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HOME VISITING SERVICE MANUAL

Table of Contents Mission and Vision; Introduction/Overview....3 Research-based Philosophy ...4 Competency-Based Practice Relationship-focused & Family Centered Approach Home Visiting Defined5 Eligibility Guidelines/Criteria ...5 Service Components 5-6 Evaluation Components..6 General Staffing Requirements... 6-7 Department of Public Safety and CYFD Overview of Staff Requirements Clinical Support Requirements Safety and Risk Reduction..7-8 Supervision of Staff.. 8-9 Home Visiting Service Requirements/Core Components Expanded Detail. 10-14 Documentation/File Maintenance..... 14-16 Appendix A Home Visiting Forms.17 Appendix B Definitions ..... 49 Appendix C CYFD Background Clearance..55

MISSION OF THE HOME VISITING PROGRAM Home visitors partner with families to promote child development and confident parenting by supporting the relationship among the family, home visitor, and the community. VISION OF THE HOME VISITING PROGRAM New Mexico families are supported to raise children who are resilient and loved for generations to come. INTRODUCTION/OVERVIEW This Home Visiting Service Definition Manual is produced and disseminated by The State of New Mexicos Children, Youth and Families Department (CYFD). Using the research which states that positive early experiences lay a foundation for healthy development (Shonkoff. Center on the Developing Child - Harvard University. N.p., n.d. Web. 22 Sept. 2010. http://developingchild.harvard.edu), the purpose of this manual is to define practice parameters, standards, and reporting activities for all Home Visiting programs funded through CYFD. CYFD is committed to supporting Home Visiting programs that provide services leading to positive, measurable outcomes for infants, toddlers and their families. The overarching goals established for all CYFD state-funded Home Visiting programs are: 1. Babies are born healthy. a. Home Visiting services improve the physical well-being of pregnant women and their to-be born babies. 2. Children are physically and mentally healthy. a. Home Visiting services support optimal physical health and developmental capacities of infants, toddlers and their caregivers/families, including the social, emotional, and mental health of all; 3. Children are safe. a. Home Visiting services support the safety of infants and toddlers and their families; 4. Children are nurtured by their parents and caregivers. a. Home Visiting services actively promote healthy caregiver-child interactions and relationships through an established curriculum. 5. The family is connected to formal and informal supports in their community. a. Home Visiting service providers identify concerns/risk factors early, support caregivers to access and advocate for themselves and their children, and refer/link with families with formal and informal community services and supports. Note: The department intends to analyze current data to assess whether outcomes being measured are meeting the goals and needs addressed in this program.

Home Visiting programs funded by CYFD provide a continuum of services to families based on family preferences, needs, strengths and risk factors. Services provided through home visiting programs are: Flexible and designed to meet the needs of clients within communities at the local level; Inclusive of and responsive to the ethnic, cultural, racial, linguistic, and socioeconomic diversity of families served;

COMPETENCY-BASED PRACTICE; RELATIONSHIP-FOCUSED AND FAMILY-CENTERED APPROACH Many of the practice and supervision requirements defined in this manual are based on the competencies outlined by the New Mexico Association for Infant Mental Health Endorsement System for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health (http://www.nmaimh.org). In addition, a family-centered approach that is responsive to the needs of individual families underlies many of practice standards for programs. As noted above, all home visiting services are delivered with cultural competence and appropriate responsiveness to the unique needs of the diverse communities served in New Mexico. The core research behind the development of CYFD Home Visiting services is the belief that the quality of the caregiver-child relationship is primary in supporting all aspects of child development and health. It is well documented that nurturing caregiver-infant/toddler interactions are critical to the development of secure attachment relationships, optimal development in all domains of functioning, and later school readiness for children. To optimize the positive influence home visiting programs can have on the parent-child relationship; adult family members must also experience a strong, collaborative relationship with their home visitors. This represents the concept of parallel process. This means the quality of relationship between parents/caregivers and their home visitors can be seen as directly linked to the quality of the emerging interactions and developing relationship between the unborn child and/or infant/toddler and his or her caregiver(s). Related to this, caregivers and families are full partners and collaborators in the development of their home visiting plan and services. Home visiting programs should provide services from both a relationship-focused and family centered perspective. The latter refers to the need to view the family as a whole and with openness to supporting all caregivers/family members in the service of optimizing the emerging caregiver-child relationship and infant/toddler development. Giving up on families or labeling them as unmotivated or resistant is not acceptable within this framework. In instances where services are not accepted and/or families are not satisfied, providers reflect and try to understand the familys perspective. Additionally, CYFD believes wholeheartedly in the strengths and resiliency of families. Families are our partners in service delivery and we must advocate to enhance their safety and well-being. We respectfully serve and support children and families in a responsive community based system of care that is client/family-centered and culturally competent. CYFD Home Visiting program services are always voluntary.

WHAT IS HOME VISITING? A Home Visiting model of service delivery represents a strategy that can be used to provide a variety of informational, educational, developmental, referral/ linkage, screening/evaluation, and other direct intervention and support services for families. CYFD Home Visiting programs provide an array of services to promote parental competence and successful early childhood health and development by building optimal relationships with families and between parents and children in their home environments.* Home Visiting from this perspective can be seen as both a promotion and prevention level strategy. Providing services in the family home provides the opportunity for services to be delivered in the real world with families. This real-life focus offers the potential for better understanding of a familys real experience, and thus for home visitors to better support wellness across multiple domains (physical health, developmental competence, social and emotional well-being, community involvement, etc.) for both infants/young children and their caregivers/families. *A home environment may include schools or even jails, wherever the parent and child can be seen together, based on the specific needs of each particular family. ELIGIBILITY GUIDLEINES/CRITERIA: First time expectant mothers; First time parents of infants and toddlers birth to three; First time caregivers of infants and toddlers birth to three; Adoptive parents of infants and toddlers birth to three; Expectant teens and teen parents with children under the age of three. Blended families: first time parent (other children in the family can be any age) All children in the home are under age 3, even if not first time parents. All children in the family under the age of 3 receive HV services and are considered clients of the program. Children cannot be in foster care. SERVICE COMPONENTS State-funded Home Visiting programs are required to offer a variety of services and supports to families during the prenatal period and up until children in the home turn three years of age. CYFD Home Visiting programs are expected to include, at a minimum, the following service components. Service components are to be offered based on CYFDs guidelines for screening and curricula use, in combination with each familys needs, preferences, cultural context, and risk factors: (how does this connect with the outcomes?) Support and assistance in accessing prenatal care for pregnant women Support and assistance around accessing primary medical care for newborns, infants and toddlers served by the program Screening for possible risk factors within the child, caregiver, and family (using, at a minimum, CYFD selected tools and measures), including home safety, developmental concerns in children, pre/postnatal depression in mothers, domestic violence, and family social support

Development of safety plans with families presenting with issues of concern or high risk Provision of information on community and educational resources Referral and linkages to other needed or recommended health, developmental, mental health, community and educational supports for the child, caregiver and family as appropriate Provide developmental guidance and parent-child interaction support based on a research based curriculum; Identification of informal and formal social supports; referral of families to community resources; Provision of home visits based on families needs and desires from prenatal through third year of childs life. Follow up and engagement in collaboration with other service providers families are working with and/or have been referred to for additional services Provision of appropriate referrals and follow up at the completion of Home Visiting services to appropriate community, educational, and other services and informal support networks. If family wishes, provide a plan for transition and follow up.

EVALUATION COMPONENTS State-funded Home Visiting programs are required to participate in the CYFD defined evaluation process. This includes administering all screening tools at the intervals and frequency defined by CYFD, collecting and reporting required data using the data base and mechanisms outlined by CYFD (see page 19). Please refer to Home Visiting Program Service Requirements/Core Components and Appendix A for further information on evaluation requirements for Home Visiting programs. GENERAL STAFF REQUIREMENTS DEPARTMENT OF PUBLIC SAFETY AND CYFD All staff, supervisors and consultants working in CYFD funded Home Visiting programs must receive criminal record clearances through CYFD/Early Childhood Services as required by regulation.

STAFF REQUIREMENTS CYFD Home Visiting programs must be staffed by individuals suited to perform the core Home Visiting service components outlined above. This array of service components requires staff members who have knowledge of pregnancy and the prenatal period, infant/toddler safety and health, early childhood development, early childhood mental health principles and practices, knowledge of community resources, and strong relationship-building skills. It is, in reality, rare that any one individual will hold all these skills and knowledge his/herself. As such, the Home Visiting team is by definition multidisciplinary and composed of licensed/credentialed professionals who have knowledge in early childhood development and early childhood mental

health in combination with non-degreed professionals or other disciplines. Each Home Visiting program is expected to be staffed by multidisciplinary personnel. Some examples of disciplines appropriate to work in Home Visiting programs include: Nurses Social Workers Psychologists Counselors Early Childhood Educators Promotoras/Community Health Workers Case Managers Developmental Specialists Other non-degreed professionals with appropriate background/experience

CLINICAL SUPPORT Each Home Visiting programs must have access to at least one Masters level clinically licensed mental health professional who is available for consultation when potential high risk situations, crises, and/or other clinical issues or concerns arise. This individual possesses the clinical training and experience to provide meaningful, mental health consultation to home visitors. Additionally, dependent on the staffing patterns of the program, this individual may also provide brief direct service support for families if/when clinical issues or needs prove beyond the scope or skill level for the primary home visitor. Such consultation may be warranted when safety concerns arise (in the home, for the family and/or or for the home visitor); when there are suspicions of child abuse or neglect; if/when screening tools (or home visitor observation) indicate the presence of pre/post-natal depression in mothers; there are indications of other mental health or substance abuse concerns in the home; and/or domestic violence is a concern. In addition, the licensed professional is knowledgeable of issues related to pregnancy, postnatal adjustment, early childhood mental health, early childhood and family development, and resources in the community served. Note: In the event that such a professional is difficult to find in your community, professional development within your program is encouraged to increase your own competence and knowledge in these areas. SAFETY AND RISK REDUCTION Overview: At their core, CYFD Home Visiting services have the goal of optimizing health and well-being by reducing the potential negative impact presented by family and child risk factors. In keeping with this overarching vision, CYFD Home Visiting programs are required to actively screen for risk factors in children, caregivers and families using tools according to the periodicity defined by CYFD. If risk is identified, Home Visiting programs bear the responsibility to assess immediate safety, refer to other community providers, and support linkages and collaboration with other needed services. As the first line screeners for risk, Home Visiting programs must have qualified personnel, as well as programmatic and supervisory policies in place, to support home visitors when possible risk situations and safety issues are identified either via screening

tools or more informal observation by the home visitor. Clearly stated, Home Visiting programs are able to respond to families when an immediate crises or risk situation is identified. This response includes (with appropriate supervision and consultative support) the development of an initial plan with the family to define strategies for safety. In addition, the home visiting program provides referrals and linkages for families to additional resources in their communities. Staffing patterns and program practices in all Home Visiting programs funded by CYFD support this level of care and intervention for families served. Family Strategies to Promote Safety: The capacity to respond appropriately with a plan for family strategies to promote safety when an immediate safety or risk situation arises is not intended to imply that Home Visiting programs provide clinical treatment for mental health issues or other services outside the scope of services defined by CYFD. However, programs must have mechanisms and personnel in place to respond to immediate safety issues and identified risk factors as they are discovered by home visitors. Home visitors will often be the first to identify areas of concern in young families. This reality exemplifies the very essence of home visiting as a strategy for prevention. If home visitors are present and can identify risk early, they then can help the family access additional services as needed and potential future negative impacts on children, parent-child relationships, and families can be minimized. (Information related to Safety Plans - Appendix section page 30-40). Community Relationships/Referral: The ability to respond to risk and safety issues requires that Home Visiting programs and staff cultivate and sustain relationships within their communities with medical care providers, mental health practitioners, domestic violence services and other community agencies. Building relationships within communities is essential to the development of a meaningful and comprehensive system of care to address the myriad of needs presented by the target population. As such, programs are required to have a plan for cultivating and deepening community relationships in support of the families they serve and for the development of a community-based system of care that is responsive to the needs of the families they serve.

