quality assurance readiness guide · 2019-08-13 · 4 | page quality assurance report (qa report)...

8/13/2019

QUALITY ASSURANCE

READINESS GUIDE

FY 2020 EDITION

Dear Executive Directors, Program Directors, Board Members, and Staff:

We believe the quality assurance process is one of the most effective ways Texas CASA partners

with local CASA programs in our shared vision of a CASA volunteer for every child, and we look

forward to working with you. This Readiness Guide is designed to assist you in preparing for the

review and includes step-by-step information about the process.

Fiscal year 2020 marks the beginning of a new quality assurance monitoring cycle within the

CASA network. During this process, reviewers from Texas CASA assess program compliance

comparing a checklist of monitored standards and requirements against program policies and

practices through document review, onsite interviews, file assessments, and quarterly

performance data submitted to Texas CASA. Additionally, fiscal year 2020 introduces two new

elements to the quality assurance process: a mandatory self-audit checklist to be completed and

submitted with the Indicators of Compliance (IoC) documents and an optional, facilitated, full-

board conversation. Combined, these activities culminate into a nonprofit organizational

assessment of five areas of operation: Nonprofit Governance, Advocacy for Children, Volunteer

Management, Nonprofit Administration, and Financial and Risk Management.

Programs will receive two documents throughout the quality assurance process— an Indicators

of Compliance (IoC) Outline and a Quality Assurance Report. The IoC Outline will detail

preliminary findings identified prior to the onsite visit when reviewing documents submitted by

your program as Indictors of Compliance. The Quality Assurance Report is the final report which

will include any requirement(s) to be addressed by the program and specify any required action

after the onsite visit.

Our team is always available to provide resources, tools, samples, and assistance, so please do

not hesitate to contact us at any time prior to, during, or following your Quality Assurance

Review. Your feedback and evaluation of the process is welcomed and appreciated as it plays a

vital role in our journey to service excellence.

Sincerely,

The Texas CASA Program Operations Team

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TABLE OF CONTENTS

Quality Assurance Review Timeline 3

An overview of the process with key milestones

Indicators of Compliance Documents (IoCs) 5

List of documents to be submitted prior to the onsite review for desk review

Checklists of Monitored Standards and Requirements 6

List of all of the requirements evaluated as part of the Texas CASA Quality Assurance Review

Instructions for Running Cases/Children and Volunteer Reports 25

Step-by-step instructions for running required reports (to be submitted with the IoCs)

Instructions for Calculating a 2-Year Volunteer Retention Rate 26

Step-by-step instructions for calculating the retention rate (to be submitted with the IoCs)

Instructions for Submitting the IoCs 27

Step-by-step instructions for submitting the IoCs

Additional Documents Requested While Onsite 28

Details on documents reviewed and assessed by the reviewer while onsite

Instructions for Background Check Verifications 29

Step-by-step instructions for running the reports (to be submitted with the IoCs)

Overview of Onsite Assessment of Volunteer Screening & Training 30

Process used by the reviewer onsite to assess volunteer files

Sample Documentation of Volunteer Screening & Training Assessment Form 31

Form used by the reviewer while onsite to assess volunteer files

Overview of Onsite Assessment of Documentation of Advocacy 32

Process used by the reviewer while onsite to assess advocacy on a case

Sample Documentation of Advocacy File Assessment Form 33

Form used by reviewer while onsite to assess advocacy on a case

Program Response Submission Instructions 34

Step-by-step instructions for sending all required action from the QA Report in one email

Alternative Program Response Requirements 35

Details on two alternative program response requirements: immediate responses and priority compliance responses

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QUALITY ASSURANCE REVIEW TIMELINE

NOTIFICATION AND SCHEDULE

• Programs will be notified of the month in which their onsite visit will occur at the Quality

Assurance Preparation Training in August.

• The Executive Director (ED) is then contacted no later than 90 days prior to the first day of the

month of their onsite visit to select the dates for their onsite visit. In addition, a pre-review

conference call will be scheduled at that time. In an effort to make the QA Review as successful

as possible, Texas CASA requires the participation of the ED, Board Chair, and Treasurer on the

call.

PRE – REVIEW CONFERENCE CALL

• The pre-review conference call is scheduled for at least 80 days prior to the onsite visit.

A reminder email will be sent to the ED, Chair, and Treasurer two days prior to the call

• Questions about the QA process are welcomed and encouraged from all participants during the

call.

INDICATORS OF COMPLIANCE DOCUMENTS (IoCs)

• The Indicators of Compliance (IoC) documents and newly required self-audit checklist are due to

Texas CASA no later than 20 days prior to the onsite visit. See page 27 for step-by-step

submission instructions for the IoCs and self-audit checklist.

A reminder email will be sent to the ED, Chair, and Treasurer seven days prior to the IoC due date

• The reviewer will then complete a desk review of the submitted documents. No later than five

days before the onsite visit, the ED, Chair, and Treasurer will receive an outline of any preliminary

findings. No action is required upon receipt of the outline.

ONSITE QUALITY ASSURANCE VISIT

• During the onsite visit, the reviewer will discuss the IoC outline and self-audit checklist, evaluate

various documents, conduct interviews with staff and board members, and host “A Board

Conversation (ABC)”. See page 28 for a list of documents reviewed onsite.

Select Dates for Onsite Visit

Pre-Review Conference

Call

IoCs and self-audit

checklist due to Texas CASA

Onsite Visit

Post-Review Conference Call & Final QA Report sent to Program

Texas CASA Assistance Provided

Program Response

Due*

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QUALITY ASSURANCE REPORT (QA REPORT) AND POST-REVIEW CONFERENCE CALL

• The Quality Assurance Report (QA Report) is an organizational assessment that includes findings

from the desk and onsite reviews.

• A draft of the report is emailed to the ED, Chair, and Treasurer within 16 days of the review. The

ED, Chair, and Treasurer will have the opportunity to discuss the draft with the reviewer during the

Post-Review Conference Call.

• Within three days after the Post-Review Conference Call, Texas CASA will send the final QA

Report which will outline each requirement that the program must submit to Texas CASA to bring

the program into compliance with the monitored Texas CASA Standards.

• A response to each of the requirements listed in the final QA Report is due within 90 days after

the Post-Review Conference Call unless noted otherwise on the report. See page 35 for additional

details on immediate and priority compliance responses.

TEXAS CASA ASSISTANCE

• The resources and information that the reviewer identifies as beneficial to the program, referred to

as Texas CASA assistance, will be provided by the reviewer within 30 days of the Post-Review

Conference Call.

PROGRAM RESPONSE

• Failure to submit a response to any requirement outlined in your final QA Report by the specified deadline may result in a financial hold. In certain circumstances, an extension for up to 60 days may be granted. Requests must be made in writing to the Chief Program Operations Officer.

• For your convenience, you can view deadlines and the full list of requirements to bring your program into compliance via your QA Review page in the Online Data Manager (ODM).

Reminder emails will be sent to the ED, Chair, and Treasurer 30 and 10 days prior to the due date

• Within 14 days of receiving the full submission, Texas CASA will update the QA Review page and

send notification of which requirements have been met and/or which require additional action. If

additional action is required, a due date for the second response will be provided by Texas CASA

at that time.

