on-one staff resumes their post.

• Youth who attempt to AWOL and youth aged eighteen (18) years and older are not a qualified one-on-one reason

• One-on-Ones are not to be requested during school hours.

Additionally, One-on-Ones supervision hours are utilized when a child is not receiving any other services, community supports or activities supervised by non facility staff.

• If the one-on-one staff needs to use the restroom, another staff is required to temporarily take over the supervision of the child until the One-on-One staff resumes his or her post.

• The One-on-One staff is required to be right outside the door if the child is using the restroom or changing clothes, etc. The door is to be opened as soon as the child completes the task.

• One-on-One staff shall be limited to two (2) per facility, additional one-on-one’s require approval from the Program Administrator

• If telephone monitoring is requested, the one-on-one staff is required to dial the telephone number and ensure that the appropriate person is on the line before turning the call to the child. The One-on-One staff is required to monitor the child's telephone communication for appropriateness.

• The Placement Administration must be notified immediately if the authorized amount of hours needs to be adjusted or canceled.

• The One-on-One staff is required to track the date, time, number of hours per day the service was provided, and maintain the information on a daily log.

• Upon completion of services, the daily log and the authorization letter should be submitted with the invoice to the appropriate Department for reimbursement.

• In order to approve a one on one extension, a child needs to continue to display high need behaviors and/or have complex medical needs requiring significant management and/or care.

Verification of efforts to advocate for appropriate services must be indicated in the Exhibit XI. One-on-One extension needs to be requested prior to the end date of the current approved hours.

If incident report(s) were written up, refer to it in the progress report and attach.

Congregate Care One-On-One Supervision Guidelines

One-on-one supervision is provided to a child to ensure the safety of the child as well as other residents and staff. Please refer to the one-on-one supervision guidelines.

The Exhibit XI should provide a clear understanding of why the one-on-one supervision is needed and the efforts to decrease need

Primary Language/Means of Communication

Date of Birth Last Name

School Name

Name (First, Middle Initial)

PI Number

Facility

Facility Staff and Shift Schedule

Child's Information

Female Male Self-Disclose:Gender:

Facility Contact E-Mail Address

Facility Name

Facility Physical Address City

Facility Phone:

State Zip

School Schedule

Saturday Monday Tuesday Wednesday Thursday Friday Sunday

Service Schedule

Saturday Monday Tuesday Wednesday Thursday Friday Sunday

Visit Schedule

Saturday Monday Tuesday Wednesday Thursday Friday Sunday

Extra-curricular Activities Schedule

Saturday Monday Tuesday Wednesday Thursday Friday Sunday

Congregate Care One-On-One Supervision Guidelines

One-on-one supervision is provided to a child to ensure the safety of the child as well as other residents and staff.

Please refer to the one-on-one supervision guidelines.

The Exhibit XI should provide a clear understanding of why the one-on-one supervision was needed and the progress accomplished.

Attach a current copy of the One-on-One Supervision Daily Log, Coordinating Staff schedule, incident reports to the to Placement Administration by emailing BedHold@azdcs.gov.

A. Behaviors and/or medical complexities

1. Please confirm staffing ratio, total number of children in the home and any other youth receiving one-on-one supervision

3. Describe the events preceding the behavior and/or medical complexity.

2. Describe what days and times the behaviors and/or medical complexities are typically observed.

4. What services/actions can be implemented to prevent the escalation of behavior or medical complexity?

mailto:BedHold%40azdcs.gov?subject=

Congregate Care One-On-One Supervision Guidelines

B. The Supervision.

1. During the one-on-one supervision time period, were there any unusual incidents? If so, please attach to this submission.

3. Barriers to ending or decreasing one on one supervision hours.

2. If there were no unusual incidents during the one on one supervision, what types of supervision, redirection and deescalation techniques were used that were successful?

4. Events/activities and or appointments

Congregate Care One-On-One Supervision Guidelines

C. Behavioral Health/Medical Services And Supports

1. What date and time did the group home request an emergency Child and Family Team Meeting to discuss implementation of appropriate behavioral and/or medical services and who was included in the request?

2a. What is the status of behavioral health or medical services requested?

2. What behavioral health and medical services were requested and arranged through the Department Health Plan?

2b. Are there delays in implementation?

3. What is the contact name, number and email address of the last person to give an update on each service that is delayed?

Email this completed form to BedHold@azdcs.gov mailto:BedHold%40azdcs.gov?subject=