MILWAUKEE ACADEMY MILWAUKEE ACADEMY

PARENTPARENT

HANDBOOKHANDBOOK

CLINICARE

A Greater Promise for Life

Milwaukee Academy ● 9501 W Watertown Plank Rd. ● Wauwatosa ● WI ● 53226 ● 414.257.3141 ● www.clinicarecorp.com

TABLE OF CONTENTS

• Introduction…... ............................................................................................... ..…3

• Admission Process ................................................................................................ 4

• Program Descriptions ............................................................................................ 4

• Description of Motivation and Discipline Procedures ............................................ 7

• Child/Parent Contact ............................................................................................. 9

• Personal Possessions ......................................................................................... 11

• Resident Rights ................................................................................................... 12

• Resident’s Responsibilities .................................................................................. 14

INTRODUCTION Milwaukee Academy is a residential treatment center for girls, located in Wauwatosa, Wisconsin. The Academy is owned and operated by Clinicare Corporation of West Allis, Wisconsin. The Academy was established in 2000, and is licensed by the State of Wisconsin Department of Health and Family Services to provide services for up to 24 female residents between the ages of 10 and 18 years old. Treatment areas for the residents at the Academy may include mental illness, emotional problems, conduct problems, learning problems, chemical abuse problems, difficulties from past traumatic experiences, sexual abuse/offender issues, and peer and family problems. MISSION The mission of Milwaukee Academy is to improve the well-being of the children in our care. VISION The vision of Milwaukee Academy is to be responsive to the changing needs of children in our society.

PHILOSOPHY

Milwaukee Academy utilizes a cognitive-behavioral therapeutic approach in meeting the needs of the youth and families whom we serve. The Academy

recognizes that each youth and their families possess individual strengths and weaknesses. Through a cognitive-behavioral approach to our interventions, we

are committed to the goal of assisting individuals and families to work through the past traumas they may have experienced in order to have a more healthy and

satisfying life style. VALUES

We value......

• RESPECT.....for the children and families in our care • INTEGRITY.......through excellence in service • COMPASSION.....for children and families reaching their potential • RESPONSIBILTY........in our treatment environment

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ADMISSION PROCESS Once your child has been accepted for treatment, a placement date will be established and some preliminary treatment goals will be developed. Admission paperwork will need to be completed and signed by you or the designated legal guardian of your child. You are welcome to have a copy of the consents that you sign, unless prohibited by a court of law. Everyone on the treatment team of your child are important participants in the creating of your family and child’s treatment plan. You are encouraged to come with your child and the placing agency to the Academy on the placement date. At that time, you and your child will meet with the Director of Admissions who will explain the program, provide a tour, connect you to the Case Manager who will be your main connection to the programming at the Academy and answer any questions you may have. Items that will need to be either provided to the Academy prior to the date of admission, or brought with your child upon the date of admission include: the completed admission packet, the signed permission forms, as well as your child’s clothing and personal possessions (please refer to Clothing Inventory in the admission packet and Personal Possessions section later in this handbook). PROGRAM DESCRIPTION TREATMENT PROGRAM The unit therapist and program case worker coordinate the assessment process which takes place during the first 30 days of placement. Assessment and/or screeners conducted on all residents include: physical/health check, psychiatric needs, nursing, psycho-social, social and family, education, group living, alcohol and other drug abuse (AODA), trauma and loss, suicide risk, and overall developmental and independent living skills needs assessments. The more open and honest everyone is about what your daughter and family need to help everyone heal is very important during this time to help the Academy’s clinicians work with you and your team to create the best treatment plan possible. It is recommended that the team slow down during this time to help reassess how to have safe and positive passes, visits, and how to implement community and residential resources in the most safe and helpful manner. An initial staffing is held within the first month of placement to present and summarize the results of the evaluations as well as initial treatment goals. You, your child, and the placing agency are invited and encouraged to attend the initial staffing as well as all subsequent staffings. Your input and participation throughout the treatment