• Once all requirements have been met, a certificate of QA Review completion is emailed to the

ED, Chair, and Treasurer.

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INDICATORS OF COMPLIANCE DOCUMENTS (IoCs)

The following documents must be submitted no later than 20 days prior to the onsite visit. If a document

is contained within another listed below, only the primary document needs to be submitted. For

example, if the board job description is included in board policies and procedures, you will only need to

submit the board policies and procedures one time.

•Current Board Member Roster with Term Dates

•Board Member Job Description

•Program Planning Documentation & Process for Monitoring (i.e. strategic plan and dashboard)

•Written plan addressing needs of children served from a diversity perspective (i.e. diversity plan, if not included in strategic plan)

•Bylaws

•Board Policies and Procedures

•Past 12 Months of Board Meeting Minutes and Attachments

•Written Succession Plan

•Documentation of Formal Board Orientation (e.g., overview/table of contents of board manual/packet or agenda/schedule of board orientation)

•DFPS Automated Background Check System (ABCS) activity list

•Fingerprint-Based Background Check (FBC) worklist

•Documentation of any waiver previously granted by Texas CASA Board of Directors

Nonprofit Governance

•MOU or Working Agreement with the Courts

•DFPS MOU with Local Signatures (including state signature if local addendums were added)

•Results of Volunteer, Judicial, and Stakeholder Surveys (conducted within the past 24 months)

•Cases by Date Report OR Active Children by Supervisor by Date Report (based on quarter in which the onsite review will occur; instructions on page 25 )

Advocacy for Children

•Volunteer Job Description

•Volunteer Policies and Procedures

•Pre-Service Training Agenda and Calendar

•Current In-Service Training Schedule

•Volunteer Recruitment Plan (if not included in strategic or diversity plan)

•2-Year Volunteer Retention Calculation (instructions for how to calculate are on page 26)•Volunteer by Date Report OR Active Children with Assigned Volunteer Report (based on quarter in which the onsite review will occur; instructions on page 25)

Volunteer Management

•Organizational Chart (with start dates if available)

•Job Description for Each Staff Position

•All Personnel/Employee Policies and Procedures (include all other standalone policies)

•Umbrella Agreement (if applicable)

Nonprofit Administration

•Board Approved Budget for Current Fiscal Year

•Most Recent Annual Report

•Financial Policies and Procedures

Financial & Risk Management

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CHECKLISTS OF MONITORED STANDARDS AND REQUIREMENTS

The Quality Assurance Checklist of Monitored Standards and Requirements is a listing of all of the

requirements evaluated as part of the Texas CASA Quality Assurance Review. This includes a

review of policy and/or practice during the desk and/or onsite portion of the review.

As of FY20, programs are required to use this checklist in preparation for a QA Review. An

editable copy of this checklist with additional space to insert notes on how your program can

demonstrate compliance (e.g. page numbers or section numbers within policy) is available for

download at: https://texascasa.org/learning-center/resources/quality-assurance/

Though some monitored requirements remain the same for each QA cycle, other requirements

will change. Those highlighted in yellow denote requirements newly monitored during this QA

Cycle – either in the desk or onsite portion of the review. Those in red denote an immediate

response is required if a final determination is made that a program is out of compliance during

the onsite review.

NONPROFIT GOVERNANCE

STND REQUIREMENT HOW THE REQUIREMENT IS ASSESSED IN POLICY

HOW THE REQUIREMENT IS

ASSESSED IN PRACTICE

3.A.1.-2.

The program adopts and implements a written plan to guide and measure progress in diversifying its governing body, staff and volunteers. As part of the planning process, the program: Identifies specific measurable goals; Reviews those goals to measure progress, at least annually; Identifies new goals and activities to be met in the future. The program creates and implements a written plan that addresses the needs of the children served from a diversity perspective.

Plan submitted (either separately or as part of strategic plan) must include ways to address diversity needs beyond volunteer recruitment. Planning must include diversification of board, staff, and volunteers. As per Standard 1.A.5, the plan reflects diversity of the children served.

5.A.8.

Governing body reviews financial reports at least quarterly comparing actual versus budgeted expenditures and revenues.

Practice verified through a review of board minutes.

https://texascasa.org/learning-center/resources/quality-assurance/

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5.A.12.c.

The CASA/GAL program's bylaws or written operational procedures: Set the minimum number of board members at no fewer than nine members, with an Executive Committee comprised of at least a President, Vice President, Secretary and Treasurer.

Must be included in bylaws or board policies or procedures.

Practice verified through a review of the current board roster.

5.A.12.e.

The CASA/GAL program's bylaws or written operational procedures: Set the quorum for these meetings of at least a simple majority of the current membership of the governing body.


Practice verified through a review of board minutes.

5.A.13.

The governing body serves as the link between the program, the court, and the community, establishes and evaluates the program's goals, develops resources, and approves policies.

Practice verified by reflection in the board minutes or by inclusion of board revision dates on policies.

5.C.5.

Board members receive formal orientation and on-going education related to the CASA/GAL program's goals, objectives, structure, methods of operation, and fiduciary responsibilities, including financial oversight. The members are familiarized with its services, dynamics of child abuse, family violence and legal statutes. They are provided with key documents related to governance and board responsibilities.

Must submit verification of formal orientation.

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STND REQUIREMENT HOW THE REQUIREMENT

IS ASSESED IN POLICY



5.C.6.a.-f.

Record checks are completed on each board member including: Social security number verification; Texas criminal record check obtained from the Texas Crime Information Center maintained by the Texas Department of Public Safety; National criminal record check obtained from the National Crime Information Center (NCIC) maintained by the Federal Bureau of Investigations; Texas Public Sex Offender Registry check maintained by the Texas Department of Public Safety; National Sex Offender Registry check maintained by the United States Department of Justice; The Child Abuse and Neglect Central Registry maintained by the Texas Department of Family and Protective Services.

Must be included in bylaws or board policies or procedures. Will not monitor for social security number verification.

Practice verified by comparison of DFPS Automated Background Check System (ABCS) activity list and Fingerprint-Based Background Check (FBC) worklist against current board member roster.

6.A.7.a.

The governing body adopts a written succession plan. The plan makes provision for the following in the event of the replacement of a chief executive officer: Designates an interim chief executive officer/program administrator, if necessary and notifies Texas CASA.

Must submit written succession plan that includes the process and designee in the event of a temporary or emergency absence.

6.I.5.a.

The governing body: Evaluates the performance of the chief executive officer/organization administrator in writing at least annually against written performance criteria and objectives established for the time span between evaluations.

Must be included in bylaws, policies or procedures, or board job description.

Practice verified onsite through review of the ED's personnel file.

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9.B.3.b.-e.

The strategic planning process includes: Developing long- and short-term measurable goals for child outcomes, volunteers and resource development; Determining objectives with an action plan related to agency goals; Assessment and tracking progress; Carrying out tasks with related timeframes and specified person responsible.

Plan submitted must contain measureable goals, actions, timeframes, persons responsible, and tracking. If not included in strategic plan, tracking can be submitted as a separate document.

10.B.1.

The CASA/GAL program follows a written plan for securing and maintaining diversified financial resources adequate to accomplish its established goals and objectives.