SUPERVISION OF STAFF Supervisor Requirements: Home Visiting program supervisors are required to have a minimum of one year of supervisory experience and two years work experience with the target population. Supervisors should possess knowledge of pregnancy and prenatal issues, early childhood and family development (including social and emotional development), reflective practice, and family centered care. Home Visiting supervisors must be able to provide, or be prepared to hire qualified staff/consultants to provide, reflective supervision for all home visiting staff. Reflective supervision is critical to effective infant and early childhood practice and provides a regular forum for staff and supervisors to thoughtfully sort through the complexities presented by the work of home visitors. All direct service staff must receive at a minimum two hours per month of individual reflective supervision with a qualified supervisor. If an individual serves a dual role in the program as both a direct service provider and a supervisor for other staff, such individuals need to be provided with supervision from another qualified supervisor to support their home visiting work with families. Reflective Supervision guidelines: Reflective supervision is to be provided on an individual basis for all home visiting staff at a minimum of twice per month. Supervision

is provided individually and enhanced through group sessions. Supervision meetings are consistently scheduled; conducted by a qualified practitioner who is trained and knowledgeable in early childhood development or early childhood mental health utilizing reflective practice principles. Supervision sessions must be documented in the data base. (NMAIMH guidelines and other reflective practice information p. 41-49). Field Supervision: Supervisors accompany their home visitors on family visits at least twice in the first year of employment for new home visitors and once annually for all staff thereafter and provide documentation in the data base. Aspects to be looking for during these visits may include but are not limited to:
Home visitors relationship with family Home visitors focus on: baby, mom or case management? Too much of one and not enough of another Home visitors attention to Parent/child interaction and mutual competence

Administrative Supervision is provided for all home visiting staff. In addition to agency supervision practices, Home Visiting supervisors include quality assurance for services provided, adherence to all CYFD policies, and review of screening tools and results. The current Home Visiting screening tools and responsibilities of supervisors include the following: Review ASQ and ASQ: SE for cut off scores and assure referrals are completed to appropriate services when indicated Review Edinburgh Postnatal Depression Scale and assure referrals when necessary Review WAST-Short and assure referrals when necessary Review Knowledge of Infants Development Inventory (KIDI) and discuss with Home Visitor Review Medical Assistance Division Anticipatory Guidance (MAD) and discuss with Home Visitor Review the Social Support Index and discuss with Home Visitor

Screening Tools: When reviewing screening tools, it is probable that administrative review of screening tools will at times lead to the need for a more reflective dialogue between staff and supervisor around how to approach issues of identified risk with a family and what referrals or additional services may be needed. As tools are reviewed, supervisors should keep an eye toward the need for consultation with the licensed mental health consultant on the team to assist with formulating a plan for dialogue with the family, referral strategies, or other more clinical issues that may arise as the result of actively screening for risk factors with families.

HOME VISITING PROGRAM SERVICE REQUIREMENTS/CORE COMPONENTS EXPANDED DETAIL


Home Visiting programs are expected to provide an array of service components designed to address five broad outcomes. These outcomes are again: 1. Babies are born healthy. 2. Children are physically and mentally healthy. 3. Children are safe. 4. Children are nurtured by their parents and caregivers. 5. The family is connected to formal and informal supports in their community.

Core components for Home Visiting programs include the following: 1. No Cost to Families All Home Visiting services are offered at no cost to qualified families. 2. Target population First time expectant mothers; First time parents of infants and toddlers birth to three; First time caregivers of infants and toddlers birth to three; Adoptive parents of infants and toddlers birth to three; Expectant teens and teen parents with children under the age of three. Blended families: first time parent (other children in the family can be any age) All children in the home are under age 3, even if not first time parents. Children cannot be in foster care. 3. Voluntary Participation Home Visiting services are voluntary for all families. 4. Prenatal home visits include the following components: Focus attention on parent/caregiver attributions Support and assistance to access prenatal care that is consistently utilized and attends to the physical and emotional health care as needed and/or as requested by the pregnant woman/family; Provision of active assistance to families in identifying informal support networks; Provision of referrals to health, community and other resources AND follow up to support and link services as necessary;

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Provision of information on prenatal health care, newborn care (establishing Medical Home), and infant/child development, including developmental guidance using a recognized curriculum; Determination as to whether families have been referred to Medicaid on Site; Initiation of Assistance/Presumptive Eligibility (PE/MOSAA) if appropriate.

5. Post-Partum visits include the following components: Focus attention on parent/caregiver/child interactions, mutual competence and parent/caregiver attributions; Support and assistance to access Post-Partum care that attends to the physical, emotional and social well being of the mother; Assessment of any concrete needs the family is experiencing; Other needs as identified by the family. 6. Home visits available for the first three years of the childs life include the following components: Focus attention on parent/caregiver/child interactions, mutual competence and parent/caregiver attributions; Support and assistance to access pediatric care as needed and as appropriate depending on age of baby at intake. Developmental screening Evaluation of eligibility for Women Infant and Children (WIC); support around enrollment in WIC for qualifying families; Guidance to families through recognized developmental curricula; Assistance to families in identifying informal support networks; Provision of referrals to community resources as necessary; Determination if families have been referred to PE/MOSAA. Training: Home visiting staff must be trained in the following topic areas: i. Relationships based practice ii. Pregnancy and Early Parenthood iii. Parent child interaction; iv. Infant/child growth and development; v. Community resources; Home Visiting Staff, Managers and supervisors participate in the training provided by CYFD. Staff are trained on required screening tools and data base entry. 7. Collaboration: Development of a referral and follow-up system for families to community services. Collaboration with program evaluators by providing the necessary data, allowing access to information needed, including evaluation protocols. Collaboration with hospitals, Women Infants and Children (WIC), teen parent centers, OB-GYN practitioners, midwives, Primary Care Providers (PCPs),
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pediatricians and other entities that may have contact with this population to discuss and develop referral and networking process.

8. Participation:

Individuals in management/supervisory positions consistently participate in quarterly meetings and conference calls with other funded home visiting programs. Participation in the continued development of a comprehensive Service Definition Manual to be used by New Mexico Home Visiting Service agencies.

9. Confidentiality: All agencies must have policies and procedures in place that address confidentiality of client information, both written and verbal, that are in accordance with the policies of the Health Information Portability and Accountability Act (HIPAA). 10. Cultural Sensitivity: Cultural sensitivity in all aspects of program planning and service delivery by having bi-lingual and culturally competent staff as appropriate. Supervision: Reflective Supervision: Provide reflective supervision session on an individual basis at a minimum of twice per month. Supervision is provided individually and enhanced through group sessions. A practitioner who is trained and knowledgeable in early childhood development or early childhood mental health and utilizes reflective practice principles must conduct supervision. Supervision will be documented by a sign in sheet to include a short summary of the session. Field Supervision: Supervisors will accompany their home visitors on family visits at least twice in the first year of employment for new home visitors and once annually for all staff thereafter. Administrative Supervision: i. Ensure that all screening tools materials are completed and entered into the database in a timely manner. ii. Review client files for proper documentation. iii. Ensure that home visitors utilize the child development curriculum information with families on a regular basis and that this use is documented in contact/progress notes. iv. Review status regarding acquisition of a Medical Home v. Prenatal, Postpartum and Home Visiting components are followed according to Service Delivery Manual. vi. Supervisors regularly review all completed screening tools and measures with their home visitors, including: 1. ASQs and ASQ: SEs for cut off scores and assure referrals are completed to appropriate services when indicated

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2. Edinburgh Postnatal Depression Scale instruments and assure referrals when necessary 3. WAST-Short and assure referrals when necessary 4. Knowledge of Infants Development Inventory Adapted (KIDI) and discuss with home visitor 5. Medical Assistance Division Anticipatory Guidance (MAD) and discuss with home visitor 6. Review the Social Support Index and discuss with home visitor 12. Community Education: Community Education and development activities represent efforts made at the local and state levels to assure awareness of home visiting services. Activities may include: Public awareness activities to promote community knowledge of the agencys services and outreach to serve the target population. Advocacy, education, policy development and networking on behalf of the target population through formal systems. Consultation, education and training of other community service providers in the community to increase inter-agency collaboration and maximum service provisions to clients. Provision of presentations in order to educate, raise awareness, or provide materials such as child development, maternal infant social-emotional attachment, and brain development. Documentation of dates, times, person performing the activities, number of attendees and a description of those activities in quarterly and annual reports. 13. Outcomes/Screening/Evaluation/Performance Measures and Activities: All Home Visiting programs must utilize the following screening and evaluation tools with all families at the defined frequency and periodicity outlined by CYFD: i. Ages and Stages Questionnaire (ASQ) and Ages and Stages Questionnaire Social/Emotional per required sequence (ASQ:SE)* ii. Edinburgh Postnatal Depression Scale iii. WAST-Short iv. Medical Assistance Division (MAD) Anticipatory Guidance v. Social Support Index (SSI) vi. Knowledge of Infants Development Inventory Adapted (KIDIAdapted) Home Visiting Program shall maintain data according to the data base requirements *When a child screens positive for potential developmental delay using the ASQ, and appropriate referral and linkages are made to the NM Family Infant Toddler (FIT) program, Home Visiting staff in discussion with their supervisors use their own discretion as to whether or not to continue to screen development based on recommended periodicity. Any potentially detrimental impact on the family of a child with an identified delay or a diagnosed disability should be considered thoughtfully in deciding to discontinue use of a recommended measure. A decision to discontinue the use of a screening tool and the rationale for doing so should be noted clearly in the client file and in the Home Visiting database.

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* It is the familys choice to remain in FIT and/or the CYFD Home visiting program yet, if they are enrolled in both programs, request FIT provider to put the Home Visitor in the IFSP with a clear function and role. 14.Follow Up and Referral: a. Provision of Follow Up and Referrals at least once at the completion of Home Visiting Services. b. 15.Completion of a Family Satisfaction Survey

DOCUMENTATION File maintenance is required for client/agency interaction from initial referral and admittance to the program through discharge. Documentation in client files is required for all home visiting services. The agency shall provide for suitable storage, access, and disposal of client records for three years after the contract has terminated. DOCUMENTATION REQUIREMENTS Client Record (Examples of DAP and SOAP notes will be added to appendix) 1. Documentation at Intake/Admission (to be maintained in individual file): a. Determine if the client meets the eligibility criteria described above. b. Client Intake which includes a complete social history c. Additional forms as follow: i. Client Rights/Responsibilities/ Grievance Procedures ii. Client Release of Information (Confidentiality Statement) iii. Consent Forms (Documentation of consent, or attempt to obtain consent of the client and/or parent/legal guardian for admission, evaluation, aftercare, photo/video or research). iv. Client Assessment (A day in the life) . d. All forms must be signed and dated by the family and /or parent or legal guardian, and agency staff. A separate Release of Information Form must be used for each request. Guardian must sign unless child has been emancipated. e. Client must also be informed of data collection methods utilized by the agency and to whom information will be reported including file reviewers. An evaluation Consent Form must be signed and dated by the family and/or parent/legal guardian.

NOTE: The funded agency must ensure compliance with HIPAA requirements. 2. Documentation of Appropriate Family and Infant/Toddler Goals. Document when the goals were achieved. Documentation of Screening Tools. a. Completion of required performance measurement tools and/or data collection - please refer to periodicity grid (page 19). Documentation of client progress through home visit records.
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3.

4.

