Refuge House, Inc. · Compliance

FY-26 SSCC Joint Monitoring Tool — Desk Review

FY-26Desk ReviewTemporary · Archivable Manifest generated 2026-06-16 · Tool rev. 12-01-2025
Total items
69
Sections
7
Reviewed
0
Transitioning
0
Legacy
0
Unmapped
0
Scope: the Desk Review portion of the FY-26 SSCC Joint Monitoring Tool — the shared administrative items one reviewer group works once on behalf of all SSCCs, plus each SSCC's own desk-review items. All SSCC sections render the same underlying material (defined once under "requirements"); each SSCC adds its own citations for the aspects it monitors.
Classification Legacy Transitioning → T3C New (T3C) Not a policy Unmapped what these mean

Refuge House is migrating its policies into the T3C framework, so each item is tagged by state. Legacy = the pre-T3C document currently in force. Transitioning = actively being rewritten into T3C. New (T3C) = the published T3C version. Not a policy = an operational check. Unmapped = classification still to be assigned. Change any item's tag with its dropdown.

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Criminal Background Check Policy all-0
Drug Testing Policy all-1
Current standalone extract of the Drug Testing & Substance Abuse Policy from the Personnel Manual (June 2026). This is where the requirement is CURRENTLY met; the old standalone PDF is superseded.
Admissions – Emergency Placements all-2
Admissions – Non-Emergency Placements all-3
Emergency Behavior Intervention (EBI) Policy all-4
Discipline Policy all-5
Treatment Services Policy all-6
Adoption Services Policy all-7
Legacy: provide the previously-submitted Adoption Services PDF (per decision, not migrated to T3C).
Abuse and Neglect Prevention & Reporting Policy all-8
Firearms/Weapons Policy all-9
Grievance Policy (Stakeholders) all-10
HIPAA Policy all-11
Pre-service Experience Policy all-12
Training Policy – Personnel all-13
Training Policy – Caregiver/Foster Parent all-14
Babysitting and Respite Policy all-15
For PMN Providers, RN available on-call all-16
RN (Ashley Bahena BSN RN) documented in the Staffing Plan; provide if RH serves Primary Medical Needs (otherwise N/A).
IT Policy all-17
Encrypted Email Policy/Procedure all-18
Encrypted-email is IT Policy §5 + FP Agreement §5 (No-PHI-by-email).
Policy and Procedures Manual (Program Specific) – Current all-19
Provide the full current policy set — the compliance-API policy manual (site index) IS the live manual. The submitted PDF is a prior snapshot.
Professional Staffing Plan (Program Specific) – Current all-20
PROVIDE: Staff Roster (clean) + Staffing Plan + both org charts.
DERPP – Current all-21
Residential – 24-hr Awake Supervision schedule all-22
N/A for a CPA (no residential awake-supervision shifts). On-Call covers self-report if a child requires awake supervision.
Residential – staff ratio (waking hours) all-23
N/A — CPA/foster homes, not residential.
Assets
None — N/A
Residential – staff ratio (overnight) all-24
N/A — CPA/foster homes, not residential.
Assets
None — N/A
Disruption Mitigation Policy/Plan (all SSCCs) disruption-*
Named Disruption Mitigation Process = Discharge Procedure §3 + Policy §3; per-SSCC citations inline.
Client satisfaction program (2INgage, EMPOWER) satisfaction-*
EBI training curriculum (4Kids, Belong) ebi-training-*
Curriculum = SAMA; provide the Study Guide PDF.
CPA foster-parent support (2INgage, Belong, EMPOWER) support-*
Support types itemized in R&R Procedure §5.
Non-compliance reporting to DFPS (2INgage, 4Kids, EMPOWER) noncompliance-*
Abeyance-list / Credential verification (all SSCCs) abeyance-credentials-*
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Accreditation status (all SSCCs) accreditation-*
PROVIDE the Accreditation & Licensure Statement (Option B — not nationally accredited; aligns CQI with COA standards).
SSCC reviews CLASS before visit (all SSCCs) class-*
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
Disruption Mitigation Policy 21ngage-25
Mapped + named Process formalized (Jun 16 2026): now anchored by a named Disruption Mitigation Process at T3C Discharge & Permanency Planning Procedure §3 (+ Policy §3), carrying the 2INgage-specific reqs — 1-business-day contact on unplanned disruption, 30-day pre-removal documentation, cmd@2ingage.org + PCM notice, TPG Disruption/Discharge Form (top-2 reasons), due-diligence exhaustion checklist, 2INgage-facilitated Disruption Mitigation Plan / ECAP reassessment (2INgage Manual Rev.1.2026 §§4-5). Layered measures (FC6-01 matching + quarterly stability review + Crisis Mgmt + Discharge) feed into it. See disruption-mitigation reference sheet.