Must submit separate fund development plan if not included in strategic plan.

10.G.4.b.-c.

The CASA/GAL program evaluates and reduces its potential liability by: Ensuring that appropriate bonding, self-insurance, or external coverage is adequate to meet the potential liability of the CASA/GAL program; Developing a process to identify risks in terms of their nature, severity and frequency.

Practice verified through onsite interviews.

ADVOCACY FOR CHILDREN





1.C.1.-2.

The CASA/GAL program has a written agreement with the court, reviewed every two years, that defines the working relationship between the program and the court. The written agreement between the CASA/GAL program and the court must be renewed when there is a change in the judicial leadership or changes in policy, law, or local court rules that substantially impact the relationship between the program and the court.

A signed, written agreement within the last 24 months establishing the working relationship between the program and each court served must be submitted.

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1.C.5.

The CASA/GAL program has a written agreement which defines the working relationship between the program and the Department of Family and Protective Services (DFPS), reviewed every two years, and other agencies as deemed appropriate.

Local CPS signatures on the statewide MOU, within the past 24 months, must be submitted for each CPS region served.

7.D.8.

A volunteer will not be assigned more than two cases at a time. An exception may be granted in the discretion of the CASA/GAL program staff; however, the decision to permit a higher caseload shall be documented as to the justification for and reasonableness of the exception. Under the exception, a volunteer will not be assigned to more than five cases.

Practice verified onsite through review of Volunteer by Date Report.

7.D.9. The minimum ratio of volunteers to assigned cases is 80%.

Practice verified during desk review through a review of performance measures reported through the ODM for previous quarter. Practice verified onsite through the review of Cases by Date Report (to date of the onsite review, separated by supervisor)

7.E.5.a.

Written roles and responsibilities will include the following. The advocate will: Identify and advocate for the best interest of the child by obtaining first hand a clear understanding of the needs and situation of the child, by conducting an ongoing review of all relevant documents and records and by interviewing the child, parents, social workers, teachers and other persons to determine the facts and circumstances of the child’s situation.

Must be included in volunteer policies or procedures or job description.

Practice verified onsite through review of case files randomly selected from Cases by Date Report OR Active Children by Supervisor by Date Report.

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7.E.5.b.i.-ii.

Written roles and responsibilities will include the following. The advocate will: Have regular and sufficient in-person contact with the child where they live to ensure in-depth knowledge of the case and make fact-based recommendations to the court. The CASA volunteer shall meet in-person with the child once every thirty (30) days at a minimum. An exception may be granted: If the child(ren) are placed more than 1 but less than 3 driving hours away, CASA will meet in person with the child(ren) at least once every three months; If the child(ren) are placed more than 3 driving hours away, CASA will meet in person with the child(ren) at least once every six months.

Must be included in volunteer policies, procedures, or job description.


7.E.5.b.iii.

Written roles and responsibilities will include the following. The advocate will: Have regular and sufficient in-person contact with the child where they live to ensure in-depth knowledge of the case and make fact-based recommendations to the court. The CASA volunteer shall meet in-person with the child once every thirty (30) days at a minimum. An exception may be granted: In addition to in-person contact, [the advocate will] have other types of monthly age appropriate contact with the child(ren) including telephone calls, emails, video conferencing and letters as applicable for the child’s age and interests.

Must be included in volunteer policies or procedures, or job description.


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7.E.5.c.

Written roles and responsibilities will include the following.The advocate will: Communicate with the DFPS caseworker after appointment and at least one time per month for the duration of the case.



7.E.5.d.

Written roles and responsibilities will include the following. The advocate will: Meet in person with the child’s primary placement provider, in a timely manner, after placement occurs. Communicate with the placement provider at least once per month thereafter for the duration of the child’s case.



7.E.5.e.

Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties.



7.E.5.e.-f. (EDU)

Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties. Determine the child(ren)’s permanent plan, access the educational portfolio and health passport and make recommendations regarding permanency, and education and medical services, as appropriate.



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7.E.5.e.-f. (MED)

Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties. Determine the child(ren)’s permanent plan, access the educational portfolio and health passport and make recommendations regarding permanency, and education and medical services, as appropriate.



7.E.5.g.

Written roles and responsibilities will include the following. The advocate will: Appear at all hearings to advocate for the child’s best interests and provide testimony as needed.


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7.E.5.h.

Written roles and responsibilities will include the following. The advocate will: Provide at every hearing reports which include findings and recommendations, including specific recommendations for appropriate services for the child and, when appropriate, the child's family.


7.E.5.i.

Written roles and responsibilities will include the following. The advocate will: Participate in all case-related meetings.


7.E.5.l.

Written roles and responsibilities will include the following. The advocate will: Maintain complete records about the case, including appointments, interviews and information gathered about the child and the child’s life circumstances and return all records to the program after the case is closed.



7.E.5.m.

Written roles and responsibilities will include the following. The advocate will: Communicate at least once monthly with CASA supervisor and participate in case conferences as scheduled.



9.C.1.a.

At least once in a two-year period, the CASA/GAL program conducts a review which includes assessment of the program goals, objectives and outcomes as well as alignment with those of National CASA and Texas CASA that pertain to local CASA/GAL programs: Degree to which the program identifies and meets the advocacy needs of the children it serves, as assessed through surveys of volunteers, judges, and other key stakeholders.

Survey results from within the last 24 months must be submitted with Indicators of Compliance. If the survey has not been conducted within the last 24 months, a copy of the questionnaire can be submitted with the Indicators of Compliance. New survey results must then be submitted to reviewer upon their arrival onsite.

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VOLUNTEER MANAGEMENT




2.B.3.

CASA volunteers take an oath of confidentiality upon completion of training and sign a statement of confidentiality upon acceptance of each case.

Practice verified onsite through review of volunteer files randomly selected from Volunteer by Date Report.

7.A.2.

The recruitment plan demonstrates that inclusiveness and diversity are essential components of quality advocacy and includes targeted strategies to attract a diverse volunteer pool.

Must be included in volunteer recruitment plan or as part of a strategic or diversity plan.

7.B.4.

The CASA/GAL program has a policy regarding the reactivation of volunteers who have been inactive for more than one year. The policy shall include guidelines under which a volunteer would not have to be retrained. The program shall document the specific information when reactivating a volunteer without retraining.

Must be included in volunteer policies or procedures or as separate document.

7.B.7.b.

All CASA volunteer applicants are required to: Submit the names of three or more references that are unrelated to the applicant.

Practice verified onsite through review of volunteer files randomly selected from Volunteer by Date Report.

7.B.8.c.i.-vi.

The CASA/GAL program is required to secure the following: Record checks on each volunteer applicant including: Social security number verification; Texas criminal record check obtained from the Texas Crime Information Center maintained by the Texas Department of Public Safety; National criminal record check obtained from the National Crime Information Center (NCIC) maintained by the Federal Bureau of Investigations; Texas Public Sex Offender Registry check maintained by the Texas Department of Public Safety; National Sex Offender Registry check maintained by the United States Department of Justice; The Child Abuse and Neglect Central Registry maintained by the Texas Department of Family and Protective Services.