Documentation may include but not limited to: a. Parent/child interactions b. Family Health c. Systems Issues d. Environmental Factors e. Social Supports f. Mental Health g. Strengths h. Concerns i. Curriculum j. other The progress notation shall also include date, time and duration of contact, type of service, signature and credentials of individual completing the note. 5. Documentation of Supervisory Chart Reviews. (Please see Supervisory section above) Supervisors must review active client files every 90 days or more frequently as needed to include: a. Review of services offered to the family b. Review of appropriateness and effectiveness of services provided c. Review of the intake, screening, progress notation and other pertinent information in file d. Review progress with regard to goals e. Reports of case staffing with supervisors and other involved professionals f. Developmental issues or concerns g. Developmental achievements that are age appropriate h. Parental/Caregiver concerns/developmental guidance given i. Review supplemental information attached to ASQ *Note: Written summary notations must include the date and signature of the supervisor, licensure (if applicable) and be placed in the client file. 6. Documentation of Significant Events and Incident/Occurrence Reports. All Home visiting agencies must have policies and procedures in place that address unusual occurrences and/or significant events that has threatened or could threaten the health, safety or welfare of the family or staff of the program. All Home Visiting agencies must report these significant events to the CYFD Program Manager within 24 hrs. Documentation of any significant disciplinary action, health and safety issue, rules violation, or action involving liability may include but is not limited to: a. Fire, flood or other natural disaster that creates structural damages or poses health hazards; b. An outbreak of contagious disease dangerous to public health, e.g. Tuberculosis, food poisoning, Hepatitis A; c. Any human act(s) by staff members that present or pose possible physical and/or psychological impairment of a client;

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d. Any human act(s) by staff member(s) that results in serious illness, injury or physical and/or psychological impairment of a client; e. Any suicide or attempted suicide of a client; f. Death of client; g. Accidents involving or injuries to the client; h. Any suspected abuse, neglect or exploitation; Suspected abuse or neglect must be reported to Protective Services Statewide Central Intake at 1-800-797-3260, and documented according to agency policy. It is recommended that programs contact local Protective Services to provide staff the necessary training/information about the reporting process. 7. Documentation of Service Discontinuation: Face to face contact with a client (when possible) to complete a summary that addresses Reason for discontinuation of services Summary of services provided Goals attained or not attained Recommendations and Referrals

Quarterly Reporting: Using template in appendix (page 43-44), Quarterly Reports are due the 15th of October, January and April and the Final and Summary Report on June 30. Dates and numbers are not needed in these reports as they are in the data base. These reports are an opportunity to describe your families, babies, home visitors and communities. Additional anecdotal information may be added at the discretion of programs.

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APPENDIX A

HOME VISITING FORMS

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The completion of these screening tools is required as outlined in the periodicity grid below. They are: 1. 2. 3. Edinburgh Postnatal Depression Scale Knowledge of Infant Development Inventory Ages and Stages Questionnaire (ASQ) including supporting documents Ages and Stages Questionnaire: Social /Emotional WAST-Short Social Support Index Medical Assistance Developmental Guidance

4. 5. 6. 7.

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Frequency of CYFD New Mexico Home Visiting Screening Tools

Compiled for the Home Visiting Quarterly Meeting - February 4, 2010


6 Weeks

12 Months

18 Months

24 Months

30 Months

33 Months

20 Months

10 Months

14 Months

15 Months

16 Months

22 Months

ASQ Date & Initials ASQ-SE Date & Initials EPDS Date & Initials KIDI Date & Initials SSI Date & Initials WAST Date & Initials NM MAD RAG* Date & Initials X X X

27 Months

2 Months

3 Months

4 Months

9 Months

1 Month

0 to 8 weeks of age or entry into program and as needed per observation

If family enters program after 3 mos., Admin 1x before 12 mos.

Within 6 wks of enrollment,

Within 6 wks of enrollment,

* NM MAD RAG Data entry is every 6 months based on age. Screening tools may be used more frequently if and when the home visitor observations indicate the need for further information. The home visitor/supervisor discretion can be used to determine the appropriateness of using the ASQ for 19 children referred to and enrolled in NM Family Infant Toddler Services.

36 Months

6 Months

8 Months

Newborn

Prenatal

1 Week

FORMS INCLUDED BELOW ARE EXAMPLES AGENCIES MAY DEVELOP OR USE


Forms included in the Service Definition Manual are:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Home Visit Record Day in the Life Baby goal/Family goal Family Satisfaction Survey Safety Assessment/DV safety plan Parent Satisfaction Survey Reflective Practice/Supervision Quarterly Report Recommended curriculum Sample letters to families

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Home Visit Record


Visit # _________

1.

Status of Home Toys Available Reading Materials Available Safety Problems

Describe Safety Problems. _______________________________________________ _______________________________________________________________________


2. Status of the Child Not at home Clean Sleeping Appears Healthy

Sick 3.

Alert

Active

Inactive

Quiet

Smiley

Playful

Status of Participant Sleepy Appears Healthy Sick Quiet Alert Clean Talkative Expecting Other ______________________________________________________________

4. Parent Child Interaction Cues/Attunement:_______________________________________________________________ ______________________________________________________________________________ __________________________________________________________________________ Holding/Reflection and Embellishment: ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________ Eye Contact/Tone ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________ Empathy ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________ Environment
_____________________________________________________________________________________ _________________________________________________________________________________

Rhythmicity Reciprocity/Flexibility

________________________________________________________________________ ______________________________________________________________________
Smiles/Affect ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________

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Home Visit Record contd

Child name: Date of visit :

Family Name: Length of visit:

Location of visit:

WHAT DID YOU DO DURING YOUR VISIT?

AREA OF FOCUS/ACTIVITY: Increase Parenting Skills _________________________________________________________________________ Improve Family Health _______________________________________________________________________ Improve Family Environmental Factors ________________________________________________________________________ Increase Social Support Systems ________________________________________________________________________ Improve Positive Mental Health ________________________________________________________________________ Curriculum Use: Name: ____________________________ Section: _____________________________________________________________________ Name: __________________________________________________________________________ Section: __________________________________________________________________________ ________________________________________________________________

Strengths: _____________________________________________________________________ Concerns: _____________________________________________________________________ Next Visit: ____________________ Follow Up: ______________________________________ ______________________________________________________________________________

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Family Goal/Service Plan A Day in the Life of _______________ (childs name)


Children learn and grow everyday. They learn through play, through interaction with others, and through everyday routines like bedtime, mealtime, bath-time, play, etc. Please use the following prompt questions, in your own conversational style, to look at the familys daily routine. How does your family spend the day? Where and with whom does your child spend time? Please describe what dressing, bath time, mealtime, and other routines look like for you child (include who participates in these activities). What about weekends or special times together? Who live in your home? Do you have family/friends who visit you regularly or who you visit? Any changes since the last Family Service Plan?

(your program name here)

Which people, toys, activities, routines and places interest your child?

Which people toys, activities, routines and places are challenging for your child?

Family priorities and concerns (support systems, stressors, lifestyle, behaviors, discipline, etc.):

Things Ive done that Im proud of (accomplishments):

(Your program name here)

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A DAY in the LIFE of (Childs Name) ___________ Family Name _______________ Date: _________
Please date each entry/update

Children learn and grow everyday. They learn through play, through interacting with others, and through everyday routines like bedtime, mealtime, bath-time, play, etc. Please use the following prompt questions, in your own conversational style, to look at the familys daily routine.
How does your family spend the day? Where and with whom does your child spend time? Please describe what dressing, bath time, mealtime, and other routines look like for your child (include who participates in these activities). What about weekends or special times together? Who lives in your home? Do you have family/friends who visit you regularly or who you visit? Any changes since the last plan? Which people, toys, activities, routines and places Which people, toys, activities, routines and interest your child (bath time, park, grocery store, places are challenging for your child? Why? daycare schedule, sleep)? Why?

Family priorities and concerns (support systems, stressors, lifestyle behaviors, discipline, etc.):

Things Ive done that Im already proud of (accomplishments):

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Family Name: My Familys Goal for (Childs Name):

Childs Age:

Date:
Benefits for my child/family? (Why do I want to reach this goal?)

Based on what we have discussed so far, one specific goal I want for my child is:

Personal strengths, family and community resources that can help our family with this goal (strengths):

What could get in the way of achieving this goal? How could you handle this challenge?

What I/we will do to get theresteps to take over the next 6 months: Steps:

Routines

Date (when will this happen)

How did this go?

What we learned/outcome of goal

Developed:

Parent(s) Signature:__________________________Date:_____________ Parent(s) Signature:_______________________Date:___________


Home Visitor:_________________________Date:__________SUP:____________

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The Family Goal____________________________


(Familys Name)
Based on what we have discussed so far, one specific goal I want for myself or my family is:

Date:

Benefits for my child/family? (Why do I want to reach this goal?)

Personal strengths, family and community resources that can help me with this goal:

What could get in the way of achieving this goal? How could you handle this challenge?

What I/we will do to get theresteps to take over the next 6 months: Steps:

Date (when will this happen?)

How did this go?

What we learned/outcome of goal

Developed:

Parent(s) Signature: ________________________Date:___________ Parent(s)Signature: _________________________Date:____________


Home Visitor :____________________________Date: _______SUP:_________

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Parent Satisfaction Survey (Enter in data base) 1. How would you rate the quality of services you have received from ______________. A. Excellent B. Good C. Fair D. Poor 2. Have the services youve received helped you? A. Yes, theyve helped a great deal B. Yes, theyve helped a little C. No, they havent helped much D. No, theyve seemed to make things worse 3. Would you recommend our service to others if they needed support? A. Yes, definitely B. Yes, probably C. No, probably not D. No, definitely not 4. Has your home visitor spent enough time with you? A. Yes, always B. Yes, most of the time C. No, not usually D. No, never 5. About how long is each visit? _____________________________________________ 6. Have you been treated with respect and consideration? A. Yes, definitely B. Yes, pretty much C. No, not really D. No, definitely not 7. Overall, how satisfied are you with the help you have received from the home visitor? A. Very satisfied B. Satisfied C. Not satisfied D. Very dissatisfied 8. Have you been satisfied with the information received on child development and parenting skills? A. Very satisfied B. Satisfied C. Not satisfied D. Very dissatisfied

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9. How often has your home visitor talked with you about your baby, parenting and his/her health and development? A. Every visit B. Some visits C. Seldom during visits D. Almost never 10. If applicable, have you been satisfied with the group activities (make-up party, infant massages, Christmas party and outings, etc.)? A. Very satisfied B. Satisfied C. Not satisfied D. Very dissatisfied Do you have any suggestions to make the groups better? _______________________________________________________________________ _______________________________________________________________________ Do you have any ideas for group gatherings? _______________________________________________________________________ _______________________________________________________________________ 11. Please mark (x) the following styles of your home visitor. ___Supportive ___Critical ___Truthful ___Warm ___Understanding ___Phony ___Rude ___Informed ___Rigid ___Calm ___Unavailable ___Helpful ___Organized ___Not Organized ___Not on time ___On time ___Respectful of family ___Smothering ___Doesnt listen ___Too business like ___Encourages me to do things for myself ___Available ___Easy to talk to

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___Hard to talk to ___Trustworthy ___Other ____________________ 12. Which areas of your life have improved since beginning the program? (Please check those areas that apply to you). ___ More support ___ My ability to solve problems ___ My ability to cope with problems and stress (worry less) ___ More friends ___ My relationship with my boyfriend/husband/girl friends/family members ___ Taking care of my children ___ My living situation ___ My ability to control my temper ___ My knowledge about the warning signs of potential child abuse/neglect (i.e. anger, depression, low self esteem) ___ My patience with my childs negative behavior ___ My understanding of child development and parenting ___ The heath care of my child(ren) ___ Other improvements _____________________________________________ 13. Please add suggestions regarding the program or your home visitor that could better assist you better _________________________________________________________________ How long have you been in the program? _____ weeks ____ months ____ years If you are leaving or have left the program, give your reasons. Please be honest, remember, we are not asking you to sign your name.

14. 15.