Citations 1
  • 2INgage2INgage Manual Rev.1.2026 §§4-5
Review of Staffing List against 21Ngage's Abeyance List 21ngage-26
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Is there a formal client satisfaction program (surveys/tools used to measure program effectiveness) 21ngage-27
Gap closed (Jun 16 2026): created lean CQI/PQI Policy + Procedure (FC-CQI-01 / .1) — no CQI doc previously existed. Its §2 Client & Stakeholder Satisfaction Program is the formal program: caregiver, youth/young-adult (youth voice), staff, and stakeholder satisfaction surveys + concern channel, compiled quarterly into PQI. Consolidates existing tools (Aftercare/Transition youth surveys, R&R family-satisfaction analysis, Kinship caregiver surveys, SIR PQI trend review). Cited to 2INgage Manual §12 p.51 (satisfaction surveys; DO-RITE).
Citations 1
  • 2INgage2INgage Manual §12 p.51
Is the Provider Accredited? If yes, by who? 21ngage-28
PROVIDE the Accreditation & Licensure Statement (Option B — not nationally accredited; aligns CQI with COA standards).
Verification of Personnel Credentials/Certifications 21ngage-29
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Any logs of non-compliance regarding 24 hours awake supervision requirement? 21ngage-30
Confirmation of timely submission of non-compliance to DFPS? 21ngage-31
Covered (Jun 16 2026): On-Call Policy/Procedure self-report 24-hr-awake-supervision non-compliance to DFPS within 24 hrs via the §1115 portal; FC-SIR-01 reports serious incidents via TPG within 24 hrs (§1411). 2INgage cross-ref added (Manual §11 p.47: timely record forwarding + Monthly Case Status Report by the 10th).
Citations 1
  • 2INgageManual §11 p.47: timely record forwarding + Monthly Case Status Report by the 10th
SSCC reviews CLASS system before Monitoring Review/Visit 21ngage-32
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
For CPAs – Verify types of Provider's support to foster parents 21ngage-33
Covered (Jun 16 2026): R&R Procedure §5 (Ongoing Retention & Support) — 24/7 four-level availability, RHU/TBRI training, TCM/clinical consult, respite (FC18-01), events/socials, holiday support, secure caregiver portal, twice-monthly visits + transportation. Inline 2INgage cite added (Manual §4 pp.21–23).
Citations 1
  • 2INgageManual §4 pp.21–23
Disruption Mitigation Plan (In-state Providers only) 4kids-34
Covered (Jun 16 2026): satisfied by the named Disruption Mitigation Process (T3C Discharge & Permanency Planning Procedure §3 + Policy §3), which now carries a 4Kids citation (4Kids4Families Joint Ops Manual Dec 2025 — Disruption Mitigation Plan item; 1-day discharge-staffing pp.132–133). Built on FC6-01 matching + Crisis Mgmt + Discharge + quarterly stability review.
Citations 1
  • 4Kids4Families4Kids4Families Joint Ops Manual Dec 2025 — Disruption Mitigation Plan item; 1-day discharge-staffing pp.132–133
SSCC reviews CLASS system before Monitoring Review/Visit 4kids-35
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
Training Curriculum used for EBI training 4kids-36
Covered (Jun 16 2026): EBI training curriculum = SAMA (Satori Alternatives to Managing Aggression), named in FC-16.06 (8 hrs child-care / 16 hrs treatment, competency-based, certified instructor). The actual curriculum was previously submitted: temporary-reference/SSCC/SAMA.EBI Training.pdf (SAMA Study Guide) + EBI Policy.pdf. EBI Procedure TRAINING section now points to it with a 4Kids citation.
Is the Provider Accredited? If yes, by who? 4kids-37
PROVIDE the Accreditation & Licensure Statement (Option B — not nationally accredited; aligns CQI with COA standards).
Any logs of non-compliance regarding 24 hours awake supervision requirement? 4kids-38
Confirmation of timely submission of non-compliance to DFPS? 4kids-39
Covered (Jun 16 2026): On-Call Policy/Procedure self-report 24-hr-awake non-compliance to DFPS within 24 hrs (§1115 portal); FC-SIR-01 reports serious incidents via TPG within 24 hrs (§1411). On-Call non-compliance section now carries a 4Kids citation (Joint Ops Manual Dec 2025 — Daily Notifications by 9am/5pm + Significant Events, pp.34–36).
Citations 1
  • 4Kids4FamiliesJoint Ops Manual Dec 2025 — Daily Notifications by 9am/5pm + Significant Events, pp.34–36
Verification of Personnel Credentials/Certifications 4kids-40
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Review of Staffing/Foster Home List against 4Kids4Families' Abeyance List 4kids-41
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Training Curriculum used for EBI training belong-42
Covered (Jun 16 2026): EBI training curriculum = SAMA (named in FC-16.06; submitted SAMA Study Guide at temporary-reference/SSCC/SAMA.EBI Training.pdf). EBI Procedure TRAINING section now carries a Belong citation (Belong Manual Aug 2025 p.29 — behavior-intervention approach, restraint reduction, "raising the yellow flag" early support).