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programming is highly valued. Three plans are developed at the initial staffing: the Individual Treatment Plan, the Permanency Plan, and the Home Visit Plan. All of these areas are continuously reviewed in each subsequent staffing as well. The Individual Treatment Plan outlines the treatment goals and interventions designed by and for you and your child during their placement at the Academy. You are an active participant in creating the goals and objectives, not only for your child, but for your family. Goal creation begins at the referral process and intake, continues through the assessment and orientation phases in the first 30 days, and is ongoing throughout treatment during reviews of the goals in each staffing, during family therapy, and through informal discussions about day to day progress of your child in the treatment program. The Permanency Plan projects the length of stay expected for your child to complete treatment and the discharge placement for your child. Factors that contribute to your child’s length of stay at the Academy include the placing agency’s expectations, the seriousness of the referral problems, your child’s attitude and cooperation toward placement, as well as your own support of your child’s treatment. The intent is for your child to complete their treatment program in the shortest amount of time possible. The Home Visit Plan is developed to ensure that home visits become a part of your child’s treatment plan as well as treatment work, and not merely vacations from treatment. You and the placing agency and Milwaukee Academy work together to determine the home visit resources and timetable for your child. This process begins at admission and is an ongoing plan that is reviewed and adjusted at periodic times in your youth’s placement. Milwaukee Academy encourages open visitation for families and support professionals to visit. It is recommended that visitation be planned around the various group and treatment programming to insure the maximum benefit to Milwaukee Academy’s treatment program. Throughout the treatment process your child will be involved in individual and group therapy. The individual therapy will address issues that are addressed in your child’s individual treatment plan. The therapy groups that your child may be involved in include: trauma from abuse/neglect, substance abuse and relapse planning, women’s health and education, corrective thinking, Dialectical Behavioral Therapy (DBT), goal setting, and community resolution/problem solving. Family therapy is encouraged for you and your child. This may occur either at the Academy, another designated site such as the placing agency offices, or in your home. Other options available for family therapy include videoconference or teleconference. These alternatives need to be discussed and approved by your placing social worker. Your child will also have a case manager while at the Academy. Case management services include arranging home visits, communicating with the placing agency and yourself, and coordinating the clinical pieces of your child’s treatment programming for ongoing development and reviewing of your child’s treatment goals. Throughout your child’s placement at the Academy, clinical staffings will be held on a

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monthly basis. These staffings will provide a formal system of reviewing your child’s progress toward their treatment plan goals, an update of the Permanency Plan and discharge resource, as well as an opportunity to revise or adapt the treatment plan and interventions as needed. All members of the treatment team working with you and your child will be invited to the staffing. As always, your involvement in your child’s staffings is highly valuable. As your child progresses in treatment, a discharge date will be developed with yourself, the placing agency, and the Academy. Recommendations for future aftercare and community treatment services for you and your child after she is discharged from the Academy will also be developed and provided. PSYCHIATRY During the evaluation period, your child will be seen for a psychiatric assessment which will cover biological and emotional factors related to your child’s presenting difficulties, as well as her ability to think clearly to get along with others comfortably. Throughout the stay, your child will participate in bi-monthly reviews with our doctor. Different psychotherapeutic approaches will be encouraged to fit the personal needs of your child. If any psychiatric medication is recommended, an additional permission and signature by your child and you (or guardian) will be obtained prior to the use of the medication. MEDICAL/NURSING SERVICES Each child at Milwaukee Academy receives an initial and yearly physical. If there are special medical problems, the child will be treated for them by a doctor in the community. We currently are using the Downtown Health Center. Wisconsin regulations state that residents must have semi-annual dental examinations with treatment as necessary. We ask that you certify your child has been seen by a dentist within six months prior to placement and that all necessary dental work has been completed. If this has not been able to occur, our nurse will meet with each resident upon admission to determine when a dental exam will occur. The Academy has a licensed nurse available to provide health care services. These services include: active involvement in the clinical program through direct clinical assessment and consultation with staff, physical assessment for injuries/illnesses with follow-up as needed, updating immunizations, administering physician prescribed medication, along with coordinating the use of community medical services and Academy psychiatric services. Our nurse also provides regular health groups to teach the girls a variety of educational topics (i.e: healthy eating, understanding and taking care of her body). The Academy strives to ensure that all residents are served balanced meals. When there is a need for any child to be placed on a special diet, these diet plans are coordinated between the nursing and food service departments, per a physician’s order. LIVING UNIT There are ten to twelve residents of the similar age and similar treatment needs on a living unit. The Academy abides by the State of Wisconsin standards which dictate that there is no more than a four year span of ages among residents on the same living unit. The units have skilled Youth Development Specialists who, under the supervision of the