Practice verified by comparison of DFPS Automated Background Check System (ABCS) activity list and Fingerprint-Based Background Check (FBC) worklist against Volunteers by Date Report.

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7.C.2.

The training consists of and the program documents at least 30 hours of required pre-service training and 12 hours of required in-service training per year. The number of in-service training hours required for newly trained volunteers will be adjusted (or prorated) dependent on the time of year the volunteer is trained.

Practice verified onsite through review of randomly selected volunteer files.

7.C.6.

The CASA/GAL program documents that volunteers successfully complete at least 30 hours of pre-service training during which the volunteer must spend a minimum of 10 hours in personal contact with and under the supervision of the program staff delivering the training sufficient for staff to evaluate the applicant’s appropriateness to serve as a volunteer.

Pre-Service Training Agenda must show 30 hours of instruction with at least 10 classroom hours designated. Practice verified onsite through review of randomly selected volunteer files.

7.C.7.

In addition to the 30 hours of pre-service training, if allowed by the court, the program requires each volunteer to visit the court served by the CASA/GAL program while the court is in session to observe abuse/neglect proceedings before appearing in court for an assigned case.


7.C.9.

In-service training opportunities must include, but are not limited to, cultural competency on an annual basis, disproportionality, disparity in outcome training, and recognizing abuse.

Annual in-service schedule must include cultural competency/humility training opportunities.

7.D.6. The CASA/GAL program has written procedures for the support and supervision of volunteers.

Must be included in volunteer policies or procedures or as separate document.

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7.D.7.

The CASA/GAL program supervisor conducts an in-person review of the case and evaluation of the volunteer’s work on the case as a component of case closure.


7.E.3.

Each volunteer receives a copy of the volunteer policies and procedures and provides signed acknowledgement of reading and understanding the policies.


7.E.6.a.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer reports any incident of child abuse or neglect, or any situation in which the CASA volunteer has reason to believe that a child is in imminent danger to the appropriate authorities and the CASA supervisor, as mandated in the Texas Family Code.

Must be included in volunteer policies or procedures.

7.E.6.c.ii.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer does not engage in the following activities: Giving legal advice or therapeutic counseling.


7.E.6.c.iii.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer does not engage in the following activities: Making placement arrangements for the child.


7.E.6.c.iv.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer does not engage in the following activity: Giving money or expensive gifts to the child, the child’s family or caregiver.


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7.E.6.c.v.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer does not engage in the following activities: Taking a child on an overnight outing.


7.E.6.c.vi.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer does not engage in the following activities: Any activities which are likely to result in a conflict of interest or expose the program or volunteer to criminal or civil liability.


7.E.6.e.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA volunteer discusses all recommendations concerning the case with the program supervisor prior to submitting recommendations to the court.


7.E.6.f.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: CASA program supervisors do not alter reports or recommendations without the knowledge and agreement of the CASA volunteer.


7.E.6.g.

The CASA/GAL program’s volunteer policies and procedures include but are not limited to the following: The CASA/GAL program has a clear policy to resolve conflicts between a volunteer and the program supervisor regarding the handling of a case, reporting of information or the recommendations to be included in a report to the court.


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7.E.7.a.

When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Has passed a motor vehicles division record check.



7.E.7.b.

When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Provides annually to the program a copy of a valid current driver’s license, a safe driving record and adequate personal automobile insurance.



7.E.7.d.

When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Obtains permission of the CASA supervisor or director.


7.E.7.e.

When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Obtains permission of the child’s legal guardian or custodial agency.


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NONPROFIT ADMINISTRATION




2.B.4. CASA staff sign a statement of confidentiality upon hire.

Personnel/employee policies and procedures, oath, acknowledgement of handbook, or job descriptions, must include this requirement.

Practice verified onsite through review of personnel files.

5.B.1.

Clear lines of accountability and authority exist at all levels of the program's organizational and management structures and are formalized in a chart of the organization showing lines of accountability to which all staff, volunteers, and board members have received orientation.

Organizational chart submitted must include lines of authority for staff (all positions and correct position titles), volunteers, and board.

5.B.2.a.-d.

If the CASA/GAL program is under the umbrella of a parent organization, a written agreement is developed that: Details the rights and responsibilities of the program and the parent organization; Includes procedures for resolving situations in which a conflict of interest exists between the CASA/GAL program and its parent organization; Contains the protocol for resource development activities of both organizations; Sets a time frame of no more than two years for review and possible revisions of the agreement.

If the CASA/GAL program is under the umbrella of a parent organization, a signed umbrella agreement stipulating the working relationship between the CASA program and the umbrella organization dated within the last two years must be submitted.

6.A.4.

The chief executive officer or designee is delegated overall personnel management authority by the governing body and ensures that the CASA/GAL program's personnel management is carried out in accord with written agency policy.


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6.B.2.

The CASA/GAL program has a written job description for each position or group of similar positions which clearly specifies qualifications and responsibilities.

Practice verified through comparison of job descriptions to organizational chart.

6.C.3.

Each staff receives a copy of the personnel policies and provides signed acknowledgement of reading and understanding the policies.

Personnel/employee policies and procedures must include this requirement.


6.E.4.b.

The CASA/ GAL program is required to complete the following: Secure three or more references, either written or documented by the program in writing who are unrelated to the applicant.


6.E.4.c.i.-vi.

The CASA/GAL program is required to complete the following: Secure the following record checks on an applicant being considered for employment: Social security number verification; Texas criminal record check obtained from the Texas Crime Information Center maintained by the Texas Department of Public Safety; National criminal record check obtained from the National Crime Information Center (NCIC) maintained by the Federal Bureau of Investigations; Texas Public Sex Offender Registry check maintained by the Texas Department of Public Safety; National Sex Offender Registry check maintained by the United States Department of Justice; The Child Abuse and Neglect Central Registry maintained by the Texas Department of Family and Protective Services.


Practice verified by comparison of DFPS Automated Background Check System (ABCS) activity list and Fingerprint-Based Background Check (FBC) worklist against organizational chart.

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6.E.14.b.

If the CASA/ GAL program permits staff to transport children or drive on behalf of the program, the applicant shall provide to the program at the time of the application: Proof of adequate personal automobile insurance.


6.E.15.a.-e.

The CASA/ GAL program secures a motor vehicle division records check on each prospective staff. In addition, the CASA/ GAL program has policies and procedures in place to assure that the following occur prior to CASA staff members transporting children: Obtains permission of the supervisor or director; Obtains permission of the child's legal guardian or custodial agency; Are knowledgeable of the potential personal risk of liability; Obtains proof of personal automobile insurance. Insurance must be the required state minimum; Chooses to accept the responsibility.


6.F.2. Newly hired directors and volunteer supervisors are required to attend volunteer pre-service training.

Personnel/employee policies and procedures or job descriptions must include this requirement.


6.G.3.

The training and development program requires a minimum of 12 hours of continuing education annually for volunteer supervisors and includes the opportunity for other staff to pursue continuing education to upgrade knowledge and skills to fulfill the requirements of their respective positions.

Practice verified onsite through review of personnel files and/or data system.

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6.I.2.

At least once a year, the performance of staff is evaluated by the person to whom they are accountable, using a standardized evaluation form, to review their performance against established criteria. The staff is an active participant in this process.