Date: __________________ Home visitor name ________________________________ PLEASE MAIL THIS SURVEY IN THE STAMPED ENVELOPE PROVIDED REMEMBER, WE ARE NOT ASKING YOU TO SIGN YOUR NAME

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Safety Assessment and Plan (to be completed at initial meeting and updated upon program completion) Family Name___________________ ______________ ID #________ Staff Name___________________________ ID#_________ Child(ren) Name(s) and Age(s)___________________________________________________________ ______________________ Date of Assessment__________________ Update __________________ Write N for No or Y for Yes for safety concerns. If Y, describe concern Family Environment Safety Plan 1.Housing Stability ________________________________________________________________ ________________________________________________________________ 2.Safety in community ________________________________________________________________ ________________________________________________________________ 3.Habitability of Housing ________________________________________________________________ ________________________________________________________________ 4.Income/Employment ________________________________________________________________ ________________________________________________________________ 5.Financial management ________________________________________________________________ ________________________________________________________________ 6.Food and nutrition ________________________________________________________________ ________________________________________________________________ 7.Personal hygiene ________________________________________________________________ ________________________________________________________________ 8.Transportation ________________________________________________________________ ________________________________________________________________

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Social Support System Safety Plan 1. Emotional support______________________________________________________ ____________________________________________________________ 2. Material support______________________________________________________ ____________________________________________________________ 3. Personal support______________________________________________________ ____________________________________________________________ 4. Community connections___________________________________________________ ____________________________________________________________

Service Utilization 1. Regular services_____________________________________________________ ____________________________________________________________ 2. Medical/health________________________________________________ ____________________________________________________________ 3. Behavioral health_______________________________________________________ ____________________________________________________________ 4. Emergency___________________________________________________ ____________________________________________________________ 5. Adult education/employment prep________________________________________________________ ____________________________________________________________

Caregiver Characteristics Safety Plan 1. Parenting skills________________________________________________________ ____________________________________________________________ 2. Parental supervision___________________________________________________ ____________________________________________________________ 3. Developmental expectations__________________________________________________ ____________________________________________________________ 4. Perception of child________________________________________________________ ____________________________________________________________ 5. Bonding with child________________________________________________________ ____________________________________________________________

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6. Interaction with Safety Plan child________________________________________________________ ____________________________________________________________ 7. Mental health/DD____________________________________________________ ____________________________________________________________ 8. Physical health_______________________________________________________ ____________________________________________________________ 9. Substance use_________________________________________________________ ____________________________________________________________ Family Interaction 1. Marital/domestic relationships__________________________________________________ ____________________________________________________________ 2. Mutual support______________________________________________________ ____________________________________________________________ 3. Other_______________________________________________________ ____________________________________________________________ Family Safety 1. Abuse of children_____________________________________________________ ___________________________________ 2. Emotional support of children_____________________________________________________ _________________________ 3. Sexual abuse of children_____________________________________________________ ______________________________ 4. Neglect of children_____________________________________________________ __________________________________ 5. Violence between caregivers___________________________________________________ ____________________________ Child Well Being (complete for each child) 1. Physical health_______________________________________________________ ___________________________________ 2. Mental health_______________________________________________________ ____________________________________

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3. Substance Safety Plan use_________________________________________________________ __________________________________ 4. Behavior_____________________________________________________ __________________________________________ 5. Developmental/school__________________________________________ __________________________________________ 6. Relationship with caregiver____________________________________________________ ____________________________ 7. Relationship with siblings______________________________________________________ ____________________________ 8. Peers_______________________________________________________ ___________________________________________ 9. Motivation/cooperation__________________________________________ __________________________________________ Staff signature________________________________________ID#_______Date__ ______ Client signature________________________________________ Date____________

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Mental Heath Decision Making Tree


Safety Guideline Manual For Home Visitors, Home Visitation Leadership Advisory Coalition, Oklahoma State Department of Health

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Substance Abuse Decision Making Tree


Safety Guideline Manual For Home Visitors, Home Visitation Leadership Advisory Coalition, Oklahoma State Department of Health

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Domestic Violence Decision Making Tree


Safety Guideline Manual For Home Visitors, Home Visitation Leadership Advisory Coalition, Oklahoma State Department of Health

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(your program name here) Domestic Violence Safety Plan


Being ready for a crisis Planning to leave

If I decide to leave, I will __________________________________________. (Practice how to get out safely. What doors, windows, elevators, stairwells or fire escapes would you use?) I can keep my purse and car keys ready and put them _____________ in order to leave quickly. I will leave money and an extra set of keys with _________________ so I can leave quickly. I will keep copies of important documents or keys at _____________________. If I have to leave my home, I will go ____________________. If I cannot go to the above location, I can go __________________________________. The domestic violence hotline number is _____________. I can call it if I need shelter. If it's not safe to talk openly, I will use ______________ as the code word/signal to my children that we are going to go, or to my family or friends that we are coming. I can leave extra clothes with ___________________.

I can use my judgment

When I expect my partner and I are going to argue, I will try to move to a space that is lowest risk, such as _____________________________. (Try to avoid arguments in the bathroom, garage, kitchen, near weapons, or in rooms without an outside exit.) I will use my judgment and intuition. If the situation is very serious, I can give my partner what he wants to try and calm him down. I have to protect myself until I/we are out of danger. I can also teach some of these strategies to some/all of my children, as appropriate. I will keep important numbers and change for phone calls with me at all times. I know that my partner can learn who I've been talking to by looking at phone bills, so I can see if friends will let me use their phones and/or their phone credit cards. I will check with ___________and _______________ to see who would be able to let me stay with them or lend me money, if I need it. I can increase my independence by opening a bank account and getting credit cards in my own name; taking classes or getting job skills; getting

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copies of all the important papers and documents I might need and keeping them with __________________________________________. Other things I can do to increase my independence include: _________________________________________________________. I can rehearse my escape plan and, if appropriate, practice it with my children. If I have a joint bank account with my partner, I can make arrangements to ensure I will have access to money.

I can get help


I can tell _________________ about the violence and request that they call the police if they hear noises coming from my house. I can teach my children how to use the telephone to contact the police and the fire department. I will make sure they know the address. If I have a programmable phone, I can program emergency numbers and teach my children how to use the auto dial. I will use _______________ as my code word with my children or my friends so they will call for help.

After I Leave

I can enhance the locks on my doors and windows. I can replace wooden doors with steel/metal doors. I can install security systems including additional locks, window bars, poles to wedge against doors, an electronic system, etc. I can purchase rope ladders to be used for escape from second floor windows. I can install smoke detectors and put fire extinguishers on each floor in my home. I will teach my children how to use the phone to make a collect call to me if they are concerned about their safety. I can tell people who take care of my children which people have permission to pick them up and make sure they know how to recognize those people. I will give the people who take care of my children copies of custody and protective orders, and emergency numbers.

At Work and in Public

I can inform security, my supervisor and/or the Employee Assistance Program about my situation. Phone numbers to have at work are _______________________________________________________. I can ask __________________to screen my calls at work or have my phone number changed. When leaving work, I can ______ ____________________________. When traveling to and from work, if there's trouble, I can__________. I can ask for a flexible schedule.

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I can ask for a parking space closer to the building. I can ask to move my workspace to a safer location. I can ask security to escort me to and from my car. I can change my patterns to avoid places where my partner might find me, such as ______________________, (stores, banks, laundromats). I can tell ______________ and ____________________ that I am no longer with my partner and ask them to call the police if they believe my children or I are in danger. I can explore the option of telecommuting with my supervisor and human resources office.

With an Order of Protection


I will keep my protection order_________, where I know it will be safe. I will give copies of my protection order to police departments in the community in which I live and those where I visit friends and family. I will give copies to my employer, my religious advisor, my closest friend, my children's school and day care center and____________. If my partner destroys my protection order or if I lose it, I can get another copy from the court that issued it. If my partner violates the order, I can call the police and report a violation, contact my attorney, call my advocate, and/or advise the court of the violation. I can call a domestic violence program if I have questions about how to enforce an order or if I have problems getting it enforced.

Items to Take When Leaving


Identification for myself Children's birth certificates My birth certificate Social Security cards School/vaccination records Money, checkbook, bank books, cash cards Credit cards Medication/prescription cards Keys house, car, office Driver's license/car registration Insurance papers Public Assistance ID/Medicaid Cards Passports, work permits Divorce or separation papers Lease, rental agreement or house deed Car/mortgage payment book Children's toys, security blankets, stuffed animals Sentimental items, photos My Personalized Safety Plan

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My Emotional Health

If I am feeling down, lonely, or confused, I can call _________ or the domestic violence hotline_________________. I can take care of my physical health by getting a checkup with my doctor, gynecologist, and dentist. If I don't have a doctor, I will call the local clinic or ___________ to get one. If I have left my partner and am considering returning, I will call ____________________ or spend time with __________ before I make a decision. I will remind myself daily of my best qualities. They are: ________________________ ________________________ ________________________ I can attend support groups, workshops, or classes at the local domestic violence program or __________________ in order to build a support system, learn skills or get information. I will look at how and when I drink alcohol. If I am going to drink, I will do it in a place where people are committed to my safety. I can explore information available on the websites listed in the back of this guide. Other things I can do to feel stronger are: __________________________________

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New Mexico Association for Infant Mental Health: Reflective Supervision The primary objectives of the reflective supervision/consultation relationship are to: Establish consistent and predictable meetings and times Ask questions that encourage the in depth sharing of details about the infant, parent, and emerging relationship Remain emotionally present Teach/guide Nurture/support Apply the integration of emotion and reason Foster the reflective process to be internalized by the supervisee Explore the parallel process and create time for personal reflection Attend to how reactions to the content (what is happening or being addressed) affect the process underlying the activities, including feelings evoked by both the content and the process The following are best practice guidelines that one can consider when reflecting on the supervision/consultation experience: The Supervisor/Consultant: Agrees with supervisee on a regular time and place to meet Arrives on time and remains open, curious, and emotionally available Protects against interruptions (turns off phone, closes door) Sets the agenda with the supervisee before beginning the discussion Respects each supervisees pace and readiness Allies with supervisees strengths, offering reassurance and specific feedback that is helpful for professional growth Observes and listens carefully, attending to both the process and the content that is shared Strengthens supervisees observation and listening skills Uses gentle inquiry to explore the internal experiences of the supervisee and to support the supervisee to hypothesize about the internal experiences of the infant, parent and team mates as appropriate to increase awareness and alternative approaches to the work Suspends harsh and critical judgment Invites the in depth sharing of details about a particular situation, infant/toddler, parent, their competencies, behaviors, interactions, emerging relationship, strengths and concerns Listens for the emotional experience that the supervisee is describing when discussing a situation or response to the work, e.g. joy, pleasure, ambivalence, anger, impatience, sorrow, confusion, etc. Invites supervisee to recognize and talk about feelings awakened in the presence of an infant/toddler and parents Wonders about, names, and responds to those feelings with appropriate empathy As the supervisee appears ready or able, encourages exploration of thoughts and feelings that the supervisee has about the work with the infant/toddler and family as well as about ones responses to the work Encourages exploration of thoughts and feelings that the supervisee has about the experience of supervision as well as how that experience might influence his/her work with infants/toddlers and their families or his/her choices in developing relationships Holds the content and processes explored with the supervisee from one session to the next and keeps track of patterns/trends in each supervisees interaction tendencies and professional development Maintains a shared balance of attention on the infant/toddler, parent/caregiver and supervisee

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Reflects on the current supervision/consultation session in preparation for the next meeting Remains available between sessions if there is a crisis or concern that needs immediate attention

The Person Receiving Reflective Supervision/Consultation: Agrees with the supervisor or consultant on a regular time and place to meet Arranges schedule to avoid disrupting or missing supervision/consultation sessions Arrives on time and remains open and emotionally available Comes prepared to share the details of a particular situation, home visit, assessment experience, or dilemma Asks questions that encourages thinking more deeply about ones own work with very young children, their families, and oneself With the supervisors/consultants support and guidance, hypothesizes about the internal experiences of the infant, parent and team mates as appropriate to increase awareness and alternative approaches to the work Increases awareness of the feelings experienced in response to ones own work and in the presence of an infant, very young child and parent(s) As the supervisee is ready and able, shares her feelings with the supervisor/consultant Explores the relationship between ones own feelings and the work one is doing Allows the supervisor/consultant to provide support; tells the supervisor/consultant what feels helpful and supportive Remains curious and open to new interpretations of and possibilities for the work Suspends harsh and critical judgment of self and others Reflects on the supervision/consultation session to identify what works well to enhance your professional practice and personal growth

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Model for Structured Reflection** Reflective Cue Help your supervisee slow down and bring the mind home Focus on a description of an experience that happened this week (in this session, etc.) that seems significant in some way What seems most significant about this? What do you find yourself wondering about? Where there things that were confusing or mysterious? How do you imagine the child, parent, or colleague was feeling and what do you think made them feel that way? How were you feeling? What do you think made you feel that way? What factors or pressures were influencing your thinking or feeling? What were you really trying to do in this moment? Did you feel effective in that moment? What was the impact of what you did or said on the child, parent, or colleague? What knowledge informed you or what knowledge or skill did you feel you needed? Do you feel you understood the culture of context of the people involved and the situation? Did you feel understood? How did you think you were seen? If I could replay the scene, are there things you might want to do differently? How do you think this might play out? Thinking back on what happened in this session are there things you understand in a different way now than when we started this conversation? Do you think this well change the way you work with this family or child the next time? This model has several critical components: Calming the mind and relaxing,

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selection of some specific event or scene form the supervisees work, examining the event from multiple perspectives. It is not meant to be a series of questions always asked in this sequence. Supervisors should find their own words and phrasing that is comfortable in their setting. *Model developed by Mary Claire Heffron inspired by work of Christopher Johns (Becoming a Reflective Practitioner) 2008.