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Program Therapist, Director, Director of Youth Care Services and Case Manager, provide care, supervision, and guidance to your child. It is with these staff that your child will share in unit duties, go to meals, prepare for school, engage in recreational activities, learn to relate positively with persons their own age, and learn to accept guidance and direction. EDUCATION While your child is a resident at the Academy, they will attend the Milwaukee Academy school. The school is staffed with faculty members all certified in their areas of specialization by the Wisconsin Department of Public Instruction. Your child is placed in a classroom according to the unit they are living on. Classrooms range in size from ten to twelve residents. Special intervention is also available to assist your child in developing behaviors necessary to be successful in school. In addition to the 9 month school year, an 8 week summer school is also provided. The summer program combines half-days of school with half-days of structured recreational programming. RECREATION The Academy believes that recreation provides a way to reduce anxiety, anger and depression, as well as improve self-esteem, confidence, and social skills. Leisure time activities are provided through the living unit staff, recreation staff, and physical education staff. These activities include: movies, roller skating, biking, picnics, shopping, arts and crafts, use of the on-grounds gym and outdoor recreation area, as well as other seasonal recreation activities. STAFF INFORMATION In accordance with State Licensing procedures, all Academy staff have had criminal background checks. All professional staff hold a Bachelors or Masters degree and are qualified to deliver the care and services required by their respective disciplines. To be an approved driver, a check is done on the employee’s driver’s license to ensure a safe driving record. Staff must also complete the Academy van driving safety course. RESIDENT RIGHTS/GRIEVANCE PROCEDURE Please review the attached segment of the Handbook for Residents which describes the rights and responsibilities of the resident. The Academy also has available to your child a grievance procedure in the event that your child may feel that their rights are violated. This grievance procedure provides your child with a form on which to write their concern. DESCRIPTION OF MOTIVATION AND DISCIPLINE PROCEDURES PHASE SYSTEM The Academy has developed a phase system with the intention of using it as a tool to motivate, educate, and hold your child accountable for becoming increasingly more aware of their own strengths, accountability to others, and readiness for age appropriate independence. The Phase System provides opportunities for your child to gain more privileges as they work through their individual treatment plan. Your child’s progress through the levels system should mirror their progress in treatment in general. As they

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obtain higher levels within the Phase System, they obtain higher privileges which also have higher expectations of responsibility and demonstration of independent living skills. All residents begin on the Bear Phase, which is the beginning level, and can work their way up through higher levels of privileges, as well as gaining mastery of skills that will allow her to have more responsibility. A full description of the Phases, privileges in each phase, and skills to master to move to a higher phase are in the Resident Handbook. Other terminology which may be helpful for you to understand as your child communicates with you about their Phases are safety or trust violation, which means your child does not have certain privileges due to a rule infractions such as not following through on day to day programming expectations, aggression, theft, property destruction, running away, and/or other dangerous acts. They may also be placed on a safety or trust precaution which is a clinical order put into place to offer a higher level of supervision due to some clinical stressors including suicidal ideations or self harm concerns. FLOW OF INTERVENTIONS The Academy believes that all residents have the right to be treated with dignity and respect. The Academy also takes seriously its responsibility to provide a safe living environment for all residents. As interventions with residents become necessary, the least restrictive and most appropriate to safely manage the resident’s behavior is preferred. The following interventions are described in the order of least restrictive to most restrictive. Verbal Intervention: Good communication and listening can often be the only level of intervention which is necessary with a resident. Unless extreme danger is imminent, this intervention is always the first intervention utilized to resolve situations with residents. Removal from Group/Time-Out in the Area: The next level of intervention that may be beneficial with a child is to remove them from their immediate peer group to the Thinking Chair, however, remain in the treatment area (living unit, classroom). A short period of time wherein the child is able to reflect more individually upon the immediate behavior often provides them with an opportunity to regain control of their own behaviors, while also presenting them with the motivation of rejoining the group. This technique is generally very short in duration. Multi-Sensory De-escalation Room: To continue to teach and build internal change in your child, we have encourage our youth to utilize our MSD room when facing a stressful moment in their daily routine. This intervention is used to help them learn to identify on their own or with staff encouragement when they are becoming upset or agitated. The goal is for them to voluntarily go into this room to calm themselves down so that they can return to the issue they were struggling with in a more effective manner. Supervised Time-Out Room: When a time-out or time in the MSD is unsuccessful, a child may be more responsive to a supervised time-out in an area away from the living