Citations 1
  • BelongBelong Manual Aug 2025 p.29 — behavior-intervention approach, restraint reduction, "raising the yellow flag" early support
Verification of Personnel Credentials/Certifications belong-43
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Review of Staffing List against Belong's Abeyance List belong-44
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
SSCC reviews CLASS system before Monitoring Review/Visit belong-45
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
Disruption Mitigation Policy belong-46
Covered (Jun 16 2026): satisfied by the named Disruption Mitigation Process (T3C Discharge & Permanency Planning Procedure §3 + Policy §3), now carrying a Belong citation (Belong Manual Aug 2025 p.15 — 30-day pre-removal documentation, 1-business-day contact, 24/7/365 crisis support, Discharge Notice to the Belong discharge mailbox). Built on FC6-01 matching + Crisis Mgmt + Discharge.
Citations 1
  • BelongBelong Manual Aug 2025 p.15 — 30-day pre-removal documentation, 1-business-day contact, 24/7/365 crisis support, Discharge Notice to the Belong discharge mailbox
For CPAs – Verify types of Provider's support to foster parents belong-47
Covered (Jun 16 2026): R&R Procedure §5 (Ongoing Retention & Support) — 24/7 availability, training, TCM, respite, events, portal, twice-monthly visits. Belong citation added (Belong Manual Aug 2025 p.15 — "deliver foster parent support services to minimize placement disruptions").
Citations 1
  • BelongBelong Manual Aug 2025 p.15 — "deliver foster parent support services to minimize placement disruptions"
Disruption Mitigation Policy empower-48
Covered (Jun 16 2026): satisfied by the named Disruption Mitigation Process (T3C Discharge & Permanency Planning Procedure §3 + Policy §3), now carrying an EMPOWER citation (EMPOWER Provider Manual Rev.1.2026 §4 Placement Stability pp.24–25 — parallel to 2INgage; 1-business-day contact). Built on FC6-01 matching + Crisis Mgmt + Discharge + quarterly stability review.
Citations 1
  • EMPOWEREMPOWER Provider Manual Rev.1.2026 §4 Placement Stability pp.24–25 — parallel to 2INgage; 1-business-day contact
Review of Staffing List against EMPOWER's Abeyance List empower-49
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Is there a formal client satisfaction program (surveys/tools used to measure program effectiveness) empower-50
Covered (Jun 16 2026): CQI/PQI Policy + Procedure (FC-CQI-01 / .1) §2 Client & Stakeholder Satisfaction Program (caregiver / youth-voice / staff / stakeholder surveys + concern channel, compiled quarterly). Now cites EMPOWER §12 (satisfaction/feedback) alongside 2INgage §12 and OCOK §4.09.
Is the Provider Accredited? If yes, by who? empower-51
PROVIDE the Accreditation & Licensure Statement (Option B — not nationally accredited; aligns CQI with COA standards).
Verification of Personnel Credentials/Certifications empower-52
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
Any logs of non-compliance regarding 24 hours awake supervision requirement? empower-53
Confirmation of timely submission of non-compliance to DFPS? empower-54
SSCC reviews CLASS system before Monitoring Review/Visit empower-55
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
For CPAs – Verify types of Provider's support to foster parents empower-56
Support types itemized in R&R Procedure §5.
Disruption Mitigation Plan (In-state CPA Providers only) ocok-57
Covered (Jun 16 2026): satisfied by the named Disruption Mitigation Process (T3C Discharge & Permanency Planning Procedure §3 + Policy §3), now carrying an OCOK citation (OCOK Network Mgmt Ops Manual Rev.7-1-2025, p.40 — Network Providers submit a Disruption Mitigation Plan, if applicable). Built on FC6-01 matching + Crisis Mgmt + Discharge + quarterly stability review.
Citations 1
  • OCOKOCOK Network Mgmt Ops Manual Rev.7-1-2025, p.40 — Network Providers submit a Disruption Mitigation Plan, if applicable
Review of Staffing List against OCOK's Abeyance List ocok-58
PROVIDE OUR STAFF LIST: the clean RH Staff Roster (Dallas + SA) — names/roles/credentials — for the reviewer to compare against each SSCC's Abeyance list and verify credentials. Staffing Plan is the fuller companion.
SSCC reviews CLASS system before Monitoring Review/Visit ocok-59
N/A to provide — SSCC pulls CLASS on their side.
Assets
None — N/A
Disruption Mitigation Plan (In-state Providers only) saintfrancis-60
Covered (Jun 16 2026): satisfied by the named Disruption Mitigation Process (T3C Discharge & Permanency Planning Procedure §3 + Policy §3). SFCS citation added — Saint Francis Affiliate Provider Agreement (Region 1, Oct 8 2019; now in repo regulatory-references/SFCS/) has placement-change notification + smooth-transition + placement-stability Performance Measures but NO standalone disruption section (predates the framework), so the named Process + SSCC Master Contract govern. Newer SFCS provider manual not on hand.