6.L.1.

The governing body of the CASA/GAL program adopts a "whistleblower policy" which provides members of the governing body, staff and volunteers a procedure for reporting unethical, inappropriate or illegal activities by members of the governing body, staff or volunteers and such policy affords the reporter protection in making good faith report about such activities.

Personnel/employee policies and procedures must include this requirement.

7.D.3.

For staff assigned to supervision as a full-time function, the staff will not supervise more than 30 active volunteers or a maximum of 45 cases. In the event the staff is required to perform duties other than supervision of volunteers, the number of volunteers the staff can supervise shall be reduced pro rata.

Verified onsite through review of Cases by Date Report.

8.A.5.

The CASA/GAL program has a written policy that guides their utilization of online communication and social networking.

Personnel/employee and volunteer policies must include this requirement.

8.A.7.

The CASA/GAL program has a written crisis management plan that addresses issues that may have significant impact on the credibility, reputation or funding at the local, state or national level. This crisis management plan provides for information sharing between national, state and local organizations within 24 hours, subject to confidentiality limitations.

Must be submitted as a separate document or included in policies or procedures.

TAC § 377.113

a.9.

A local volunteer advocate program must have in writing: A grievance procedure for employees, volunteers, and community members.

Must be submitted as a separate document or included in policies or procedures.

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FINANCIAL & RISK MANAGEMENT




10.A.1.-2.

The CASA/GAL program has a written budget which guides the management of its financial resources, based on: Funding anticipated during the program year; Fixed and incremental costs of operating the CASA/GAL program and identification of potentially changing costs and conditions. The budget is reviewed and approved by the governing body prior to the beginning of the fiscal year.

Must submit board approved budget for current fiscal year.

10.C.2.

The CASA/GAL program assures that an annual report is developed which includes financial, statistical and service data summary information.

Must submit most recent annual report.

CVC/VOCA Assurance

2.e.

The local CASA program has written policies and procedures in place to ensure adequate separation of accounting responsibilities/duties in the receipt, payment, recording and reconciliation of funds. At a minimum the written policies and procedures must include: The local CASA program has safeguards in place to ensure adequate separation of accounting responsibilities/duties in the receipt, payment, recording and reconciliation of funds. At a minimum the safeguards must include: checks are signed only by positions approved by the Board of Directors.

Must be included in financial policies or procedures.

Practice verified onsite through the review of 3 months of bank records.

CVC/ VOCA Grant

Contract Assurance

2.f.

The local CASA program has written policies and procedures in place to ensure adequate separation of accounting responsibilities/duties in the receipt, payment, recording and reconciliation of funds. At a minimum the written policies and procedures must include: The local CASA program has safeguards in place to ensure adequate separation of accounting responsibilities/duties in the receipt, payment, recording and reconciliation of funds. At a minimum the safeguards must include: all checks are signed by two authorized persons, although a reasonable minimum check limit can be established with dual signatures required over a set amount.

Must be included in financial policies or procedures.

Practice verified onsite through the review of 3 months of bank records.

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INSTRUCTIONS FOR RUNNING CASES/CHILDREN AND VOLUNTEER REPORTS

The Quality Assurance Review includes an onsite assessment of Documentation of Advocacy (Minimum Expectations of Service to a Case) and Volunteer Screening and Training through the examination of randomly selected case and volunteer files. Two separate lists are required to be submitted with the Indicators of Compliance for these file reviews: REPORTS TO RUN FOR THOSE WITH AN ONSITE VISIT IN FY20 Q1:

1. Cases by Date Report: Cases reported as being served by the program during the last full quarter of performance measures data submitted to the ODM (prior to the date of the onsite review). Some of these cases may have been closed since the last quarterly report.

2. Volunteer by Date Report: Volunteers reported as assigned to a case from the first day of the current fiscal year through the last full quarter of performance measures data submitted to the ODM. Some of these volunteers may not have a current case assignment.

REPORTS TO RUN FOR THOSE WITH AN ONSITE VISIT IN FY20 Q2 OR Q3:

1. Active Children by Supervisor by Date Report: Children reported as being served by the program during the last full quarter of performance measures data submitted to the ODM (prior to the date of the onsite review). Some of these children’s cases may have been closed since the last quarterly report. Please run the exception report and make necessary corrections prior to submitting Active Children by Supervisor by Date Report.

2. Active Children with Assigned Volunteer Report: Volunteers reported as assigned to a child from the first day of the current fiscal year through the last full quarter of performance measures data submitted to the ODM. Some of these volunteers may not have a current case assignment. Please run the exception report and make necessary corrections prior to submitting Active Children with Assigned Volunteer Report.

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INSTRUCTIONS FOR CALCULATING A 2-YEAR VOLUNTEER RETENTION RATE

The volunteer retention rate is a measure of the length of time newly trained volunteers remain with a CASA program, within a particular time frame. For the purposes of the QA Review, we are requesting a 2-year volunteer retention rate calculation be sent with your IoCs to determine how many volunteers who were trained in fiscal year 2017 (cohort) were still assigned to cases during fiscal year 2019.

*Adapted from Texas CASA’s The Art of Coaching for Volunteer Retention

HOW TO CALCULATE • Step 1: Compile a list of volunteers who completed preservice training during FY17.

• Step 2: Compile a list of volunteers assigned during FY19.

• Step 3: Compare the two lists and count the number of retained volunteers (those appearing on

both lists).

• Step 4: Divide the number of retained volunteers by the total number of volunteers in the training

cohort (the number of volunteers on the FY17 list).

• Step 5: Multiply this number by 100 to obtain the 2-year retention rate as a percentage.

𝑽𝑽𝑽𝑽𝑽𝑽𝑽𝑽 𝑽𝑽𝑽𝑽𝑽𝑽𝑽𝑽 × 𝟏𝟏𝑽𝑽𝑽𝑽 = 𝑽𝑽𝑽𝑽𝑽𝑽𝑽𝑽

EXAMPLE

Nine advocates successfully completed pre-service training and were sworn in during FY17. Most of these newly trained advocates were assigned cases during the fiscal year. Julia was unable to complete her first case because her mother became ill and she became her primary caretaker. Julia’s Volunteer Supervisor took over the case and completed it during the FY. Janet’s company transferred her from Houston to London early in 2017. Thomas became very involved in another non-profit and felt he could not devote the time required to be an effective CASA, so he declined to take another case. Frank did not want another case because he disagreed with the CPS placement recommendation ordered by the court.

VYr0

Trained FY17

Assigned FY18 VYr2

Assigned FY19 1 Ashley Ashley Ashley 2 Janet 3 Cynthia Cynthia Cynthia 4 Thomas Thomas 5 Rachel Rachel Rachel

6 Frank Frank 7 Bonnie Bonnie Bonnie 8 Maria Maria Maria 9 Julia

VYr0 = 9 VYr2 = 5

𝟓𝟓𝟗𝟗 × 𝟏𝟏𝑽𝑽𝑽𝑽 = 𝟓𝟓𝟓𝟓%

VYr2: Count of members of Cohort 0 assigned to cases in FY19

VYr0: Count of volunteers who completed pre-service training during FY17

VRR2: 2-Year Volunteer Retention Rate

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INSTRUCTIONS FOR SUBMITTING THE IoCs

• Step 1: Create a new file folder called “QA Prep” to store all Indicators of Compliance documents.