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unit or classroom. Milwaukee Academy utilizes a structured time-out room, which also requires your child to complete a problem solving assignment before they return to the regular living environment. Physical Intervention: In the event of imminent danger, such as a child becoming assaultive to others or harmful to themselves or others, a physical hold may become necessary. Staff are trained in physical intervention techniques which are designed to provide safety for both the resident and the staff. Physical holds are utilized only as long as they are necessary to assist the child in committing to making safe decisions again, and are released as soon as the child is able to do this. Seclusion Room: Criteria for a seclusion room placement is limited to a resident who is a danger to themselves or others. This intervention is designed for the safety of staff and residents, and can avoid your youth from requiring a physical hold to maintain safety. This intervention is highly monitored throughout the entire time your youth may be in this room. The length of time as well as the door being unlocked or locked is determined by the amount of aggression your child may be presenting at the time she is in the room. A viewing window allows communication, both verbal and visual, between the child and staff. Your youth is monitored every 4 minutes via this window to insure safety at all times. CHILD/PARENT CONTACT The Academy encourages you and your child to maintain regular and consistent contact throughout your child’s placement at the Academy. While we recognize that separation from your child at this time may be very difficult, the contact is also encouraged to be in support of the treatment programming at Milwaukee Academy, so as to provide ample opportunities for your child to fully engage in the treatment process. LETTERS/PHONE CALLS Milwaukee Academy will work with you to support the open and ongoing communication with your youth. The Academy provides your child with paper, envelopes, and a daily stamp for writing to immediate family members, their attorney, and social worker, and others approved by the team. Your child is allowed to receive mail freely while in placement at the Academy, making sure that your approvals on mail recipients as well as all court orders are being followed. In following the licensing guidelines regarding telephone contact with your child, please note that your child will be able to make and receive unlimited phone calls to their legal counsel. They will also be able to make phone calls to their placing social workers, probation officers, and other professionals as much as they need by putting in a written request to the Caseworker to arrange during the business day. Your child will have a designated call day that is arranged to best work with your family’s schedule once per week. They will have access daily to the phone to talk with you, but having a day set aside for your daughter has been shown to be helpful for them to be able to look forward to sharing their progress in in their treatment work. You may call in to your child every day if you choose to. These calls are private between the two

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of you unless otherwise determined by court orders, special treatment plans, or other pertinent orders. Phone calls will be limited to 10 minutes, as we have sometimes up to 22 girls receiving calls. Please also be aware that if you have approved multiple family members to be able to call your child, we have to limit the number of calls in per day to allow for all of the residents’ families to have a change to have at least one call in to their child. Evenings (in between groups, gym, chores, and other daily routines) and weekends are the times when your child would be most available to receive phone calls. Please do remember that there are sometimes 22 girls at the Academy, with a full day of treatment programming which can result in you calling and getting the voicemail during busy times. Please do leave a message, as the staff WILL call you back. Calling repeatedly will only interrupt treatment programming on the floor. Also, please also understand that there may be a few calls ahead of yours, and the staff will ask you if you would like to have them call you back or give you the option of calling later as well. Individual plans for phone calls to your child can and may be set up with your child’s treatment team that reflect changing treatment needs (ie: supervised calls per court order). Any restrictions or modifications of phone calls will be discussed and planned with you in advance as much as possible, will be reviewed weekly, and documented in your child’s file. VISITATION TO MILWAUKEE ACADEMY You are always welcome to visit your child at the Academy. As mentioned earlier, some moderation in the frequency of your visitation will assist your child in fully involving themselves in the treatment process. You may always visit with your child in the building. Upon occasion, as the treatment team you are working with approves this, you may take them out of the building for day passes. This is not encouraged during the first two weeks of placement, as this is time for your child to become connected to the treatment programming. Any visitation to the Academy, whether in the building or for a day pass, must be planned in advance with Milwaukee Academy’s case worker. A phone call to the case worker during business hours at least one day prior to your expected visit will allow your child’s case worker to inform all members of the team making decisions for your child, the necessary Milwaukee Academy personnel of your arrival time, as well as provide the written Authorization for Supervision form to be ready for your signature upon your arrival. If you are calling about weekend passes, those requests need to be in by Thursday, 5 pm to allow for the Case Manager to connect with other team members on the visit request. The Academy is a weapons, substance, and smoke-free environment so smoking is not allowed on the grounds or in the building. A visiting area will be designated to you. Bathrooms are available in the near vicinity, and we ask that you not leave the designated area without escort by Academy staff. If Milwaukee Academy staff suspect any indications of drug or alcohol use by a visitor, they reserve the right to ask that visitor to leave the premises. They will also not able to approve anyone picking up your child to drive under the influence of any substances. Due to the physical nature of the building, the doors to the Unit are locked. Though this provides safety for the staff and residents, it can seem a bit ‘uninviting’ to our visitors when they begin visiting. Visitation to your child’s living unit and bedroom may certainly occur when accompanied by staff and when other residents are not in the area. This adheres to confidentiality standards which the Academy upholds. At times, when your child may be on a precaution or going through some volatile treatment work, visitation

