Family Violence Monitoring Tool REVISED- Jan 2010

7/29/2019 Family Violence Monitoring Tool REVISED- Jan 2010

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1GA. Dept. of Human Services/Family Violence Unit Monitoring Tool- 1/10

Division of Family and Children ServicesFamily and Child Safety Unit

FAMILY VIOLENCE AGENCY MONITORING TOOL


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TABLE OF CONTENTS

Topic Page

Shelter/Facility..... 5

General/Overall Outside ..... 5 Common Area.. 5 Living Room.... 6 Bedroom. 7 Bathroom 8 Kitchen... 9 Food 10 Dining Room....... 10 Laundry Area.. 11 Donation Area. 12

Play Area. 12 Play Ground. 13 General/Overall Outside.. 13

Health and Safety

Fire . 15 Natural Disaster .. 15 Bomb Threat 16 Intruder 17 Other Incidents 17 Substances.... 18 Accidental Injuries... 18


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TABLE OF CONTENTS (contd)

Topic Page Medical Concerns... 18

Agency Responsibilities 20

Agency Guidelines 20 Crisis Calls 21 Client Services.. 22 Children Services.. 27 Community Resource 29

Client Rights... 30

Confidentiality.... 32Personnel 34

New Hire Employees. 34 All Employee Information. 35

Work Rules 36 Training. 37

Volunteers. 38

New Volunteers 38 Volunteer Information 38 Training.. 39

Board of Directors.. 40

Financial Management.. 42

Audit/Tax Preparation 42 Insurance 43 Payroll 43

Data Tracking. 44


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Division of Family and Children ServicesFamily and Child Safety UnitFAMILY VIOLENCE AGENCY MONITORING TOOL DEFINITIONS

Area of Review-Performance standards of agency operations.

I, O, D- Methods used to assess the area of review (standards).

I-Interviews O-Observation D-Documentation

DM, M

DM-Did not meet M-Meet

P &P- Policies and Procedures that demonstrate the agencys operational measures.

Policies- A written general course of action formulated for the operation of an agency. Procedures- An established written method of accomplishinga specific duty; steps used to apply or implement the policy. The steps should

include:

whatactions and duties are required to implement this policy how are the actions completed who is responsible when or how often is this policy monitored

Practice- Agency implementation of the policies and procedures.

Unit Information-DHSreviewers means to assess the agencys compliance of the standard.


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SHELTER/FACILITYFacility must be maintained in conformity with regulations adopted by State and Local Fire Marshals, Division of Community Health and the GeorgiaDepartment of Natural Resources

Area of Review Unit Information I,O,D

P&P

DM, M

Practice

DM,MA. General /Overall Inside

The agency has policies, procedures and practices that demonstrate the overall care of

the facility for the items listed below:

1. Facility is clean and properly sanitized to prevent the spread ofinfection/disease

Review manual and tour shelter

2. Walls and woodwork are maintained and in clean condition Review manual and tour shelter

3. Agency provides regularly scheduled pest control in the facility Review manual, tour shelter, pestcontrol

4. All entrances and exits including windows and doors are securable Review manual and tour shelter

5. The agency has a monitored security system at the shelter Review manual, tour shelter,security contract, test system

6. Electrical service is inspected/approved annually by a local fire marshal or

qualified electrician

Review manual, tour shelter, copy

of inspection report7. Installation and maintenance of emergency lights Review manual and tour shelter

8. Installation and maintenance of smoke detectors Review manual and tour shelter

9. Fire extinguishers are maintained and installed in visible location

Review manual, tour shelter,

review extinguisher tags

10. Installation and maintenance of Carbon Monoxide Detectors

Review manual and tour shelter;

one detector per floor (for

agencies with gas appliances only)

11. Agency provides a confidential area for private interviews Review manual and tour shelter

12. General area must accommodate residents with impaired mobility Review manual and tour shelter

B. Common Area (s) (Stairwell, Hallway)


the common area for the items listed below:

1. Furnishings are clean and in good repair Review manual and tour shelter


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SHELTER/FACILITY

Area of Review Unit Information I,O,DP&P

DM, MPracticeDM,M

10. Living room has adequate lighting Review manual and tour shelter

11. Living room has adequate heat Review manual and tour shelter

12. Living room has adequate ventilation/air conditioning Review manual and tour shelter

13. All vent covers and ceiling fans are free of dust, dirt and mold Review manual and tour shelter

D. Bedroom

The agency has policies, procedures and practices that demonstrate the overall care ofthe bedroom (s) for the item listed below:

1. Furnishings are clean and in good repair Review manual and tour shelter

2. Walls and woodwork are maintained and in clean condition Review manual and tour shelter

3. Agency has no lead, chipped or peeling paint on room

walls/windows/s/furniture/cabinets/doors


4. All electrical outlets, which are not being used must have outlet coverings Review manual and tour shelter

5. All blind cords are secured and out of reach of children Review manual and tour shelter

6. Bedrooms are free of any hazards which could cause an accidental injury Review manual and tour shelter

7. Hazardous materials are securely stored and out of childrens reach Review manual and tour shelter

8. Evacuation plans are accurate and posted in each room Review manual and tour shelter

9. Electrical switches, devices and fixtures are maintained Review manual and tour shelter

10. Bedrooms have adequate lighting Review manual and tour shelter

11. Bedrooms have adequate heat Review manual and tour shelter

12. Bedrooms have adequate ventilation/air conditioning Review manual and tour shelter

13. All vent covers and ceiling fans are free of dust, dirt and mold Review manual and tour shelter

14. At least one bedroom must accommodate residents with impaired mobility Review manual and tour shelter

15. The agency provides bedding, towels, washcloths, soap, and access to othersupplies for the personal hygiene of residents