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Supervisor Feedback Form


(In current form is used with clinicians please modify for your own use)
Supervisee _______________________ Supervisor ______________________________

NOTE: Different descriptors accompany the YES response for each item. In many cases, the most detailed or in-depth item is listed last. However, please be aware that the last item might not be the most appropriate or desirable with regards to every interns needs or every training experience. Please write-in comments, also. Supervisory Responsibilities The supervisor was at supervisory meetings promptly and reliably. ___ NO ___ YES, but was late more than 15 minutes more than 2 times. ___ YES, reliably on time, with minimal delays. The supervisor was available for spot supervision. ___ NO ___ YES, with limited availability. ___ YES, with clear communication about several available times throughout the week and frequent immediate availability for quick questions. The supervisor educated me fully about documentation and confidentiality issues. ___ NO ___ YES, when concerns arose and as needed. ___ YES, and helped me identify potential difficulties that I may not have anticipated. Supervisory Content The supervisor discussed ethical issues pertaining to patient care. ___ NO ___ YES, when concerns arose and as needed. ___ YES, and helped me identify potential difficulties that I may not have anticipated. The supervisor discussed diversity issues related to my training experience. ___ NO ___ YES, as needed. ___ YES, and relevant current professional writings were provided to me and/or current literature was referenced in our discussions and/or diversity issues were discussed in depth on an ongoing basis. The supervisor educated me about coping with risk issues such as suicidality and homocidality in therapy, including assessment, documentation, contracting and addressing the issue therapeutically. ___ NA ___ NO ___ YES, when concerns arose and as needed. ___ YES, and helped me identify potential difficulties that I may not have anticipated.

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The supervisor shared case material and therapeutic difficulties relating to the supervisors own patients with me. ___ NO ___ YES, and I appreciated learning about how the supervisor addressed clinical difficulties of her or his own. ___ YES, and this was helpful to my own clinical development since the examples provided were pertinent to the cases at hand and my developing clinical style. Audiotapes were played in supervision. ___ NO ___ YES, 1-2 times ___ YES, 3-4 times ___ YES, 5 times or more The supervisor made in vivo observations of my work (can include observation of testing, joint bedside consultations, and co-leading groups). ___ NO ___ YES, 1-2 times ___ YES, 3-4 times ___ YES, 5 times or more

Supervisory Process The supervisor fostered good communication, respect and trust. ___ NO ___ YES, indirectly fostered, through nonverbal communication and a comfortable climate. ___ YES, directly and indirectly fostered, including discussion of process issues in supervision as needed. We discussed difficulties in the supervisory relationship. ___ NA, no difficulties were noted by either of us. ___ NO ___ YES, but we are still having difficulties. ___ YES, and I feel that we have better communication about these matters now. ___ YES, and difficulties were fully resolved to the satisfaction of both parties. I felt comfortable with how the supervisor gave me feedback on my work. ___ NO ___ YES, although sometimes I struggled with how to implement the feedback. ___ YES, and appropriate, constructive feedback was given that I was able to utilize and incorporate into clinical practice and my developing clinical style. The supervisor fostered an environment that made me feel comfortable discussing countertransference issues. ___ NA ___ NO ___ YES, indirectly fostered, through nonverbal communication and a comfortable climate. ___ YES, directly and indirectly fostered, including encouragement to discuss countertransference.

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The supervisor concentrated on my training needs during supervision and was interested in my growth as a clinician. ___ NO ___ YES, my training needs were attended to. ___ YES, and we discussed my training needs on at least on occasion. ___ YES, and incorporated my feedback regarding supervisory needs into supervision sessions and training throughout the rotation.

Assistance in Professional Development

The supervisor facilitated the process of me becoming a valuable member of the treatment team. ___ NA, treatment team work was not emphasized on this training experience. ___ NO ___ YES, I was introduced to all team members, included in team meetings and encouraged to discuss issues with them as appropriate. ___ YES, my input was valued and well-received in the treatment planning and case review process. In group therapy, the supervisor was an effective role model for me. ___ NA, no group therapy for this training experience. ___ NO ___ YES, I learned by observation and discussion of group members in supervision. ___ YES, and my supervisor helped me to learn specific interventions, therapeutic techniques and/or more about group process. The supervisor was flexible about my duties as needed for my professional growth, while consulting about time management as appropriate. ___ NO ___ YES, but I was still often unable to complete all assigned duties within the time allotted. ___ YES, and I was able to successfully complete assigned duties in the time allotted per week for them, on average. The supervisor encouraged positive professional relationships with colleagues through rolemodeling and discussion. ___ NA, treatment team work was not emphasized on this training experience. ___ NO ___ YES, I learned by observation of my supervisors interactions with colleagues. ___ YES, and my supervisor discussed how to facilitate positive professional relationships in supervision as needed. The supervisor encouraged me in greater autonomy, as my capabilities and skills allowed. ___ NO ___ YES, and some activities for more autonomous functioning were available. ___ YES, and when I was ready, the supervisor allowed ample opportunity for me to engage in activities such as doing groups alone, working on assessments more autonomously or treating selected individual psychotherapy cases more independently.

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As appropriate, we discussed how to minimize the impact of anxiety and stressors on professional functioning. ___ NA, not needed. ___ NO ___ YES, indirectly fostered, through nonverbal communication and a comfortable climate. ___ YES, directly and indirectly fostered, including discussion of professional challenges that we both have faced as needed. As needed, we discussed the development of my professional identity as a psychologist. ___ NA, not needed. ___ NO ___ YES Assistance in Development as Scientist-Practitioner The supervisor was knowledgeable about the literature and research in the appropriate specialty areas, discussing research findings and professional writings that pertained to cases. ___ NO ___ YES, although more updates on current literature would have been helpful. ___ YES, up-to-date with relevant current literature. The supervisor suggested specific professional readings and/or encouraged me to seek out professional literature as needed. ___ NO ___ YES Summary Ratings Exceeds Unacceptable Marginal Acceptable Requirements Outstanding

Fulfilled supervisory responsibilities Supervisory content Addressed diversity issues Supervisory process

1 1

2 2

3 3

4 4

5 5

1 1

2 2

3 3

4 4

5 5

Assistance in professional development 1 Assistance in development as a scientistpractitioner Overall rating

1 1

2 2

3 3

4 4

5 5

Comments Suggestions

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Guidelines for Reflective Consultation Phone Conferences Phone conference discussions are for the purposes of : providing support to supervisors in their day to day work and also seen as a way to, develop and deepen specific competencies related to the supervision of relationship based home visiting service. Supervisors are encouraged to bring their work to the calls to: Discuss supervision and service issues. Develop and support high quality services to families with infants and young children. Reflective facilitators providing the reflective phone calls are using a blended model of reflective supervision. This model means that they are working to help participants build understanding a stronger perspective of the supervisee's point of view and needs Thinking about the management and program requirement needs that factor into the overall situation. It is hoped that this model of blended reflective supervision provides a kind of model and a parallel process that supports the supervisor and helps them develop and deepen skills to better support their staff. The specific content of the group calls will be discussed with the Program Manager in addition if there are legal, ethical, or contract performance issues that come up in the calls there are several steps. The facilitator might help the individual raising the issue to communicate with appropriate staff at the program level and coach them in ways that this could be done. The facilitator might ask the person with the specific concern to discuss that issue further "off line" in a 1-1 phone conversation. The facilitator might refer the topic to the monthly "asks the manager" call that is more specifically about contract compliance issues. If the concern represented a serious concern that was threatening the quality of services to families in an on-going way or the appropriate use of program funds, the facilitator will need to bring that information to the contract manager. After each call facilitators will provide a 1-2 page summary of the call that will address the kinds of concerns and issues discussed and specific competencies and skills that were applied in the discussion. Specific programs or individuals will not be named in these summaries.

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New Mexico Home Visiting Quarterly Report Template

Agency: ________________________________ Quarterly Report For: ____/____/____/ Name and Role of Person Completing Report: ____________________ Date: ____/_____/____
1. Describe program or consumer successes and /or newly identified program strengths. Please use the verbal video principle when describing your success and program strengths. Verbal Video Results/anecdotal comments by family members completing Family Satisfaction Questionnaire. 2. Discuss any new community resources identified, and /or any trends in the nature of referrals to community services. Please give address and contact person for any new resources identified Please identify the trends you are experiencing regarding referrals 3. Describe any collaborative activities related to home visiting i.e.: integration, service expansion, etc. Discuss any results. interactive participation with other agencies training integration of services service expansion 4. Discuss any staff changes related to home visiting. Please include the names of your home visiting team. 50

New hires, promotion, recognition, awards

5. Discuss newly identified barriers to successfully serving Home Visiting, i.e., etc. service access problems changes in the community service array transportation system consumers access other 6. Identify trainings attended by staff / supervisors and any changes in practice that resulted. List training you and or your staff have attended and describe how it helps with your Home Visiting work 7. Any other information that would help us and others (funders, decision makers, etc.) understand more completely the importance and challenges of building a home visiting program in your community/state. From the caregivers point of view From the infant point of view From the staff point of view From the programs point of view From the community point of view From others you come into contact

__________________ _____________________ Signature Date

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Recommended Curriculum Florida Partners for a Healthy Baby Portage: Growing Birth to Three First Born

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Sample Letters included in the Service Definition Manual: 1. 2. 3. Contact Letter Potential Discharge Letter Closure/Parent Satisfaction Survey Letter

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YOUR LETTER HEAD

YOUR NAME AND ADDRESS

Date: ____________________________ Client's Name _____________________________ _ Address

Dear Our program has tried several times to reach you without success. Perhaps there was a misunderstanding about the dates and times we were to meet. We would love to hear from you and tell you more about what our home visiting program can actually offer you. Many of the mothers in our program like to meet with their home visitor and discuss the many changes their babies are making. Home visitors help them enjoy their babies by providing interesting activities to help their babies learn and grow in a healthy way. Babies do not come with directions. Sometimes being a parent is exhausting and frustrating. It helps to talk to someone and share concerns and ideas. Home visitors are special friends to parents and babies. If you would still like to take advantage of our home visitation service we would be glad to meet with you. Please feel free to phone me when you need to talk to someone. Sincerely,

Home Visitor

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YOUR LETTER HEAD

YOUR NAME AND ADDRESS

Date

Parent's Name:

Address: ____________________________________ _ Dear I have been attempting to contact you by phone and/or leaving messages at your home, but have not heard from you. Our program policy is that after attempts for a 3-month period have been made and a parent doesn't respond, we will discharge you from our program. Please call us at any time for any information you may need regarding your child or family's health care. Sincerely,

Home Visitor

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YOUR LETTER HEAD

Your name and address

Date: Parent's Name Address: Dear ______________________________________ _ You have been part of our program since . We have been pleased to offer you our Home Visiting Services throughout this time. It is time to end the home visits and I wish you well. Enclosed is a Parent Satisfaction Survey and self-addressed envelope. Please take the time to fill it out and mail it back to our office. This will help me to know how to best serve families. Please call on us at any time for any information you may need regarding your child or family's health care. Sincerely,

Home Visitor

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APPENDIX B HOME VISITING GLOSSARY


DEFINITION OF TERMS ASQ ASQ: SE Attachment Ages and Stages Questionnaire Ages and Stages Questionnaire: Social/Emotional An emotional bond between a parent/primary caregiver and infant that develops over time and as a result of positive care-seeking behaviors (e.g., crying, smiling, vocalizing, grasping, reaching, calling, following) and responsive care giving (e.g., smiling, talking, holding, comforting, caressing). Assigning some quality or character to a person or thing. An empathic responsiveness between two individuals, described by Daniel Stern as the performance of behaviors that express the quality of feeling of a shared affect state (1985, p142). Attunement is different from imitation.