• Step 2: Within your new folder, create five additional folders (i.e. create a folder for each area of assessment: Nonprofit Governance, Advocacy for Children, Volunteer Management, Nonprofit Administration, and Financial and Risk Management).

• Step 3: Save your completed self-audit checklist in the QA Prep folder. Then, save each IoC in the appropriate folder, based on the required Indicators of Compliance list on page 5.

• Step 4: Once ALL IoCs are saved in the folders, click back to your first folder to see the folder name.

• Step 5: Turn the “QA Prep” folder into a ZIP file by doing the following:

o Click on the “QA Prep” folder once to highlight the folder, then right-click.

o Put the curser over “Send to” and click once.

o When the second pop-up window appears, select “Compressed (zipped) folder”.

o The zipped (compressed) “QA Prep” folder will appear as highlighted below:

• Step 6: Submit the compressed zipped file containing all IoCs to your reviewer via email with the following subject line: Indicators of Compliance Submission.

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ADDITIONAL DOCUMENTS REQUESTED WHILE ONSITE

In addition to the Indicators of Compliance documents collected prior to the onsite review, the reviewer will also examine the following documents:

•Cases by Date Report (to date of the onsite review, separated by supervisor)

•Randomly selected case files (assessment process and form included on pages 34-35)

•Note: The number of case files reviewed is determined by the total number of cases the program served during the last full quarter prior to the QA

•< 100 total cases: 6 case files will be reviewed

•100 – 299 total cases: 12 case files will be reviewed

•> 300 total cases: 18 case files will be reviewed

Advocacy for Children

•4 randomly selected volunteer files (case file assessment process and form included on pages 32-33)

Volunteer Management

•Two employee/personnel files (one of which will be the Executive Director's)

•The reviewer will look for the following within the files:

•Job Description

•Reference Documentation

•Record Checks

•Performance Evaluation

•Training Records

•Confidentiality Statement

•Receipt of Employee Policies

•Motor Vehicle Check

•Current Driver’s License

•Valid Insurance

Nonprofit Administration

•Bank statements from the last 3 months

Financial & Risk Management

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INSTRUCTIONS FOR BACKGROUND CHECK VERIFICATIONS

For the purposes of the QA Review, we are requesting a copy of the DFPS Automated Background Check System (ABCS) activity list and the Fingerprint-based Background Check (FBC) worklist of subscribed persons. These lists will be compared to the program’s organizational chart, board roster, volunteer list, or elsewhere to ensure all individuals associated with the program have the requisite checks. Please note that programs are required by each entity (DFPS and DPS) to unsubscribe or deactivate their access to any individual no longer associated with the program. When printing these lists for submission, if you find you have access to past staff, board members, or volunteers no longer with the program, please take the necessary steps to remove these individuals immediately. HOW TO RUN THE REPORTS

DFPS Automated Background Check System (ABCS) Activity List • Step 1: Log in to your ABCS main page, via the HHS Enterprise Portal, to access your list or online

history. • Step 2: Here you will be able to compare the names of current board, staff, and volunteers to the

list of names in the online history. Please save as a PDF or print this history. The screenshot below is an example of the information we ask you to provide to Texas CASA:

Fingerprint-Based Background Check Worklist • Step 1: Log in to the Texas Department of Public Safety’s (DPS) Fact Clearing House and select

your program’s worklist(s). If there are multiple worklists, a copy of each is required. Note: While the worklist is the preferred report, should the worklist produced not provide a

complete list of subscribed individuals, the program may download and submit the Excel worksheet obtained through the ‘Manage Account Offline’ portal.

• Step 2: Please print the worklist(s) and then redact ALL information regarding the results of the check. Please note this includes redacting the three radio buttons on the right side of the screen. The ONLY information Texas CASA is requesting is the individual’s name and the event date.

Note: To redact the information, you may cover the results with a piece of paper and make a copy, cut this section off of the list(s), or cross it out with marker.

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OVERVIEW OF ONSITE ASSESSMENT OF VOLUNTEER SCREENING & TRAINING

Quality Assurance Reviews include an onsite assessment of Volunteer Screening and Training through randomly selected volunteer files. Programs must score 80% or higher on files reviewed to be in compliance with Texas CASA requirements. If a program scores below 50% on any single standard within the files reviewed, the program must submit a plan to increase and maintain scores 80% or above. The files will be randomly selected using the Data Lists submitted with the Indicators of Compliance and a random number generator. Volunteer files are then reviewed and scored using a numerical scoring system based on the inclusion of specific required documents. Based on this, programs receive either a “1” or a “0” for each document (see sample assessment form on page 31. Items not applicable are marked N/A.

The following are brief descriptions of some requirements assessed:

• Miscellaneous Documents o Written application o Signed statement of confidentiality o Documentation of three or more reference checks, which are unrelated to the applicant o Written performance evaluations

• Required Background Checks

o Record checks are completed on each volunteer including FBC check and ABCS child abuse registry check.

FBC: State and national criminal record check and State and national sex offender record check

ABCS: The Child Abuse and Neglect Central Registry maintained by the Texas Department of Family and Protective Services.

• Training Documentation

o Documentation of completion of at least 30 hours of pre-service training

o Documentation of at least 12 hours of in-service training annually o Documentation of court observation hours

• Transportation Requirements

o Motor vehicle division record check

o Copy of a valid driver’s license

o Proof of adequate personal automobile insurance

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SAMPLE DOCUMENTATION OF VOLUNTEER SCREENING & TRAINING ASSESSMENT FORM

Program: ______________________ Reviewer: __________________ Review Date: __________________

File 1 File 2 File 3 File 4 Points

Volunteer Initials

Yes = 1 No = 0

# of Points

Date of Volunteer Appointment

Staff Responsible for Maintaining File

Full Standard File Assessment Criteria

2.B.3. CASA volunteers take an oath of confidentiality upon completion of training and sign a statement of confidentiality upon acceptance of each case.

Signed statement of confidentiality.

7.B.7.b. All CASA volunteer applicants are required to: Submit the names of three or more references that are unrelated to the applicant.

The file contains three or more references, either written or documented by the program in writing, who are unrelated to the applicant.

7.B.8.c.i.-vi. The CASA/GAL program is required to secure the following: Record checks on each volunteer applicant including: Social security number verification; Texas criminal record check obtained from the Texas Crime Information Center maintained by the Texas Department of Public Safety; National criminal record check obtained from the National Crime Information Center (NCIC) maintained by the Federal Bureau of Investigations; Texas Public Sex Offender Registry check maintained by the Texas Department of Public Safety; National Sex Offender Registry check maintained by the United States Department of Justice; The Child Abuse and Neglect Central Registry maintained by the Texas Department of Family and Protective Services.

The program verifies a national criminal record check via the Fingerprint-Based Background Check (FBC).

The program verifies a state criminal record check via Fingerprint-Based Background Check (FBC).

The program verifies national and state sex offender registry checks via (FBC).