Review manual and tour shelter,client interviews

16. The agency ensures each bedroom and its contents are properly cleaned anddisinfected before next room assignment

Review manual and tour shelter,client interviews, staff interviews


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SHELTER/FACILITY


DM, MPracticeDM,M

17. The agency provides an individual bed for each resident at least 36 inches

wide and 72 inches long with comfortable springs, a protected mattress and a

pillow


18. Safe Cribs are provided for each infant Review manual and tour shelter,

ct. interviews

19. Each bedroom accommodates beds, storage for personal belongings, and freemovement


20. Resident bedroom doors open and close properly


equipped with side-hinged,

permanently mounted doors withpositively latching hardware

which ensures opening of the doorby a single motion, such as turning

a knob or pressing with normal

force21. Bedrooms have at least one window opening to the outside Review manual and tour shelter

E. Bathroom (s)


the bathroom (s)for the items listed below:

1. Bathroom furnishings are clean and in good repair Review manual and tour shelter

2. Agency has no lead, chipped or peeling paint on roomwalls/windows/furniture/cabinets/doors Review manual and tour shelter

3. All electrical outlets, which are not being used must have outlet coverings Review manual and tour shelter

4. All blind cords are secured and out of reach of children Review manual and tour shelter5. Bathrooms are free of any hazards which could cause an accidental injury Review manual and tour shelter

6. Hazardous materials are securely stored and out of childrens reach Review manual and tour shelter

7. Evacuation plans are accurate and posted in each room Review manual and tour shelter

(Note: Bathrooms within

bedrooms may not need an

evacuation plan)


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SHELTER/FACILITY


DM, MPracticeDM,M

8. Electrical switches, devices and fixtures are maintained Review manual and tour shelter

9. Bathroom (s) have adequate lighting Review manual and tour shelter

10. Bathroom (s) have adequate heat Review manual and tour shelter.

11. Bathroom (s) have adequate ventilation/air conditioning Review manual and tour shelter.

12. All vent covers and ceiling fans are free of dust, dirt and mold Review manual and tour shelter.

13. At least one functional toilet, sink and bathtub or shower are provided forevery six residents

Review manual and tour shelter.

14. Bathroom (s) without windows have forced ventilation to the outside Review manual and tour shelter.

15. Non-slip strips or surfacing is installed in tub/shower areas Review manual and tour shelter.

16. At least one bathroom must accommodate residents with impaired mobility Review manual and tour shelter.

(e.g. chairs, grab bars etc.)

F. Kitchen

The agency has policies, procedures and practices that demonstrate the overall care ofthe kitchen for the items listed below:

1. Kitchen must be kept in clean and in sanitary condition Review manual and tour shelter.2. Furnishings are clean and in good repair Review manual and tour shelter.

3. Walls and woodwork are maintained and in clean condition Review manual and tour shelter.

4. Agency has no lead, chipped or peeling paint on

room walls/windows/furniture/cabinets/doors Review manual and tour shelter.

5. All electrical outlets, which are not being used must have outlet coverings Review manual and tour shelter.

6. All blind cords are secured and out of reach of children Review manual and tour shelter.

7. Kitchen is free of any hazards which could cause an accidental injury Review manual and tour shelter.

8. Hazardous materials are securely stored and out of childrens reach Review manual and tour shelter.9. Evacuation plans are accurate and posted Review manual and tour shelter

10. Electrical switches, devices and fixtures are maintained Review manual and tour shelter.

11. Kitchen has adequate lighting Review manual and tour shelter.

12. Kitchen has adequate heat Review manual and tour shelter.


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SHELTER/FACILITY

Area of Review Unit Information I,O,D

P&P

DM, M

Practice

DM,M13. Kitchen has adequate ventilation/air conditioning Review manual and tour shelter.


15. Cooking appliances shall be suitably installed in accordance with approved

safety practices Review manual and tour shelter.

16. Metal hoods or canopies are suitably installed and maintained in accordance

with approved safety practices Review manual and tour shelter.

17. An ample supply of cookware, utensils and dishes are made available for

residents use


18. Cookware, utensils and dishes are in efficient condition and kept clean at all

times Review manual and tour shelter.

G. Food

The agency has policies, procedures and practices that demonstrate the provision and

safe keeping of food for the items listed below:1. The agency provides residents and their dependent children sufficient food and

nutrition, which meets the minimum USDA standards, and provides threemeals a day


knowledge of USDA standards.

2. Emergency food available on 24 hour basis Review manual and tour shelter.

3. Maintains refrigeration at 40 degrees Fahrenheit or less and Freezer at 0

degrees Fahrenheit Review manual and tour shelter.