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will be recommended to occur in our private conference room on the unit. This will be arranged with the Caseworker when arranging visits. HOME VISITS Home visits and community passes are very important aspects of your daughter’s treatment work. These passes allow her to practice using the skills she is learning, and allows for all of you to work on relationships, deal with issues and problems, and enjoy successes. All home visit decisions are made in conjunction with you, the placing agency, and the Academy personnel. Visits will be connected to treatment work and safety issues and not ‘just because’. A home visit is not considered to be a break or vacation from treatment. Early planning of home visits assists in ensuring that all components run smoothly, such as the packing of medication, getting all team members on board, and helping prepare your daughter for a successful pass. PERSONAL POSSESSIONS MONEY Your child’s money is maintained for them in a safe in the staff office on the living unit. Amounts greater than $10.00 are kept safe for your child in the Business Office of the Academy. This money can be accessed for something special or for a planned shopping outing by your child through her filling out a money request to the Caseworker. While it is permissible for you to provide money for your child while they are at the Academy, it is not necessary. The activities that are provided for your child are paid for by the Academy with activities’ funds. Your child also earns an allowance weekly, with $5 automatically being put into a discharge savings account. If your child has incurred court ordered restitution or restitution at the Academy because of property destruction or theft, their allowance and earned incentive money will be docked for the amount determined by the treatment team working with your child. After discharge and after any outstanding restitution, court ordered expenses, etc. are figured out and paid from this account, the Business Office will mail the final amount to the guardian or placing agency, whichever is decided upon by the treatment team. This process may take a few weeks after discharge. CLOTHING You are encouraged to provide your child with the clothing that is itemized on the Clothing Inventory upon admission to Milwaukee Academy. Because the Academy is a treatment center, some items of clothing are not allowed or are discouraged. Expensive clothing is strongly discouraged as it may become lost, stolen, or damaged. Seductive clothing, ill-fitting clothing, gang related clothing, or otherwise negative subgroup connotations upon or within clothing are also disallowed. These and other items deemed so by staff will not be allowed to remain at the Academy and will be sent home to you. OTHER Your child is encouraged to bring some of their personal possessions in order to feel comfortable in their new living environment as well as to provide them with things to do

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during their free time. Again, because this is a residential treatment center, some cautions are enforced in order to reduce your child being distracted by their possessions from treatment or to prevent dangerousness. You are also discouraged from sending food with your child to the Academy, as we will not keep any leftover food or snacks bought during a home visit/pass. The Academy is not responsible for lost or damaged items, therefore, it is requested that you do not send expensive items with your child. The following is a list of examples of things your child may or may not bring to the Academy.

ALLOWED

NOT ALLOWED

Radios

Glass items

Books

CD’s, CD players, IPods, MP3 players

Art supplies

Hygiene supplies containing alcohol as the first ingredient

Diaries

Expensive jewelry

Stuffed animals

Body/face piercing No Artificial nails of any kind

Games, puzzles, models with non-toxic glue, crafts, cards, educational materials

Straight razors/razor blades/disposable razors

Electric razors (without beard trimmer)

Large video game systems and TV

RESIDENT RIGHTS I. INTRODUCTION

Milwaukee Academy supports and protects the fundamental human, civil, constitutional and statutory rights of each resident.