The file contains a Texas Child Abuse and Neglect Central Registry check (ABCS).

7.C.2. The training consists of and the program documents at least 30 hours of required pre-service training and 12 hours of required in-service training per year. The number of in-service training hours required for newly trained volunteers will be adjusted (or prorated) dependent on the time of year the volunteer is trained.

The file contains documentation of 12 hours of in-service training annually.

7.C.6. The CASA/GAL program documents that volunteers successfully complete at least 30 hours of pre-service training during which the volunteer must spend a minimum of 10 hours in personal contact with and under the supervision of the program staff delivering the training sufficient for staff to evaluate the applicant’s appropriateness to serve as a volunteer.

The file contains documentation of successful completion of 30 hours of pre-service training, at least 10 of which must be spent in face-to-face classroom time.

7.C.7. In addition to the 30 hours of pre-service training, if allowed by the court, the program requires each volunteer to visit the court served by the CASA/GAL program while the court is in session to observe abuse/neglect proceedings before appearing in court for an assigned case.

The file contains documentation of courtroom observation (not included in the 30 hours of required pre-service training).

7.D.7. The CASA/GAL program supervisor conducts an in-person review of the case and evaluation of the volunteer’s work on the case as a component of case closure.

The file contains documentation of a performance evaluation conducted at case closure.

Volunteer File Assessment Percentage (10) Sum of all points

Sum of all points/40

When the CASA program has made the decision to allow volunteers to provide transportation:

7.E.7.a. When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Has passed a motor vehicles division record check.

Proof that volunteer has passed a motor vehicles division record check.

7.E.7.b. When the CASA/GAL program has made the decision to allow volunteers to provide transportation to children, it has the necessary liability insurance to cover the program. In addition it has policies and procedures which assure the CASA volunteer: Provides annually to the program a copy of a valid current driver’s license, a safe driving record and adequate personal automobile insurance.

A copy of a valid driver’s license.

Proof of adequate personal automobile insurance.

Volunteer File Assessment Percentage (13) Sum of all points

Sum of all points/52

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OVERVIEW OF ONSITE ASSESSMENT OF DOCUMENTATION OF ADVOCACY

Quality Assurance Reviews include an onsite assessment of Documentation of Advocacy through randomly selected case files. Programs must score an average of 80% or higher on files reviewed to be in compliance with Texas CASA requirements. If a program scores below an average of 80% on the total child score sheets or 50% on any single standard within the files reviewed, the program must submit a plan to increase and maintain scores 80% or above. The files will be randomly selected using the Data Lists submitted with the Indicators of Compliance and a random number generator. Case files are then reviewed and scored with the assigned Volunteer Supervisor to determine if the minimum amount of advocacy services required by Standards have been completed and documented within the required timeframes. A weighted numerical scoring system is used and assigned to each component (see sample assessment form on page 33). The weighted system is based on Texas CASA Standard 7.E.5.l. which requires advocates to maintain complete records about a case, including appointments, interviews and information gathered about the child and the child’s life circumstances. Full point scores indicate that documentation was located within the hard or electronic file, a permanent record. Partial point scores indicate that documentation was located outside of the permanent record. Zero point scores indicate that no documentation was located while onsite. The following are brief descriptions of some areas assessed but this list is not inclusive of all advocacy services assessed:

• The reviewer will note the following information on the case: number of children; children’s initials; ages of children; distance child is placed; TMC, PMC, or COS; volunteer or staff working the case; date of appointment.

• Within the hard or electronic copy of the case file, the reviewer will look at three randomly-selected, consecutive months of documentation for the following:

o Face-to-face contact (50% of contacts should occur in the placement): If the child is within 1 hour, there should be three consecutive months of contact; If the child is within 3 hours, there should be a minimum of a single contact; If the child is more than 3 hours, the reviewer will look back 6 months for a minimum of one

contact.

o Other types of monthly, age-appropriate contact. If face-to-face contact occurred, this is marked N/A. For months in which no face to face contact occurs, the reviewer will look for documentation of other contact. This can include phone, email, text, courtesy visits, video chat, etc. If contact is not age or developmentally appropriate, this is marked N/A.

o Monthly contact with the caregiver, CPS caseworker, and CASA supervisor, either in-person or by phone, email, text, etc.

o The reviewer will read case notes, court reports or other file documentation to determine the following:

Educational advocacy has occurred (as applicable to age), at least once in three months. This may include in-person, phone, email or text communication with educators; visiting classrooms, obtaining and reviewing grades, ensuring Educational Portfolio is current, attending ARD meetings, or educational recommendations within court reports.

Medical advocacy has occurred, at least once in three months. This may include in person, phone, email or text communication with medical providers; obtaining and reviewing reports, viewing the Health Passport or medical recommendations within court reports.

Legal advocacy has occurred, at least once in three months. This may include in person, phone, email or text communication with attorney ad litem, probation officer, juvenile attorney.

An interview with the parents has occurred to determine the facts and circumstances of the child’s situation.

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SAMPLE DOCUMENTATION OF ADVOCACY FILE ASSESSMENT FORM

Program: ______________________ Reviewer: __________________ Review Date: __________________

Child Initials

Age Distance TMC PMC COS

Vol/ Staff

Appt. Date

Child Initials

Age Distance TMC PMC COS

Vol/ Staff

Appt. Date

Child Initials

Age Distance TMCPMCCOS

Vol/ Staff

Appt.Date

Full Standard File Assessment Criteria Month 1

_______

Month 2

_______

Month 3

_______ Sum

7.E.5.a. Written roles and responsibilities will include the following. The advocate will: Identify and advocate for the best interest of the child by obtaining first hand a clear understanding of the needs and situation of the child, by conducting an ongoing review of all relevant documents and records and by interviewing the child, parents, social workers, teachers and other persons to determine the facts and circumstances of the child’s situation.

Practice verified onsite through review of case file.

2/1/0

7.E.5.b.i.-ii. Written roles and responsibilities will include the following. The advocate will: Have regular and sufficient in-person contact with the child where they live to ensure in-depth knowledge of the case and make fact-based recommendations to the court. The CASA volunteer shall meet in-person with the child once every thirty (30) days at a minimum. An exception may be granted: If the child(ren) are placed more than 1 but less than 3 driving hours away, CASA will meet in person with the child(ren) at least once every three months; If the child(ren) are placed more than 3 driving hours away, CASA will meet in person with the child(ren) at least once every six months.

Contact with the child(ren) where they live (50%) per standard minimum requirements.

4/2/0 4/2/0 4/2/0

7.E.5.b.iii. Written roles and responsibilities will include the following. The advocate will: Have regular and sufficient in-person contact with the child where they live to ensure in-depth knowledge of the case and make fact-based recommendations to the court. The CASA volunteer shall meet in-person with the child once every thirty (30) days at a minimum. An exception may be granted: In addition to in-person contact, [the advocate will] have other types of monthly age appropriate contact with the child(ren) including telephone calls, emails, video conferencing and letters as applicable for the child’s age and interests.

Other age appropriate contact in months without face-to-face (F2F) contact, (or in addition to) including phone, email, text, courtesy visits, or other documented contact.