4. All food items shall be stored in tightly sealed containers, once opened Review manual and tour shelter.

H. Dining Room

The agency has policies, procedures and practices that demonstrate the overall care ofthe dining room for the items listed below:

1. Furnishings are clean and in good repair Review manual and tour shelter.


3. Agency has no lead, chipped or peeling paint on roomwalls/windows/furniture/cabinets/doors



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SHELTER/FACILITY


DM, MPracticeDM,M

J. Donation Area

The agency shall provide policies and procedures for the overall care of the donation

area for the listed items below: (Note: Donation area requirements will be based

upon structure and use)


2. Agency has no lead, chipped or peeling paint on roomwalls/windows/furniture/cabinets/doors




5. Donation area is free of any hazards which could cause an accidental injury Review manual and tour shelter.

6. Hazardous materials are securely stored and out of childrens reach Review manual and tour shelter.

7. Evacuation plans are accurate and posted in each donation area Review manual and tour shelter.


9. Donation area has adequate lighting Review manual and tour shelter.

10. Donation area has adequate heat Review manual and tour shelter.11. Donation areas utilized by clients will have adequate ventilation/air

conditioningReview manual and tour shelter.


K. Play Area

The agency has policies, procedures and practices that demonstrate the overall care ofthe play area for the items listed below:

1. Furnishings are clean and in good repair Review manual and tour shelter.


3. Agency has no lead, chipped or peeling paint on room

walls/windows/furniture/cabinets/doors Review manual and tour shelter.



6. Play area is free of any hazards which could cause an accidental injury Review manual and tour shelter.


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SHELTER/FACILITY


DM, MPracticeDM,M

7. Hazardous materials are securely stored and out of childrens reach Review manual and tour shelter.

8. Evacuation plans are accurate and posted in each room Review manual and tour shelter.


10. Children toys are sanitized, cleaned and in good condition Review manual and tour shelter.

11. Play area has adequate lighting Review manual and tour shelter.

12. Play area has adequate heat Review manual and tour shelter.13. Play area has adequate ventilation/air conditioning Review manual and tour shelter.


L. Play Ground


the play ground for the items listed below:

1. Secure play space for children Review manual and tour shelter

2. Playground equipment is installed and maintained ina safe manner Review manual and tour shelter.

3. Play ground area is free from hazards, nuisances, refuse and litter Review manual and tour shelter.

4. Outdoor toys are maintained and in good condition Review manual and tour shelter.M. General /Overall Outside

The agency has policies, procedures and practices that demonstrate the overall care ofthe outside area for the items listed below:

1. Agency has no lead, chipped or peeling paint on the

walls/windows/stairs/furniture/doors/porches


2. Maintenance of the yard area to be free from hazards, nuisances, refuse and

litter


3. Sidewalks, fire escape routes and entrances shall be free of any hazards Review manual and tour shelter.

4. Exterior stairways must have securely fastened handrails on open sides Review manual and tour shelter.

5. Agency has a designated area outside of the building for smoking, away fromchildrens play area


6. Agency maintenance and monitoring of private water system according to the

state and local standard and/or regulations


review county regulation


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SHELTER/FACILITY


DM, MPracticeDM,M

7. Agency maintains and monitors the sewage disposal systems

Review manual, tour shelter

review county regulation.

8. Agency maintains and monitors that the garbage is stored in non combustible,

covered containers and removed from agency premises weekly


review county regulation.

9. Residents with impaired mobility must be able to access outside area Review manual and tour shelter.


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HEALTH AND SAFETYThe agency must have written health and safety policies

Area of Review Unit Information I, O, D

P&P

DM, M

Practice

DM,MAgency has posted a Notice Concerning Critical Incident Reporting in a common

area that is accessible to clients and the general public

Review manual, tour shelter;

Fire

The agency has policies, procedures and practices that outlines the protocol in case of

a fire, to include the following:1. The staff personnel in charge of monitoring the protocol Review manual, staff interviews.

2. An accounting of occupants Review manual, logs/ forms, staff

interviews.

3. Reporting event to proper authorities

Review manual, documentation

logs, reporting forms, staff

interviews.

4. Relating of emergency procedures to staff and residents Review manual.

5. Fire Drill to be performed quarterly or more often as required by the local fire

marshal

Review manual; drill occurs on

different shifts; drill documentation.

6. Protocol for the maintenance of the crisis line Review manual, logs/ forms.

7. Emergency housing for residents Review manual, incident reporting

form, staff interviews.

8. The investigation, evaluation and documentation of event and follow upprocedures on incident reporting form

Review manual, incident reportingform.

Natural Disaster

The agency has policies, procedures and practices that outlines the protocol, in case ofa natural disaster, to include the following:

1. The agency personnel in charge of monitoring the protocol Review manual, staff interviews.


interviews.


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HEALTH AND SAFETY

Area of Review Unit Information I, O, DP&P

DM, MPracticeDM,M

3. Reporting event to proper authorities Review manual, documentation


interviews.


5. Disaster drills to be conducted semi-annually Review manual; drill occurs on

different shifts; drill documentation .6. Protocol for the maintenance of the crisis line Review manual, logs/ forms.

7. Emergency housing for residents

Review manual, incident reporting

form, staff interviews.

8. The investigation, evaluation and documentation of event and follow up

procedures on incident reporting form


form.

Bomb Threat

The agency has policies, procedures and practices that outline the protocol, in case of

a bomb threat, to include the following:

1. The agency personnel in charge of monitoring the protocol Review manual, staff interviews.2. An accounting of occupants Review manual, logs/ forms, staff

interviews.

3. Reporting event to proper authoritiesReview manual, documentationlogs, reporting forms, staff

interviews.


5. Protocol for the maintenance of the crisis line

Review manual, logs/ forms.

6. Emergency housing for residents Review manual, incident reportingform, staff interviews.




form.


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HEALTH AND SAFETY


DM, MPracticeDM,M

Intruder

The agency has policies, procedures and practices that outline the protocol, in case of

an intruder, to include the following:

1. The agency personnel in charge of monitoring the protocol Review manual, staff interviews.


interviews.3. A safety plan for residents and staff Review manual, staff interviews,safety plan.

