Exhibit XI One on One Supervision.pdf

Exhibit XI (05/24)

CONGREGATE CARE

ONE-ON-ONE SUPERVISION GUIDELINES

ARIZONA DEPARTMENT OF CHILD SAFETY

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’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 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.

• 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.

The one-on-one supervision can be adjusted for severity, health and safety, seizures, and other medical conditions that require stricter monitoring.

• 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 provider will provide a detailed written progress report to the Child Safety Specialist on the One on One Supervision Progress Report every two weeks.

• The child's ADCS or ADJC Specialist 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.

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

Attach a current and accurate copy of the One-on-One Supervision Daily Log.

Due Every two (2) weeks for the duration of the supervision

Primary Language/Means of Communication

Date of Birth Last Name Name (First, Middle Initial)

Guardian Case Number

Facility

Child's Information

Female Male Self-Disclose:Gender:

Does young adult have knowledge of cleaning supplies, doing laundry and keeping living space clean?

Is a rental car required?

Yes Yes

No No

Facility Contact E-Mail Address

Facility Physical Address City

Facility Phone:

State Zip

Page 2 CONGREGATE CARE

ONE-ON-ONE SUPERVISION GUIDELINES

ARIZONA DEPARTMENT OF CHILD SAFETY

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 progress report 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 and completed Progress report to the assigned DCSS, PlacementsNonEmergency@azdcs.gov and;

A. Behaviors

1. Describe the behaviors that warrant the one-on-one

3. What triggered the incident and or behavior?

2. Describe where the incident occurred (setting)? i.e. during an outing, other children involved, etc.

4. What escalation intervention was used? i.e. verbal redirection, removing from the room, etc.

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

mailto:PlacementsNonEmergency%40azdcs.gov?subject=

Page 3 CONGREGATE CARE

ONE-ON-ONE SUPERVISION GUIDELINES

ARIZONA DEPARTMENT OF CHILD SAFETY

B. The Supervision.

1. What behaviors (positive and negative) were noted during the 1:1 supervision?

3. What happened when the DCS 1:1 supervision was decreased?

2. What type of redirection was needed and used during the 1:1 supervision?

4. Was the 1:1 used outside the home? For what type of activities?

5. Is there an increase or decrease needed for the 1:1? Provide reasons.

6. Are there multiple assigned staff for 1:1 supervision? Please document.

Page 4 CONGREGATE CARE

ONE-ON-ONE SUPERVISION GUIDELINES

ARIZONA DEPARTMENT OF CHILD SAFETY

C. Behavioral Health Services

1. Was the request brought before the Child and Family Team for determining whether the need arises from behaviors that pertain to the youth's Behavioral Health Diagnoses/issues or not? (Give date, time, results)

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

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

2b. Are there delays in implementation?

3. What reasons were given by CHP service providers if the requested covered service was delayed or denied?

Page 5 CONGREGATE CARE

ONE-ON-ONE SUPERVISION GUIDELINES

ARIZONA DEPARTMENT OF CHILD SAFETY

Service Date Start Time

(AM/PM)

End Time

(AM/PM)

Total Hours Printed Name

(Staff Providing Services) Signature

(Staff Providing Services)

Sum Total Hours

Date o f Birth

Month Year

Participant ID No.

Daily Log

Participant Name

Provider/Facility

Note: Signature for hours of supervision verifies the listed times and hours to be a true and accurate account of services provided for the named client by the listed staff.