2/1/0 2/1/0 2/1/0

7.E.5.c. Written roles and responsibilities will include the following. The advocate will: Communicate with the DFPS caseworker after appointment and at least one time per month for the duration of the case.

Monthly communication either F2F, email, text, phone, or other documented contact.

2/1/0 2/1/0 2/1/0

7.E.5.d. Written roles and responsibilities will include the following. The advocate will: Meet in person with the child’s primary placement provider, in a timely manner, after placement occurs. Communicate with the placement provider at least once per month thereafter for the duration of the child’s case.

Monthly communication either F2F, email, text, phone, or other documented contact.

2/1/0 2/1/0 2/1/0

7.E.5.e. Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties.

Legal advocacy, at least once in three months, to include F2F, email, text, phone or other contact with the attorney ad litem, immigration attorney, juvenile probation, or other documented legal advocacy contact.

2/1/0

7.E.5.e.-f. (EDU) Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties. Determine the child(ren)’s permanent plan, access the educational portfolio and health passport and make recommendations regarding permanency, and education and medical services, as appropriate.

Age-appropriate educational advocacy, at least once in three months, to include F2F, email, text or phone contact with the school, teachers, ARD, educational portfolio viewing, or other documented educational advocacy contact.

2/1/0

7.E.5.e.-f. (MED) Written roles and responsibilities will include the following. The advocate will: Advocate for the child’s best interests in the community through regular contact with attorney ad litem, mental health, educational and other community systems to assure that the child’s needs in these areas are met and seek cooperative solutions by acting as a facilitator among parties. Determine the child(ren)’s permanent plan, access the educational portfolio and health passport and make recommendations regarding permanency, and education and medical services, as appropriate.

Medical advocacy, at least once in three months, to include F2F, email, text, phone or other contact with medical providers, therapists, Health Passport viewing, or other documented medical advocacy contact.

2/1/0

7.E.5.m. Written roles and responsibilities will include the following. The advocate will: Communicate at least once monthly with CASA supervisor and participate in case conferences as scheduled.

Monthly communication either F2F case conferences, email, text, phone, or other documented contact.

2/1/0 2/1/0 2/1/0

Sum of Items Reviewed Sum of all points

Minimum Expectations Assessment Percentage Sum of all points / 44

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PROGRAM RESPONSE SUBMISSION INSTRUCTIONS

Step 1: Once you have finalized a response to all of the requirements in your final Quality Assurance

Report, create a Program Response file folder to store all responses to the required action

outlined in your final Quality Assurance Report.

Step 2: Once all documents for your response are copied into the new folder, click back to your folder

to see the folder name. For example:

Step 3: Click on the “Program Response” folder once to highlight the folder, then right-click.

o Put the curser over “Send to” and click once.

o When the second pop-up window appears, select “Compressed (zipped) folder”.

o The zipped (compressed) “Program Response” folder will appear as highlighted below:

• Step 4: Submit the compressed zipped file containing all IoCs to your reviewer via email with the following subject line: Program Response – [YOUR PROGRAM NAME].

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ALTERNATIVE PROGRAM RESPONSE REQUIREMENTS

Typically, a response to each of the requirements listed in the final Quality Assurance Report is due

within 90 days after the final QA Report is sent. However, there are two alternative response

requirements: immediate responses and priority compliance responses.

IMMEDIATE RESPONSE REQUIREMENTS

Certain requirements in Texas CASA Standards and the HHSC contract with local programs require an immediate response if a determination is made that a program is out of compliance during the onsite quality assurance review. Immediate response requirements fall into one of two categories: risk to children and financial risk. Additional information about the specific immediate response requirements can be found below.

RISK TO CHILDREN: BACKGROUND CHECKS

The following standards stipulate the required background checks for staff members and volunteers:

• Standard 6.E.4.c.i.-vi.

• Standard 7.B.8.c.i.-vi.

Per the cited standards, each employee and volunteer are required to have the following record checks:

• State and National Criminal History via the Fingerprint-Based Background Check (FBC)

• State and National Sex Offender via the Fingerprint-Based Background Check (FBC)

• Child Abuse and Neglect Central Registry via the Automated Background Check System (ABCS)

If any of these checks are missing or incomplete for any employee or volunteer:

• Any employee or volunteer with direct access to children must be removed immediately from all

casework responsibilities and may not return to such duties until all required checks are cleared.

• The Executive Director must submit verification to Texas CASA indicating that all files have been

reviewed and background checks have been completed within 14 days of the onsite visit.

RISK TO CHILDREN: FACE-TO-FACE CONTACT

The following standard requires a minimum amount of face-to-face contact with the child(ren) to whom

the CASA program is appointed.

• Standard 7.E.5.b.

Per the cited standard, the advocate will:

• Have regular and sufficient in-person contact with the child(ren) where they live to ensure in-depth

knowledge of the case and make fact-based recommendations to the court. The CASA volunteer

shall meet in-person with the child(ren) once every thirty (30) days at a minimum. An exception may

be granted:

• If the child(ren) are placed more than 1 but less than 3 driving hours away, CASA will

meet in-person with the child(ren) at least once every three months;

• If the child(ren) are placed more than 3 driving hours away, CASA will meet in-person

with the child(ren) at least once every 6 months.

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If it is determined during the onsite review that the child(ren) in a case has not received the minimum

face-to-face contact:

• Face-to-face contact with the child(ren) is required within 14 days of the onsite review.

• The Executive Director must then submit a statement to Texas CASA that states the face-to-face

contact with the child(ren) has occurred and is documented within 14 days.

RISK TO CHILDREN: VOLUNTEER ASSIGNED TO MORE THAN 5 CASES

The following Standard prohibits any volunteer from serving on more than 5 cases:

• Standard 7.D.8.

If it is determined during the onsite visit that a volunteer has been assigned to more than 5 cases:

• The volunteer must be removed from any number of cases above 5 or a plan to remove the

volunteer from additional cases must be submitted within 14 days of the onsite visit.

• The Executive Director must submit a statement to Texas CASA stating that the volunteer has been

removed or provide a detailed plan for removal, including timelines, within 14 days.

PRIORITY RESPONSE REQUIREMENTS

In addition to the immediate response requirements detailed above, there are other circumstances in

which Texas CASA may require a priority compliance response from a program. A priority compliance

response requires specific responses at 10, 30, 60, and 90 days after the onsite visit.

While the following list is not exhaustive, Texas CASA reserves the right to require additional program

action when any of the issues below are identified.

1. Immediate Response Requirements are not met;

2. A risk to children is identified through flagrant failure to perform minimum advocacy

standards;

3. Evidence of financial mismanagement or fraud;

4. Chronic lack of compliance/lack of improvement in volunteer to case ratio (VCR);

5. The number of final compliance findings is greater than 20;

6. A response to any requirement is not submitted or is incomplete after the due date listed in

the final QA Report.

Again, this list is not exclusive, and Texas CASA reserves the right to require priority responses for

any finding that poses a significant risk to children or program operations. Texas CASA will provide

clear, remedial actions and timeframes, as well as technical assistance and resources as program

leaders work to correct significant problems in program operations and/or advocacy for children.

*Failure to comply with the required actions within the stated timeframe may result in restriction,

suspension, reduction or termination of CVC and/or VOCA funding.