4. Reporting event to proper authorities



interviews.





form.

7. Intruder drills shall be conducted semi-annually Review manual; drilldocumentation.

Other Incidents

The agency has policies, procedures and practices that outline the protocol, for otherincidents, as listed below:

1. Possession of weapons, to include the investigation, evaluation and

documentation of event and follow up procedures


logs, reporting forms, staffinterviews.

2. An assault of client on client (including child on child) or client on staff, to

include the investigation, evaluation and documentation of event and follow upprocedures on the incident reporting form


logs, reporting forms, staffinterviews.

3. Theft, to include the investigation, evaluation and documentation of event and

follow up procedures on incident reporting form



interviews.


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HEALTH AND SAFETY


DM, MPracticeDM,M

4. The destruction of property, to include the investigation, evaluation and

documentation of event and follow up procedures on the incident reporting

form



interviews.

Substances

The agency has policies, procedures and practices that outline the protocol regarding

substances, as listed below:1. Illegal drugs found on the property or in possession of a client to include, theinvestigation, evaluation and documentation of event and follow up

procedures on the incident reporting form

Review manual, incident reportingform

2. Alcohol found on the property or in possession of a client to include, theinvestigation, evaluation and documentation of event and follow up procedures

on the incident reporting form

Review manual, incident reportingform., different for each client

3. A client is under the influence of alcohol or other substances to include theinvestigation, evaluation and documentation of event and follow up

procedures on the incident reporting form

Review manual, incident reportingform., different for each client

Accidental Injuries


accidental injuries as listed below:

1. Emergency medical care Review manual, staff interviews.


procedures including the use of the DHS Critical Incident Reporting procedure

Review manual, DHS Critical

Incident Reports

Medical Concerns


medical concerns as listed below:1. Meeting the medical needs of clients, including emergency prescription and

non-prescription medicine

Review manual, staff interviews,

review medical supplies of over the

counter medication;

2. Safe storage of client medications Review manual, staff interviews.


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HEALTH AND SAFETY


DM, MPracticeDM,M

3. Control and prevention of contagious diseases Review manual, staff interviews.

4. First Aid kit shall be maintained and kept at each location Review manual, review kit.


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AGENCY RESPONSIBILITIESThe agency must provide all of the following core services. Related policies shall be created, implemented and revised as needed;Residential/client policies/procedures shall be created, implemented and revised as needed.


P&P

DM, M

Practice

DM,MThe agency has policy, procedure and practice that demonstrates 80% of adults served

must be victims of domestic violence Review manual.

The agency has policy, procedure and practice that demonstrates that the

organizational chart is current and accurate to include the Board, staff and volunteers

Review manual.

Agency Guidelines

The agency has policies, procedures and practices that demonstrate the agency

guidelines to include the items listed below:

1. Residential handbook should include:

A.) An explanation of services provided by the agency Review manual; client handout.B.) Agency confidentiality policy Review manual; client handout.

C.) Clients rights Review manual; client handout.

D.) Shelter guidelines Review manual; client handout,guidelines (shelter rules)

2. Non-Residential handout should include:

A.) An explanation of services provided by the agency Review manual; client handout.

B.) Agency confidentiality policy Review manual; client handout.

C.) Clients rights Review manual; client handout.


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AGENCY RESPONSIBILITIES


DM, MPracticeDM,M

D.) Agency guidelines for non residents

Review manual, review guidelines (e.g.

roles and responsibilities of advocates,

roles and responsibilities for clients,

criteria to receive services, agency

responsibilities, meeting requirements,

children services including mandated

reporting requirement, length ofprogram, termination options; client

handout).

3. Client receives handbook within 24 hours of face to

face contact

Review manual, client file, client

interviews.

Crisis Calls

The agency has policies, procedures and practices outlining the agency

responsibilities for crisis calls to include the following:

1. 24 hour crisis line available and answered by center staff or volunteers without

the use of answering machines/service

Review manual, test crisis calls.

2. Agency has a minimum of two telephone lines, one of which is the designated

crisis line

Review manual.

3. Crisis line numbers are listed in the local telephone book and widely distributed

in areas served by the agency

Review manual, brochures, phone

book, staff interviews.

4. Crisis line is toll free and/or accepts collect calls Review manual, brochures, phone

book, staff interviews.

5. Crisis line should provide:

A.) Emotional support Review manual, crisis call

logs/form, client interviews, testcalls.

B.) Safety Planning Review manual, review crisis call

logs/form, client interviews, test

calls.


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AGENCY RESPONSIBILITIESArea of Review Unit Information I, O, D

P&PDM, M

PracticeDM,M

C.) Information/ referrals regarding services

Review manual, review crisis call

logs/form, client interviews, test

calls.

6. All crisis calls are documented within a format that includes an outcome Review manual, review log/ form.

7. Crisis call logs and forms are maintained for a minimum of 6 years Review manual, location of logs.

8. Procedures to meet the crisis callers needs including the following:

A.) The protocol used by staff and volunteers to determine bed availability withintheir shelter

Review manual, shift change

process, staff interviews.

B.) Bed availability updated by the staff on the DHS Family Violence Unitwebsite on a daily basis

Review manual, review DHS

website.

C.) The protocol used by staff and volunteers to make referrals to alternativelodging when the agency is at capacity Review manual, staff interviews.