All residents are entitled to equal treatment without regard to race, color or national origin. Any resident who feels that they have been denied equal treatment should file a written grievance utilizing the resident grievance form.

II. RIGHTS

Personal

..... to participate in religious worship

..... to choose and wear your own clothes and personal articles within the guidelines of our dress code

..... to have reasonable private storage space

..... to have privacy in dressing, toileting and bathing

..... to freely send and receive U.S. mail. (You will be asked to open your mail

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in staff's presence.) ..... to use the telephone during reasonable times ..... to see visitors in designated visiting places ..... to refuse to be filmed or taped or have any surveillance cameras that

record

Some of the above rights may be limited because of your treatment needs or security needs and will be specified in your treatment plan.

Treatment Rights

..... to live in a pleasant physical place and to expect considerate and

respectful care ..... to know by name the professional person in charge of your care ..... to be involved in developing your treatment plan ..... to be involved in staffings regarding your progress ..... to refuse involvement in any experimental treatment or research ..... to be treated in the least restricted environment that can effectively carry

out your treatment plan ..... to have your conversations with staff and all medical and clinical records

kept confidential within the treatment team ..... to sign a statement of informed consent regarding receiving medication ..... to use the grievance procedure available when you feel your rights have

been denied

Legal Rights

..... to be informed of your rights in writing prior to placement

..... to bring an action for damages against persons violating your rights to confidentiality

..... to petition a court for review of your placement

..... to contact your attorney

Rights Regarding Placement in the Seclusion Room

..... to be free from seclusion except in cases of emergency (defined as part of your treatment plan) a. behavior of dangerous nature to self b. behavior of dangerous nature to others Your daughter, you, or any team member should make sure that all your

questions about any physical holds or seclusions are answered to insure that you have all the facts you need to understand what decisions were made by your daughter that required staff to utilize one of these restrictive interventions as well as allow for you to discuss any concerns you may have.

Other Rights

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..... to work at a job under one of the following conditions: a. the work is part of your individual treatment plan or b. you receive wages equal to the economic value of the work or c. the work is set up as a restitution plan either by the court or the

treatment staff in charge. NOTE: You may be required to perform tasks of a personal or community housekeeping nature

..... to review your treatment record with your therapist

..... you will find posted copies of resident rights in several places throughout the Academy and you are entitled to keep this copy for yourself

Residents' Rights/Grievance Procedure ..... each resident has some basic rights which he or she is informed of in

writing. ..... the grievance procedure for those who feel their rights have been

overlooked is as follows: Upon request, the resident is provided with a Resident Grievance/Complaint form on which they can state their concern. The grievance form is submitted to the program Director who will conduct a fair and impartial review of the complaint.

RESIDENT'S RESPONSIBILITIES

It is your responsibility..... ..... to read this handbook. If there is anything you do not understand, ask a staff

member to explain it to you. ..... to stay at the Academy until you are discharged. We cannot help you if you are

not here. ..... to follow your treatment plan. ..... to tell your therapist how you feel about treatment. Instead of acting out your

feelings, talk to staff and/or your therapist. ..... to do your daily chores such as making your bed and keeping your things neat

and clean. ..... to treat your fellow residents respectfully. ..... to go to school every day and to do your best. ..... to take part in unit, group and special activities. ..... to be honest with your family about how your treatment is going and to be honest

with your staff and therapist about how your family feels about it and how you feel about them.

..... to do your best to trust your staff. We care about young people, otherwise we wouldn't be here.

..... to respect others and the environment. You are expected to work towards becoming a 'safe' person if you are not one already. This means:

You understand that you have problems with how you handle your thoughts, emotions, and behavior. You are responsible for your emotions and behavior. You will respect yourself, others, and the environment.

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You will not hurt yourself or others, or be violent in any way. You will not smoke or use drugs or alcohol. You will not engage in any sexual activity.

Your child has rights that we respect and adhere to, and she also has responsibilities for working toward becoming a safer and healthier person. There are many adults she can talk to and work with when she gives them a chance. If she finds that you or she still have concerns about an issues, she or you may complete a grievance and submit that grievance to the Director of Milwaukee Academy. While she is a resident at the Academy, she and you will have many opportunities to learn about your daughter and your family. You can also learn much about life, as it is now and how it can be in the future. Your child’s individual emotional and behavioral needs will be the guide for how these rules of conduct are adhered to.