Attributions Attunement

Childrens Protective Services a state-wide system to prevent or treat the abuse and neglect of children within the New Mexico Children, Youth and Families Department Collaborate Work willingly with other direct service providers, parents, community agencies, faculty, and other professionals to obtain, coordinate, and research services that effectively nurture infants and families. Sources that provide additional information to support or reinforce the assessment/evaluation and treatment of clients. Participation with other community entities to address the health and well being of the community as a whole Issues identified through community collaboration that are paramount to provide positive affects to the health and well being of the community Describe specific areas of expertise, responsibilities and behaviors that are required to earn the MAIMH Endorsement at Level 1 (Infant Family Associate), Level 2 (Infant Family Specialist), Level 3 (Infant 57

Collateral Contacts

Community Collaboration

Community Priorities

Competency Guidelines:

Mental Health Specialist), and Level 4 (Infant Mental Health Mentor). Areas of expertise, very generally described here, include theoretical foundations; law, regulation and policy; service systems; direct service skills; working with others; communicating; reflection; and thinking. Consultation: an opportunity for professionals to meet regularly with an experienced infant mental health professional to examine thoughts and feelings in relationship to work with infants, toddlers, and families. Someone who has a vested interest in the results of services for a specific, identified client (i.e. a judge, a public defender or an attorney).

Consumer

Contingency/Contingent interactions an adults response that is directly related to an infants behavior or actions and vice versa. Core Data Elements Ages and Stages Questionnaire as well as output data such as ages, prenatal services, address etc. Unbiased knowledge of the familys culture and language which is an integral part of all efforts to deliver services. Beliefs and practices are identified which include, but are not limited to, family organization and relational roles (traditional and non traditional), spirituality, and understanding of ethnically related stressors such as acculturation, poverty, and discrimination. Research based curriculum, which has been developed for infants zero to three. Offering individualized guidance to parents about their childrens development requirements, while focusing on the capacities of the child and the primary caregiver. Services that begin prior to pregnancy, during pregnancy or at anytime during the first three years of the childs life. Empathy is an ability to understand and feel what another person is feeling, not in a physical sense, but in an emotional sense. The expression "put yourself in someone else's shoes" is actually a description of empathy. This helps to understand other's situations, perspectives, and problems much better.

Cultural Sensitivity

Developmental Curricula

Developmental Guidance

Early Intervention

Empathy

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Engagement Cues

Engagement means that the infant wants to engage or attract the attention of her caregiver in other words, she is ready for interaction. Some familiar cues are smiling, looking at, and reaching out to another. At least one parent, caregiver, guardian, or custodian of the infant or toddler involved in the home visiting program on behalf of the identified infant/toddler. This term refers to the need to look at the family as a whole. The aim is to support the family in service of the infant.

Family

Family Centered

Family-Centered Practice The infant and family professionals ability to focus on the infant or toddler within the context of the family and to respect the familys strengths and needs as primary. First Visit A First Visit is defined as the beginning of the relationship, which is established through the implementation of the client intake form. The First Visit is different from the Informational Contact. A structured, scheduled meeting with a family. Number of pregnancies a woman has experienced. An early intervention strategy used by states and communities to improve the health and well being of children and families. Services provided by a home visitor in a familys home or other community location which occur during the first 3 years of a childs life and as requested by the family during pregnancy. A credentialed professional in early childhood development or non degreed professional who provides developmental guidance, educational and local community resource information, identifies social supports, and refers families to community resources to strengthen families and improve the well-being of children and families.

Formalized Session Gravida Home visiting

Home visiting services

Home Visitor

Human Services/Related Degree(s) that include but are not limited to Social Work, Sociology, Counseling, Human Services, Criminology/ Criminal Justice, Public Administration, Educational Counseling, Education, Nursing and Health Education. Identified/Billable Client A family who meets the definition of the target populations identified by CYFD. The Identified Billable Family

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is a first time parent and the childs age is zero to three years. Infant Family Associate A professional who meets the requirements for NMAIMH Endorsement at Level 1. A professional who meets the requirements for NMAIMH Endorsement at Level 2. An interdisciplinary field dedicated to promoting the social and emotional well-being of all infants, toddlers, and families within the context of secure and nurturing relationships. Infant mental health services support the growth of healthy attachment relationships in early infancy, reducing the risk of delays or disorders and enhancing enduring strengths.

Infant Family Specialist

Infant Mental Health

Infant Mental Health Mentor A professional who meets the requirements for NMAIMH Endorsement at Level 4. Infant Mental Health Specialist: a professional who meets the requirements for NMAIMH Endorsement at Level 3. Informational Visit Home visitor provide programmatic information ONLY to potential clients such as pregnant women, first time parents. Informal networks refer to the parents resources and access to family, friends and/or neighbors who may assist them emotionally, financially, with transportation, as in well as in other areas of potential need. Management Information System is an electronic tracking system for clients and service delivery. Care that is provided to the mother and infant including medical, emotional, and psychological aimed at maintaining and enhancing the health and well-being of the infant. Newborn is considered 0-4 weeks and an infant is considered birth to1 year of age.

Informal Networks

Database (MIS)

Newborn Care

The NM Association for Infant Mental Health Endorsement Process: A process that supports the development and recognition of infant and family professionals within an organized system of culturally sensitive, relationship-focused practice that promotes infant mental health. PARA Number of live births a woman has experienced.

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Parallel Process

Parallel Process is a way of modeling interactions, behaviors, attitudes, and possible responses exemplifying how these factors are incorporated into all aspects of home visiting. For example: Home visitor who are treated with dignity and respect will more likely apply these same values in their interactions with families. A quantitative or qualitative indicator used to assess the outcome or result of a program/or service. Prenatal care refers to care that is provided to the mother during pregnancy. This includes medical, emotional, and psychological care, aimed at maintaining and enhancing the health of the unborn child, as well as the mother. The situation where an action by one individual is returned by an action by the recipient. This give and take arrangement is usually mutually agreed upon, implicitly if not explicitly. Self aware, able to examine ones professional and personal thoughts and feelings in response to work within the infant and family field. Reflective functioning is the capacity to have ones own thoughts and feelings as well as the capacity to think about another persons thoughts and feelings. Able to examine ones thoughts and feelings related to professional and personal responses within the infant and family field.

Performance Measure

Prenatal Care

Reciprocity

Reflective:

Reflective Functioning

Reflective practice:

Relationship-based practice: Values early developing relationships between parents and young children as the foundation for optimal growth and change; directs all services to nurture early developing relationships within families; values the working relationship between parents and professionals as the instrument for therapeutic change; values all relationship experiences, past and present, as significant to ones capacity to nurture and support others. Reflective Supervision Reflective practice/supervision focuses on the development of relationships that support growth and development between supervisors and staff, staff and families, and parents and children. It is within these relationships that learning and change is able to

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take place. Is more a way of being than a way of doing (Zero to Three). Face-to-face, group or individual supervision of home visiting staff by a supervisor who meets relevant experience in reflective practice. The supervisor promotes the development of skills and responsibility in the delivery of home visiting services. Related Field An allied mental health field or counseling related field including social work, guidance and counseling, mental health, psychology, family studies, marriage and family therapy, family sciences, rehabilitation counseling, counselor education, or social anthropology. Significant and demonstrable experience in providing services to the target population. Participation with other community entities to benefit the health and well-being of children and families in the target population. A learning experience in which a professional meets regularly with an experienced infant mental health professional to examine professional and personal thoughts and feelings in relationship to work in the infant and family field.

Relevant Experience

Service Collaboration

Supervision

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Short Definitions of Screening Document


Ages and Stages Questionnaires (ASQ-3): A Parent-Completed Child Monitoring System, Third Edition is a screening system composed of 21 questionnaires designed to be completed by parents or other primary caregivers at any point for a child between 1 month and 5 years of age. These questionnaires can identify accurately infants or young children who are in need of further assessment to determine whether they are eligible for early intervention or early childhood special education services. Each questionnaire contains 30 developmental items that are written in simple, straight forward language. The items are organized into five areas: Communication, Gross Motor, Fine Motor, Problem Solving, and Personal-Social. An Overall section addresses general parental concerns. The reading level of each questionnaire ranges from fourth to sixth grade. Illustrations are provided to assist parents in understanding the items. For the 30 developmental items on each questionnaire, parents mark yes to indicate that their child performs the behavior specified in the item, sometimes to indicate an occasional or emerging response from their child, or not yet to indicate that their child does not yet perform the behavior. Program personnel convert each response to a point value, total these values, and compare the total score with established screening cutoff points. Source: Squires J, Twombly E, Bricker D, and Potter L (2009a). ASQ-3 Users Guide, Baltimore, MD: Paul Brookes. Ages and Stages Questionnaires: Social-Emotional (ASQ:SE): ASQ:SE is a screening tool, the primary purpose of which is to assist parents and early intervention and early childhood personnel in the timely identification of children with responses or patterns of responses that indicate the possibility of their developing future social or emotional difficulties. In other words, the ASQ:SE is not a diagnostic tool for identifying children with serious social or emotional disorders; rather it should be seen as an aid in identifying young children who may benefit from more in-depth evaluation and/or preventive interventions designed to improve their social competence, emotional competence, or both. The ASQ:SE is a series of eight questionnaires designed to be completed by parents to address the emotional and social competence of young children. The ASQ:SE has separate questionnaires for 6, 12, 18, 24, 30, 36, 48, and 60 month age intervals. Each questionnaire can be used within 3 months (for the 6 through 30 month intervals) or 6 months (for the 36 through 60 month intervals) of the chronological age targeted for the questionnaire. The ASQ:SE contains items related to competence and to problem behaviors. Each questionnaire can be completed by parents in 10-15 minutes. For parents who do not read English or Spanish at a fifth- to sixth- grade level, the questionnaires can be used as an interview tool. Cultural and ethnic variability will also need to be considered when using the ASQ:SE. If an item on the questionnaire is not appropriate for a family, it should be omitted. Source: Squires J, Twombl E, Bricker F (2003). ASQ:SE Users Guide, Baltimore, MD: Paul Brookes. The Knowledge of Infant Development Inventory (KIDI) was designed to assess a persons knowledge of parental practices, developmental processes, and infant norms. It was originally developed for use in research on what determines parent behavior. The KIDI was also used to evaluate parent education programs. A questionnaire eliciting previous experiences with infants accompanies the KIDI. Source: Knowledge of Infant Development Inventory (KIDI) and Catalog of Previous Experience with Infants (COPE) by David MacPhee, c1983.

Short Definitions of Screening Document


The Woman Abuse Screening Tool (WAST) was developed for use by family physicians to identify female patients experiencing abuse in their current relationships. A shorter version of the WAST was created for initial screening using the two questions with the highest comfort scores (questions 1 and 2). Source: Forgarty CT, Burge S, McCord EC (2002). Communicating with patients about intimate partner violence: screening and interviewing approaches. Family Medicine Vol. 34, 5, pp. 349-374. Social Support Index (SSI) is a 17-item instrument designed to measure the degree to which families find support in their communities. Social support has been found in a number of studies to be an important buffer against family crisis factors, and to be a factor in family resilience in promoting family recovery, and as a mediator of family distress. Thus this measure is a particularly important instrument for examining the extent of community-based social support as an ingredient in family resiliency. The SSI has been used with thousands of families in Western Europe and in the United States including families of rural bank employees and families with different ethnic backgrounds including Asian, Native Hawaiian, Caucasian, African-American, and those of mixed races. Source: McCubbin HI, Thompson AI, McCubbin MA (2001). Family Measures: Stress, Coping and Resiliency. Kamehameha Schools, Honolulu, Hawaii. CD-Rom. Edinburgh Postnatal Depression Scale (EPDS) is a 10-item screening tool. A valuable and efficient way of identifying patients at risk for perinatal depression, the EPDS is easy to administer and has proven to be an effective screening tool. Cutoff scores range from 9 to 13 points. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. The EPDS score should not override clinical judgment. A careful clinical assessment by a qualified professional should be carried out to confirm the diagnosis. The scale indicates how the mother has felt during the previous week. In doubtful cases it may be useful to repeat the tool after 2 weeks. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders. Source: Cox JL, Holden JM, Sagovsky R (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.