D.) The protocol for the provision of transportation to the shelter or

alternative sites for clients in crisis

Review manual, staff interviews.

E.) The protocol for staff and volunteers to meet the needs of Non-English

speaking clients


resource guide, and language linecontract.

F.) The protocol used for staff and volunteers to meet the needs of the Hearing

Impaired via the TTY machine


G.) The protocol used to provide services for male victims Review manual, staff interviews.

Client Services

The agency has policies, procedures and practices for how client services are

provided to include the following:1. Residential services to include:


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DM, MPracticeDM,M

A.) Involvement by the justice systems is not a requirement of admittance or forcontinuance of services

Review manual, clienthandbook,

client interviews, example of justice

systems-police or protection orders).

B.) Criteria for admission Review manual, staff interviews.C.) Intake process Review manual, client interviews.

D.) Client files to include the following items:

I. Agency intake form with identifying information Review manual, client files. client

circumstances

II. Admissions agreement Review manual, client files.

III. Emergency health releases with name/phone/address of emergency

contact person

Review manual, client files.

IV. Each residential childs name, birth date, gender, and any other

emergency medical information Review manual, client files.V. Child care release Review manual, client files.

VI. Provisions of safe keeping of monies and valuablesReview manual, client files, log,client interviews.

VII. If offered as information, the forwarding address of the resident Review manual, client files.

VIII. Release of information form Review manual, client files.

IX. Confidentiality agreement Review manual, client files.


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AGENCY RESPONSIBILITIESArea of Review Unit Information I, O, D

P&PDM, M

PracticeDM,M

X.) Documentation of all safety plans

Review manual, review safety plan

examples: the survivors court

appearances, resumption of orbeginning new job, an order for

visitation of children by the batterer,

a batterer being servedstay away

orders or being released from jail

after an arrest involving the survivorand/or children.

2. Non residential services to include:

A.) Criteria for admission


B.) Intake process


C.) Client files to include the following items :

I. Agency intake form with identifying information Review client files.

II. Each non-residential childs name, birth date, gender and any other

emergency medical information Review manual, client files.

III. Release of information form

Review manual, client files, staff

interviews.

IV. Confidentiality agreement


interviews.


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DM, MPracticeDM,M

V.) Documentation of all safety plans

Review manual, review safety plan

examples: the survivors court

appearances, resumption of orbeginning new job, an order for

visitation of children by the batterer,

a batterer being served stay away

orders or being released from jailafter an arrest involving the survivorand/or children.

3. The agency provides legal advocacy for residential and non residential clients

Review manual, client interviews,

staff interviews, client files.

4. The agency provides social services advocacy for residential and nonresidential clients

Review manual, client interviews,staff interviews, client files.

5. The agency provides TANF assessments for residential and non residential

clients


staff interviews, client files.6. The agency provides transportation services for basic client needs Review manual, client interviews,

staff interviews, client files.

7. The agency provides housing assistance to residential and non residential

clients


client files, support group logs.

8. The agency provides weekly support groups for residents Review manual, client interviews,


9. The agency provides support groups twice per month for non residents Review manual, client interviews,


10. The agency provides voluntary parenting support/education for parents at theagency or through a written agreement with a referral agency

Review manual, client interviews,client files, group logs, written

agreement.


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DM, MPracticeDM,M

11. Residential and Non Residential individualized service plans Review manual. Service plans

should include: identified goals,

documentation of services, updatedweekly, prioritize clients needs,

including safety planning, identify

resources available to clients, goals

and objectives specific to the clientsown goals, record goals in aprogram-approved service plan,

goals correlate with survivors

length of stay, if in a shelter,progression toward completion of

clients goals and objectives,

adaptation to clients changingneeds, as appropriate.

12. Clients exit procedure to include the following:

A.) Exit interview provided with follow-up services offered to each adult

client


interviews.

B.) Safety Plan is developed for clients and their dependent children Review manual, client files, staffinterviews

C.) Agency evaluation to assess agency services Review manual, client files, staffinterviews, evaluation


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P&P

DM, M

Practice

DM,M13. Professional standards used by staff to write client case notes Review manual, to include areas such as

individual contacts, group sessions, referrals

and activities conducted by the client or staffin fulfillment of the service plan; Case notes

to include: Entries are legible, in

chronological order, daily for residential

shelters and per contact for nonresidential,formatted as hand written: in black or blue

ink, signed and dated by recorder,

comprehensive, objective, and factual,

corrected by drawing line through error and

initialing (NO WHITEOUT), are not made

on sticky notes or scrap paper, lines are

drawn through unused lines and theninitialed, agency approved abbreviations are

used, clearly identifies client, only necessary

facts are recorded, notes do not contain any

diagnosis or clinical assessments, notes onone client do not include other client names.

14. Client files are well organized Review manual, sequential file order,files bound together.

Children Services

The agency has policies, procedures and practices that demonstrate how the agency

provides childrens services, to include the items listed below:

1. Intake for each residential child to assess childs needs

Review manual, childs files, and

staff interviews.2. Intake and age appropriate orientation provided for non residential child as

needed

Review manual, childs files, staff

interviews; based upon site visit

3. Age appropriate orientation provided to each residential child Review manual, children files, staffinterviews


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DM, MPracticeDM,M

4. Agency prohibition of corporal punishment, physical or verbal abuse of

children


client handbook.

5. Counseling and support services provided or referred Review manual, staff interviews,

children files.

6. Child advocate provides weekly support group services and structured activities

to the following:


and calendar.

A.) Residential and Non-Residential children to include structured activities Review manual, children files.

B.) Non-Residential children as needed. Review manual, children files.

7. Structured activities provided by the agency for residential and non residential

children emphasizing the following:

A.)Exploring feelings and adjusting to new environment Review manual, children files,calendar of events, staff interviews.

B.) Conflict resolution skills development Review manual, children files,calendar of events, staff interviews.

C.) Building positive socialization skills Review manual, children files,calendar of events, staff interviews.

D.) Education regarding health and safety issues as related to domestic

violence

Review manual, children files,

calendar of events, staff interviews

E.) Building self esteem Review manual, children files,

calendar of events, staff interviews.

8. Consent form for children to participate in agency sponsored outings (fieldtrips)

Review manual, consent form.

9. Childrens files are well organized

Review manual, file order, files

bound together.


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DM, MPracticeDM,M

10. Child care services offered to include services provided by agency or a

community resource as needed


Community Resource

The agency has policies, procedures and practices that portray the agency as a

community resource, to include the listed items below:

1. Agency shows community relationships and linkages with community

agencies

Review manual, documentation.

2. Agency provides education and awareness to the communities served Review manual, community events

sign in sheet, community check ins.

3. The agency updates the community resource directory annually and ensures

that this information is readily accessible to victims and staff

Review manual, directory.

4. The agency has guidelines to reach out to the underserved populations in their

service area

Review manual.

5. All community publications must have prior approval by DHS and identify

DHS as a sponsoring agency

Review manual, community

publications.


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CLIENT RIGHTSPolicies and procedures regarding clients rights shall be created, implemented and revised as needed .


P&P

DM, M

Practice

DM,MThe agency has policies, procedures and practices prohibiting the deprivation of anyclient rights to include the following items:

1. The equal provision of services to clients regardless of political affiliation,

religion, race, color, sex, handicap, national origin, age (including teen boys),

gender (men), sexual orientation, legally emancipated clients and disabled

clients

Review manual, client handbook.

2. The clients right to make phone calls and how this information is

communicated to the client

Review manual, client handbook,

and client interviews.

3. The clients right to receive and send uncensored mail and how this

information is communicated to the client



4. The clients right to vote and how this information is communicated to the

client



5. The clients right to serve on a jury and how this information is communicated

to the client


and client interviews.6. The clients right to inspect and request copies of

their records


and client interviews

7. Client termination to include the following:

A.) Clearly defined reasons for involuntary termination from the agency services Review manual, client closed files,client handbook.

B.) Documentation of progression towards involuntary termination of client fromthe agency services

Review manual, client closed files.

8. A grievance process Review manual, client handbook,

grievance process.


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CLIENT RIGHTS


DM, MPracticeDM,M

9. The agency has policies, procedures and practices regarding the DHS

information poster

Review manual; Sign is clearly

posted in the shelter, in each office

location of the agency with theExecutive Directors name, phone

number and email, Board

Presidents name, DHS Family

Violence Consultants name,phonenumber and email

10.The agency has policies, procedures and practices regarding the display of themost current approval certificate in a prominent location within the shelter

Review manual; Sign is clearlyposted in the shelter.


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CONFIDENTIALITYPolicies, procedures and practices regarding client confidentiality shall be created, implemented and revised as needed, including:


P&P

DM, M

Practice

DM, MThe agency has policies, procedures and practices that protects the confidentiality ofall clients, to include the following:

1. Agency determines whether or not to publish and disseminate the shelters

location, including who has the authority to do so

Review manual, review pamphlets

or information describing shelter

services

2. Visitors sign a confidentiality statement regarding the non disclosure of the

agency location or client/staff/volunteer information

Review manual, visitor logs, staff

interviews

3. Minor visitors are briefed about confidentiality and adults sign and accept

responsibility for minors

Review manual, files/logs with

signed confidential statements

4. Outlining who has access to client records and client personal information Review manual, staff interviews

5. Obtain informed and voluntary written consent from the client for thedisclosure of information contained in the client record. The consent shall

include, but not be limited to:

A.)

Name of the person and agency to whom disclosure is made Review manual, client records,client handbook, staff interviews

B.) Specific information disclosed/purpose of disclosure Review manual, client records, staffinterviews

C.) Dated signature of client or guardian and witness Review manual, client records,D.) Expiration date of the consent Review manual, review consent

form

E.) Guidelines to revoke consent Review manual, consent form,methods indicating that the consent

is revocable at the written request ofthe person giving consent and that

the client has been informed of this

right


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CONFIDENTIALITY


DM, MPracticeDM, M

6. Requiring the maintenance of client files in a secure location for a minimum

of six years following the completion of services Review manual, client handbook

7. The confidentiality of client/staff/volunteers regarding health care issues, as

required by HIPPA guidelines Review manual, client handbook

8. Clients confidentiality addressed regarding court

orders, to include:

A.) How information will be released without client consent if a court order isreceived

Review manual, client handbook,staff interviews

B.) Notification of a current and former client Review manual, client handbook,

staff interviews

C.) Safety planning with current or former clients when records are

subpoenaed


staff interviews


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PERSONNELPersonnel policies should be created, implemented and revised as needed. The following should be included:


P&P

DM, M

Practice

DM,MNew Hire Employees

The agency has policies, procedures and practices for newly hired employees to

include items listed below:

1. Agency has a staff recruitment and selection process Review manual

2. A description of the agency orientation procedure for new staff to include:

agency orientation, the history, philosophy and structure of the organization

Review manual, personnel files.