APPENDIX C CYFD BACKGROUND CLEARANCE PROCESS

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SUMMARY OF BACKGROUND CLEARANCE PROCESS The Background Clearance Unit of Family Services is responsible for ensuring children are in safe, responsible and morally positive settings. Background clearances are conducted in order to identify those adults who have relevant misdemeanor convictions, felony and/or arrests that operate as a disqualification to provide services. In addition, the Unit conducts abuse and neglect screens, utilizing Protective Services data, in order to identify those persons who pose a continuing threat of abuse and/or neglect to minors or adults in their care. PAYMENT REQUIREMENTS The cost is $34.00 for each set of fingerprint cards. The fee is used to pay the Federal Bureau of Investigation ($24.00), the NM Department of Public Safety ($7.00) and the Internet provider ($3.00). The Children, Youth and Families Department does not charge a fee for its services at this time. The fingerprint cards, along with the $34.00 fee (money order or cashiers check only made payable to the NM Department of Public Safety) must be sent to: Children, Youth and Families Department Early Childhood Services Division Background Checks Unit P.O. Drawer 5160 Santa Fe, NM 87502-5160

FREQUENTLY ASKED QUESTIONS


Q: A: Where do I get fingerprint cards? You can obtain blank fingerprint cards from the Child Care Licensing District Office in your area by calling (505) 841-4820. Where do I get fingerprinted? Your local law enforcement agency can perform these services or can refer you to another source. How soon do I need to submit my fingerprints? Two fingerprint cards must be submitted prior to commencement of employment, whether agency employed, contractual or volunteer. How soon can I begin work once the fingerprints have been submitted? All personnel (agency employed, contractual or volunteer) who have any contact with clients must have a CYFD Background Clearance within 60 days of employment. Prior to obtaining the clearance, these employees must work in direct supervision of a cleared staff person at all times. Personnel including but not limited to administrative, support and facilities staff, who do not have contact with clients must have a CYFD Background Clearance within 60 days of employment. Why do I need to submit two fingerprint cards?

Q: A:

Q: A:

Q: A:

Q:

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A:

The Children, Youth and Families Department submits criminal history inquiries to the Federal Bureau of Investigation (FBI) by scanning the fingerprint card into a computer software program. The fingerprint care image is then forwarded to the FBI electronically. In the event the computer system is unable to read the first fingerprint card, we are able to use the second fingerprint card you submitted, in an effort to avoid delays. Is there a cost? Yes. The cost is $34.00 for each set of fingerprint cards. The fee is used to pay the Federal Bureau of Investigation ($24.00), the NM Department of Public Safety ($7.00) and the internet provider ($3.00). The Children, Youth and Families Department does not charge a fee for its services at this time. Where do I send my fingerprint cards and payment? Mail your fingerprint cards along with the $34.00 fee (money order or cashiers check only made payable to the NM Department of Public Safety) to: Children, Youth and Families Department Family Services Background Checks Unit P.O. Drawer 5160 Santa Fe, NM 87502-5160 I was arrested but not convicted of the crime. Will that prevent me from receiving a Background Clearance? No. The Children, Youth and Families Department will only deny Background Clearances when relevant convictions exist. I know of someone who was denied clearance, although they had never been arrested or convicted of a crime. How did that happen? In addition to the criminal history, the Children, Youth and Families Department conducts a Protective Services screen for child/adult abuse and/or neglect. A denial of clearance is required if a fingerprint applicant is the perpetrator of certain substantiated abuse and/or neglect referrals. How long does it take to get a Clearance? The Children, Youth and Families Department is committed to providing an answer within two to four weeks of receiving the fingerprint cards. Obtaining a Clearance is not automatic. There are a number of important factors taken into consideration, such as criminal and Protective Services histories.

Q: A:

Q: A:

Q: A:

Q:

A:

Q: A:

FINGERPRINT CARD INSTRUCTIONS State and Federal regulations prohibit the verbal and written disclosure of information obtained through a background clearance and requires proper security for records containing criminal information.

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Completed fingerprint cards and accompanying information are legal documents and should be treated as such. All documents submitted to the Children, Youth and Families Department become the sole property of the Department. Two complete sets of fingerprint cards must be submitted to the Background Checks Unit in legible black print or typed in black ink. The following information is required on the fingerprint cards (Note: All numbered items in this section correlate to the information required on each fingerprint card). 1. 2. 3. 4. Last Name of Applicant First Name of Applicant Middle Name of Applicant (complete name, not initial, NMN for no middle name and __ for Initial only) Signature of Applicant in black ink (The applicant must sign the fingerprint cards after all information on the fingerprint card is correct and complete) Mailing address of Applicant (street, rural route number, P.O. Box, city, state and zip code) Aliases used by Applicant (AKA include maiden name or previous married names and any other names used) Citizenship of Applicant (identify by country, i.e., United States or US, Mexico or MX) Date of fingerprinting Signature of Official taking fingerprints Originating Case Agency Leave Blank Employer complete name, address, city, state and zip code FBI no. FBI Leave Blank Armed Forces Number of Applicant MNU (if applicant has a current or previous armed forces number, enter the number. Otherwise leave blank) Social Security Number of Applicant Miscellaneous Number of Applicant (if applicant has another identification number, enter the number. Otherwise, leave blank) Sex of Applicant (Gender) Race of Applicant Height of Applicant Weight of Applicant Eye color of Applicant Hair color of Applicant Date of Birth of Applicant Place of Birth of Applicant (enter stare and/or country) Reason Fingerprinted Fingerprints

5. 6. 7. 8. 9. 10. 11. 12. 13.

14. 15.

16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

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TITLE 8

SOCIAL SERVICES

CHAPTER 8 CHILDREN, YOUTH AND FAMILIES GENERAL PROVISIONS PART 3 GOVERNING BACKGROUND CHECKS AND EMPLOYMENT HISTORY VERIFICATION 8.8.3.1 ISSUING AGENCY: Children, Youth and Families Department [8.8.3.1 NMAC - Rp, 8.8.3.1 NMAC, 03/31/06] 8.8.3.2 SCOPE: This rule has general applicability to operators, volunteers, including student interns, staff and employees, and prospective operators, staff and employees, of child-care facilities, including every facility, CYFD contractor, program receiving CYFD funding or reimbursement, or other program that has or could have primary custody of children for twenty hours or more per week, juvenile treatment facilities, and direct providers of care for children in including, but not limited to the following settings: Childrens behavioral health services and licensed and registered child care, including shelter care. [8.8.3.2 NMAC - Rp, 8.8.3.2 NMAC, 03/31/06; A, 07/31/09] 8.8.3.3 STATUTORY AUTHORITY: The statutory authority for these regulations is contained in the Criminal Offender Employment Act, Section 28-2-1 to 28-2-6 NMSA and in the New Mexico Childrens and Juvenile Facility Criminal Records Screening Act, Section 32A-15-1 to 32A-15-4 NMSA 1978 Amended. [8.8.3.3 NMAC - Rp, 8.8.3.3 NMAC, 03/31/06] 8.8.3.4 DURATION: Permanent [8.8.3.4 NMAC - Rp, 8.8.3.4 NMAC, 03/31/06] 8.8.3.5 EFFECTIVE DATE: March 31, 2006, unless a later date is cited at the end of a section. [8.8.3.5 NMAC - Rp, 8.8.3.5 NMAC, 03/31/06] 8.8.3.6 OBJECTIVE: A. The purpose of these regulations is to set out general provisions regarding background checks and employment history verification required by the children, youth and families department. B. Background checks are conducted in order to identify information in applicants backgrounds bearing on whether they are eligible to provide services in settings to which these regulations apply. C. Abuse and neglect screens are conducted by licensing authority staff in order to identify those persons who pose a continuing threat of abuse or neglect to minors or adults in settings to which these regulations apply. [8.8.3.6 NMAC - Rp, 8.8.3.6 NMAC, 03/31/06; A 07/31/09]

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8.8.3.7 DEFINITIONS: A. ADMINISTRATIVE REVIEW means an informal process of reviewing a decision that may include an informal conference or hearing or a review of written records. B. ADMINISTRATOR means the adult in charge of the day-to-day operation of a facility. The administrator may be the licensee or an authorized representative of the licensee. C. ADULT means a person who has a chronological age of 18 years or older, except for persons under medicaid certification as set forth in Subsection I below. D. APPEAL means a review of a determination made by the children, youth and families department, which may include an administrative review. E. APPLICANT means any person who is required to obtain a background check under these rules and NMSA 1978, Section 32A-15-3 (1999). F. ARREST means notice from a law enforcement agency about an alleged violation of law. G. BACKGROUND CHECK means a screen of the departments information databases, state and federal criminal records and any other reasonably reliable information about an applicant. H. CARE RECIPIENT means any person under the care of a licensee. I. CHILD means a person who has a chronological age of less than 18 years, and persons under applicable medicaid certification up to the age of 21 years. J. CONDITIONAL EMPLOYMENT means a period of employment status for a new applicant prior to the licensing authoritys final disposition of the applicants background check. K. CRIMINAL HISTORY means information possessed by law enforcement agencies of arrests, indictments, or other formal charges, as well as dispositions arising from these charges. L. DIRECT, PHYSICAL SUPERVISION means continuous visual contact or live video observation by a direct provider of care who has been found eligible by a background check of an applicant during periods when the applicant is in immediate physical proximity to care recipients. M. DIRECT PROVIDER OF CARE means any individual who, as a result of employment or, contractual service or volunteer service has direct care responsibilities or potential unsupervised physical access to any care recipient in the settings to which these regulations apply. N. EMPLOYMENT HISTORY means a written summary of the most recent three-year period of employment with names, addresses and telephone numbers of employers, including dates of employment, stated reasons for leaving

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employment, and dates of all periods of unemployment with stated reasons for periods of unemployment, and verifying references. O. LICENSED means authorized to operate by the children, youth and families department by issuance of an operators license or certification certificate. P. LICENSEE means the holder of, or applicant for, a license, certification, or registration pursuant to 7.20.11 NMAC, 7.20.12 NMAC, 8.16.2 NMAC, 7.8.3 NMAC; 8.17.2 NMAC. Q. LICENSING AUTHORITY means the children, youth and families department. R. MORAL TURPITUDE means an intentional crime that is wanton, base, vile or depraved and contrary to the accepted rules of morality and duties of a person within society. In addition, because of the high risk of injury or death created by, and the universal condemnation of the act of driving while intoxicated, a crime of moral turpitude includes a second or subsequent conviction for driving while intoxicated or any crime involving the use of a motor vehicle, the elements of which are substantially the same as driving while intoxicated. The record name of the second conviction shall not be controlling; any conviction subsequent to an initial one may be considered a second conviction. S. RELEVANT CONVICTION means a plea, judgment or verdict of guilty, no contest, nolo contendere, conditional plea of guilty, or any other plea that would result in a conviction for a crime in a court of law in New Mexico or any other state. The term RELEVANT CONVICTION also includes decrees adjudicating juveniles as serious youthful offenders or youthful offenders, or convictions of children who are tried as adults for their offenses. Successful or pending completion of a conditional discharge under NMSA 1978, Section 31-20-13 (1994), or NMSA 1978, Section 30-31-28 (1972), or a comparable provision of another states law, is not a relevant conviction for purposes of these regulations, unless or until such time as the conditional discharge is revoked or rescinded by the issuing court. The term RELEVANT CONVICTION does not include any of the foregoing if a court of competent jurisdiction has overturned the conviction or adjudicated decree and no further proceedings are pending in the case or if the applicant has received a legally effective pardon for the conviction. The burden is on the applicant to show that the applicant has a pending or successful completion of any conditional discharge or consent decree, or that the relevant conviction has been overturned on appeal, or has received a legally effective pardon. T. UNREASONABLE RISK means the quantum of risk that a reasonable person would be unwilling to take with the safety or welfare of care recipients.