3. New hire confidentiality process that includes a signed confidentiality

statement upon hire, acknowledging non disclosure of the agency and of

any client /volunteer/ staff information including medical information

according to HIPPA guidelines

Review manual, personnel files

4. A protocol that all new hires must undergo a criminal history investigationcheck during their probationary period, according to DHS fingerprint

guidelines


5. A protocol/policy that all direct service staff must have an annual TBscreening Review manual, personnel files.

6. Description of the new hire training process to include the following:

A.) Direct service staff shall complete 34 hours oftraining. Training should include:

Prior to being scheduled for unsupervised work, position training andDomestic Violence 101 training (including partner violence where the victim

is: Male, Gay, lesbian, bi-sexual, transgender, or questioning, Differently-

abled, Elderly) -5 hours

Prior to being scheduled for unsupervised work, position shadowing/on thejob training (including shelter guidelines) - 5 hours

First available front line advocacy training by the Georgia Coalition AgainstDomestic Violence or local advocacy training- 24 hours



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PERSONNEL


DM, MPracticeDM,M

B.) A training manual will be provided to each participant Review manual, personnel file,

signature of staff receipt, staff

interviews.

C.) Staff will receive training on Universal Health Precautions (including

H.I.V.) within the probationary period

Review manual, personnel file, staff

interviews.

D.) Staff shall receive First Aid and CPR training from a qualified, certified

trainer within the probationary period

Review manual, personnel file, staff

interviews.All Employee Information

The agency has policies, procedures and practices for all employees to include the

items listed below:

1. Agency maintains a current personnel file for each employee to include the

following:

Review manual, personnel file

A.) An application for employment Review manual, personnel file

B.) Verification of citizenship Review manual, personnel fileC.) Verification of degrees/certificates and professional/personal reference(s) Review manual, personnel file

D.) Copies of W- 4 form Review manual, personnel file

2. Agency has guidelines on employee rights in regards to their personnel records

to include the items listed below:

A). The confidential maintenance of personnel records Review manual, personnel file

B.) Process to release personnel records Review manual, personnel fileC.) Person (s)responsible for maintenance of records Review manual, personnel file

D.) Who has access to records Review manual, personnel file

E.) The right for an employee to inspect his/her records Review manual, personnel file

F.) The right to submit rebuttal documents Review manual, personnel file

3. Written job description provided to each employee Review manual, personnel file

4. Job description to include the following:

A.) Job title Review manual, personnel files


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PERSONNEL


DM, MPracticeDM,M

B.) Tasks and responsibilities of job Review manual, personnel file

C.) Required skills, knowledge and experience Review manual, personnel file

D.) Definition of employment classification- full time, part time, temporary,

exempt/non exempt Review manual, personnel files

5. The agency has a personnel policy and procedures manual that will be

provided to each employee


signed receipt in personnel files.

Work RulesThe agency has policies, procedures and practices regarding work rules (according tofair labor laws), grievance procedures, and disciplinary guidelines

Review manual, staff interviews,signed receipt in personnel files

Training

The agency has policies, procedures and practices regarding training requirements aslisted below:

1. Each staff has completed 10 hours of training annually Review manual

2. The training requirements for the child advocate (may be a part of the 10 hours

annual training requirement for each staff) to include:A.) The developmental stages of childhood, including Physical, Social, Cognitiveand Emotional Stages

Review manual, childrens program,

personnel file, childrens file

B.) Developmentally appropriate ways of working with children Review manual, childrens program,personnel file, childrens file

C.) Working knowledge of family violence and its effects on children Review manual, childrens program,personnel file, childrens file

D.) Assertive discipline techniquesReview manual, childrens program,

personnel file, childrens file


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PERSONNEL


DM, MPracticeDM,M

E.) Non-violent conflict resolution Review manual, childrens program,personnel file, childrens file

F.) The warning signs of child abuse Review manual, childrens program,personnel file, childrens file3. Debriefing opportunities for staff to prevent burnout Review manual, staff interviews.


38/44


VOLUNTEERSVolunteer policies should be created, implemented and revised as needed. The following should be included :


P&P

DM, M

Practice

DM,MVolunteers

The agency has policies, procedures and practices that demonstrates how the agency

utilizes volunteers, according to each of the items listed below:

1. Minor volunteers must be supervised by appropriate personnel Review manual

2. Agency documentation of the number of volunteers and number of hours

worked

Review manual, volunteer logs,

volunteer files.New Volunteers

1. Agency has a volunteer recruitment and selection process Review manual, volunteer logs,

volunteer files.

2. Signed confidentiality statement by volunteers to include non-disclosure of

agency, of client, staff or volunteer information, prior to beginning work

Review manual, volunteer files.

3. Agency provides criminal history investigation for volunteers (except

volunteer groups) according to DHS guidelines


4. Direct service volunteers shall complete 10 hours of training prior to beingscheduled for work to include: agency orientation, domestic violence 101,position training and position shadowing Review manual, volunteer files.

5. A volunteer manual shall be provided to each volunteer to include work rules Review manual, volunteer files.

6. Universal Health Precautions training (to include HIV) should be offered todirect service volunteers


7. Direct services volunteers working with children will receive First Aid/ CPR

training within probationary period Review manual, volunteer files.

Volunteer Information

The agency has policies, procedures and practices for volunteers to include the itemslisted below:

1. Agency maintains a current volunteer file to include: Review manual, personnel file.

A.) Completed volunteer application Volunteer files.

B.) Identification Volunteer files


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VOLUNTEERS


DM, MPracticeDM,M

C.) Drivers license for volunteers transporting clients. Volunteers

transporting clients in their personal vehicle must also have current auto

insurance Volunteer files

D.) Signed volunteer job descriptions for each ongoing volunteer Review manual, volunteer files

E.) Signed receipt of volunteer manual Review manual, volunteer files

Training

The agency has policies, procedures and practices regarding training requirements aslisted below:

1. Direct service volunteers shall complete 10 hours of training annually Review manual, volunteer files


40/44


BOARD OF DIRECTORSBoard membership policies should be created, implemented and revised as needed. The following should be included:


P&P

DM, M

Practice

DM,MThe agency has policies, procedures and practices that demonstrate board

involvement for the listed items below:

1. All agency policies and procedures manuals are reviewed and updated as

needed

Review manual, minutes and agenda

2. Agency has a strategic planning developed Review manual, strategic plan

3. Agency demonstrates maintenance of 25% of funding from local sources Review manual, minutes, and plan.

4. Board membership guidelines include:

A.) Minimum of 3 members Review manual, board list.

B.) Membership reflect demographics of community Review manual.

C.) Membership include victims of family violence Review manual.

D.) Majority of board membership represents each county served Review manual.

E.) Membership has at least one representative from local, municipal, orcounty law enforcement

Review manual, board file.

F.) Each new Board member within the first year of service has completed an

orientation to include DV 101 and nonprofit Board

Review manual, board file, board

interviews.

G.) Each experienced Board member (after one year) are provided at least one

face to face discussion to include Domestic Violence related topics and

Nonprofit Board governance yearly

Review manual, board file, board

interviews.

H.) A minimum of one board member must attend the DHS contractor

training annually

Review manual, board interviews.

5. Board administration guidelines to include:

A.) Financial reports provided to the governing body at least quarterly Review manual, minutes andagenda.


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BOARD OF DIRECTORS


DM, MPracticeDM,M

B.) Board annually reviews and approves total agency budget Review manual, minutes and agenda

C.) Investigation of allegations of the mismanagement, theft and

inappropriate use of funds to include the notification of DHS

Review manual, incident report

D.) Review and investigate staff, community or

client complaints

Review manual, board interviews,

formal documentation

E.) Hiring, evaluation and dismissal of the agency director to include the

notification of DHS

Review manual, E.D.s personnel

file (evaluation)F.) Executive Director responsibilities Review manual, E.D.s personnel

file ( job description)

G.) Executive Director participation in board meetings Review manual, agenda, minutes,personnel file

H.) A plan to ensure that all duties of the Executive Director are carried out

in her absence Review manual


42/44


FINANCIAL MANAGEMENTFinancial management policies should be created, implemented and revised as needed. The following should be included:


P & P

DM,M

Practice

DM,MThe agency has policies, procedures, and practices that demonstrate financialmanagement to include the listed items below:

1. 25% of funding comes from local sources (other than State and Federal) Review manual, annual budget,

audit, annual report

2. Management of accounts receivable/accounts payable

Review manual; reviewreconciliation of bank statements

within 30 days of close out,prevention of duplicate payment of

bills/invoices (paid stamp, check

register, accounts payable software,etc.).

3. Internal control process and procedures should demonstrate the agency

financial checks and balances to include a minimum of 3 people to verify

Review manual, process

4. Maintenance of petty cash Review manual, process.5. Client financial assistance Review manual, process.

6. Verification of receipt and acknowledgement of

donations

Review manual, donations,

documentation

7. Gathering and reporting statistics and financials to DHS monthly by the 10th

working day of the following month,with no error

Review manual, stats and

expenditure reports

Audit/Tax Preparation

The agency has policies procedures and practices for audits and tax preparation to

include the following:


43/44


FINANCIAL MANAGEMENT

Area of Review Unit Information I, O, DP & PDM,M

PracticeDM,M

1. Procedure for conducting an annual independent auditReview manual, submission as

required in contract, review last

independent audit and summary

2. Tax preparation Review manual, 990.

Insurance

The agency has policies, procedures, and practices for insurance to include the

following:1. Maintenance of the agency property insurance Review manual, insurance policy.

2. Maintenance of the auto insurance on all agency owned vehicles Review manual, insurance policy.

3. Maintenance of the directors and officers insurance Review manual, insurance policy.

4. Bonding/insuring staff/volunteers with access to agency funds Review manual, insurance policy.

5. Maintenance of worker compensation insurance Review manual, insurance policy.

Payroll

The agency has policies, procedures and practices that demonstrate payroll measures

for the items listed below:

1. Appropriate payment made to employees according to established payrollprocedures

Review manual

2. Travel reimbursement and per diem made to employees

Review manual to include travel

payment is after taxes,reimbursements cost not to exceed

DHS rate.


44/44


DATA TRACKING


P&P

DM, M

Practice

DM,MThe agency has policies, procedures and practices that demonstrate the use of the datasystem to include the following:

1. Each program within the agency is actively using the Alice program to enter

data

Review manual, agency observation,

staff interviews.

2. Data is backed up on a weekly basisReview manual, agency observation,staff interviews.

3. Person responsible for data back up

Review manual, agency observation,

staff interviews.

4. Data system is password protected Review manual, agency observation,

staff interviews.

Documents

Family Violence Monitoring Tool REVISED- Jan 2010