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[8.8.3.7 NMAC - Rp, 8.8.3.7 NMAC, 03/31/06; A, 07/31/09] 8.8.3.8 APPLICABILITY: These regulations apply to all licensees and direct providers of care in the following settings: A. behavior management skills development; B. case management services; C. group home services; D. day treatment services; E. residential treatment services; F. treatment foster care services agency staff; G licensed child care homes; H. licensed child care centers; I. registered child care homes; J. licensed shelter care; K. licensed before and after school care; L. non-licensed or exempt after school programs participating in the at risk component of the child and adult care food program; M. comprehensive community support services; N. CYFD contractors and any other programs receiving CYFD funding or reimbursement. [8.8.3.8 NMAC - Rp, 8.8.3.8 NMAC, 03/31/06; A, 07/31/09] 8.8.3.9 NON-APPLICABILITY: A. These regulations do not apply to the following settings, except when otherwise required by applicable Certification Requirements for Child and Adolescent Mental Health Services 7.20.11 NMAC or to the extent that such a program receives funding or reimbursement from CYFD: (1) hospitals or infirmaries; (2) intermediate care facilities; (3) childrens psychiatric centers; (4) home health agencies; (5) diagnostic and treatment centers; (6) unlicensed or unregistered child care homes. B. These regulations do not apply to the following adults: (1) treatment foster care parents; (2) relative care providers who are not otherwise required to be licensed or registered; (3) foster grandparent volunteers; (4) volunteer parents of an enrolled child if the parent is under direct physical supervision; (5) all other volunteers at a licensed or registered facility if the volunteer spends less than six hours per week at the facility, is under direct physical supervision, and is not counted in the facility ratio. [8.8.3.9 NMAC - Rp, 8.8.3.9 NMAC, 03/31/06; A, 07/31/09]

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8.8.3.10 COMPLIANCE: A. Compliance with these regulations is a condition of licensure, registration, certification or renewal, or continuation of same. B. The licensee is required to: (1) submit two completed FBI-approved fingerprint cards for all direct providers of care by the end of the next day following of commencement of service, whether employment or, contractual, or volunteer; EXCEPTION: In the case of licensed child care homes, the licensee must submit fingerprint cards, within five working days, for any adult who resides in the home or any persons residing in the home who reaches 18 years of age; (2) submit the FBI-approved fingerprint cards to CYFD along with the specified fee; (3) submit the name, address, date of birth and any aliases of the direct care provider for a child abuse and neglect screen; (4) verify the employment history of any potential direct provider of care the verification shall include contacting references and prior employers/agencies to elicit information regarding the reason for leaving prior employment or service; the verification shall be documented and available for review by the licensing authority; EXCEPTION: Verification of employment history is not required for registered home providers, child care homes licensed for six (6) or fewer children, or relative care providers; (5) submit an adult household member written statement form for each adult household member in a registered home setting in order to conduct criminal history and child abuse and neglect screens on such household members; an adult household member is an adult living in the household or an adult that spends a significant amount of time in the home; (6) provide such other information department staff determines to be necessary; and (7) maintain documentation of all applications, correspondence and clearances relating to the background checks required; in the event that the licensee does not have a copy of an applicants clearance documentation and upon receipt of a written request for a copy, the department may issue duplicate clearance documentation to the original licensee; the request for duplicate clearance documentation must be made within one year of the applicants clearance date. C. If there is a need for any further information from an applicant at any stage of the process, the department shall request the information in writing from the applicant. If the department does not

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receive the requested information within fifteen calendar days of the date of the request, the department shall deny the application. [8.8.3.10 NMAC - Rp, 8.8.3.10 NMAC, 03/31/06; A, 07/31/09] 8.8.3.11 COMPLIANCE EXCEPTIONS: A. An applicant may not begin providing services prior to obtaining a background eligibility unless all of the following requirements are met: (1) the licensee may not be operating under a corrective action plan (childcare), sanctions, or other form of licensing disciplinary serious violations; (2) until receiving background eligibility the applicant shall at all times be under direct physical supervision; this provision does not apply to registered child care home applicants; (3) by the end of the next day after the applicant begins providing services, the applicant shall send the licensing authority a completed application form and fingerprint cards; (4) within fifteen days after the applicant begins providing services, the applicant shall provide the licensing authority with all information necessary for the background check; and (5) no more than 45 days shall have passed since the date of the initial application unless the department documents good cause shown for an extension. B. If a direct provider has a break in employment or transfers employment more than 180 days after the date of an eligibility letter from the licensing authority the direct care provider must re-comply with 8.8.3.10 NMAC. A direct care provider may transfer employment for a period of 180 days after the date of an eligibility letter from the licensing authority without complying with 8.8.3.10 NMAC only if the direct care provider submits a preliminary application that meets the following conditions: (1) the direct provider submits a statement swearing under penalty of perjury that he or she has not been arrested or charged with any crimes, has not been an alleged perpetrator of abuse or neglect and has not been a respondent in a domestic violence petition; (2) the direct care provider submits an application that describes the prior and subsequent places of employment, registration or certification with sufficient detail to allow the licensing authority to determine if further background checks or a new application is necessary; and (3) the licensing authority determines within 15 days that the direct care providers prior background check is sufficient for the employment or position the direct care provider is going to take. [8.8.3.11 NMAC - Rp, 8.8.3.11 NMAC, 03/31/06; A, 04/15/08; A, 07/31/09] 8.8.3.12 PROHIBITIONS: A. Any licensee who violates these regulations is subject to revocation, suspension, sanctions, or denial of licensure, certification, or registration. B. Licensure, certification, or registration is subject to receipt by the licensing authority of a satisfactory background check for the licensee or the licensees administrator.

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C. Except as provided in 8.8.3.13 NMAC below, licensure, certification or registration may not be granted by the licensing authority if a background check of the licensee or the licensees administrator reveals an unreasonable risk. D. A licensee may not retain employment, volunteer service or contract with any direct provider of care for whom a background check reveals an unreasonable risk. The department shall deliver one copy of the notice of unreasonable risk to the facility or program by U.S. mail and to the appropriate licensing staff at the department by facsimile transmission or hand delivery. E. A licensee shall be in violation of these regulations if it retains a direct provider of care for more than ten working days following the mailing of a notice of background check denial for failure to respond by the licensing authority. F. A licensee shall be in violation of these regulations if it retains any direct provider of care inconsistent with Subsection A of 8.8.3.11 NMAC. G. A licensee shall be in violation of these regulations if it hires, contracts with, uses in volunteer service, or retains any direct provider of care for whom information received from any source including the direct provider of care, indicates the provider of care poses an unreasonable risk to the department or to care recipients. H. Any firm, person, corporation, individual or other entity that violates this section shall be subject to appropriate disciplinary action up to and including immediate emergency revocation of license or registration pursuant to the regulations applicable to that entity. [8.8.3.12 NMAC - Rp, 8.8.3.12 NMAC, 03/31/06; A, 07/31/09] 8.8.3.13 ARRESTS, CONVICTIONS AND REFERRALS: A. For the purpose of these regulations, the following information shall result in a conclusion that the applicant is an unreasonable risk: (1) a conviction for a felony or a misdemeanor involving moral turpitude and the criminal conviction directly relates to whether the applicant can provide a safe, responsible and morally positive setting for care recipients; (2) a conviction for a felony or a misdemeanor involving moral turpitude and the criminal conviction does not directly relate to whether the applicant can provide a safe, responsible and morally positive setting for care recipients if the department determines that the applicant so convicted has not been sufficiently rehabilitated; (3) a conviction, regardless of the degree of the crime or the date of the conviction, of trafficking in controlled substances, criminal sexual penetration or related sexual offenses or child abuse; or (4) a substantiated referral, regardless of the date, for sexual abuse or for neglect characterized by a failure to protect against sexual abuse. B. A disqualifying conviction may be proven by: (1) a copy of the judgment of conviction from the court; (2) a copy of a plea agreement filed in court in which a defendant admits guilt; (3) a copy of a report from the federal bureau of investigation, criminal information services division, or the national criminal information center, indicating a conviction;

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(4) a copy of a report from the state of New Mexico, department of public safety, or any other agency of any state or the federal government indicating a conviction; (5) any writing by the applicant indicating that such person has been convicted of the disqualifying offense, provided, however, that if this is the sole basis for denial, the applicant shall be given an opportunity to show that the applicant has successfully completed or is pending completion of a conditional discharge for the disqualifying conviction. C. If a background check shows pending charges for a felony offense, any misdemeanor offense involving domestic violence or child abuse, an arrest but no disposition for any such crime, or a pending referral with the department, there shall be a determination of unreasonable risk. An arrest or criminal charge for any felony offense or for any misdemeanor offense involving domestic violence or child abuse shall result in the immediate suspension of the applicants background check status until such time as the charges are disposed of. It is the duty of the administrator of a facility or the licensee, upon learning of any such arrest or criminal charge, to notify the licensing authority immediately. A suspension of background check status shall have the same effect as a determination of unreasonable risk until the charges are disposed of. If an arrest or criminal charge results in a conviction, the applicant may reapply for background check eligibility and shall be subject to all applicable criminal records check provisions and may be determined to be an unreasonable risk. If an arrest or criminal charge results in an acquittal, conditional discharge, suspension of proceedings based on participation in a pre-prosecution diversion program or dismissal of the charges, or any other disposition that is not a criminal conviction, the applicant may thereafter reapply and be considered for a determination that the applicant is eligible. D. If a background check shows that an applicant is wanted for any offense by any law enforcement agency due to a warrant having been issued, or if the applicant is shown to have failed to appear for any pending criminal court proceeding, there shall be a determination of unreasonable risk. If such information shall be reported to the licensing authority after an initial determination that the applicant is eligible, the applicants background check status shall be suspended until such time as the matter is disposed of. After the matter has been disposed of, the applicant shall be subject to all of the background check provisions set forth in Subsections A, B, and C above. [8.8.3.13 NMAC - Rp, 8.8.3.13 NMAC, 03/31/06; A, 07/31/09] 8.8.3.14 UNREASONABLE RISK: A. The department may, in its discretion, weigh the evidence about an applicant to determine whether the applicant poses an unreasonable risk to the department or care recipients. The department may also consult with legal staff, treatment, assessment or other professionals in the process of determining whether the cumulative weight of credible evidence establishes unreasonable risk. B. In determining whether an applicant poses an unreasonable risk, the department need not limit its reliance on formal convictions or substantiated referrals, but nonetheless must only rely on evidence with indicia of reliability such as: (1) reliable disclosures by the applicant or a victim of abuse or neglect;

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(2) domestic violence orders that allowed an applicant notice and opportunity to be heard and that prohibits or prohibited them from injuring, harassing or contacting another; (3) circumstances indicating the applicant is or has been a victim of domestic violence; (4) child or adult protection investigative evidence that indicates a likelihood that an applicant engaged in inappropriate conduct but there were reasons other than the credibility of the evidence to not substantiate; or (5) any other evidence with similar indicia of reliability. [8.8.3.14 NMAC - N, 03/31/06; A, 07/31/09] 8.8.3.15 REHABILITATION PETITION: Any applicant whom the department concludes is an unreasonable risk on any basis other than those described at Paragraphs (3) or (4) of Subsection A of 8.8.3.13 NMAC, may submit to the department a rehabilitation petition describing with specificity all information that tends to demonstrate that the applicant is not an unreasonable risk. The petition may include, but need not be limited to, a description of what actions the applicant has taken subsequent to any events revealed by the background check to reduce the risk that the same or a similar circumstance will recur. [8.8.3.15 NMAC - N, 03/31/06] 8.8.3.16 APPEAL RIGHTS: A. Any licensee who is denied licensure, certification, or registration or is sanctioned pursuant to these regulations or a previously cleared direct provider of care whose eligibility has been suspended may appeal that decision to the children, youth and families department. If a licensee or a previously cleared direct provider of care alleges facts in good faith that demonstrate a conclusion of unreasonable risk will substantially affect a present vested right such as current employment or other similar currently vested rights the licensee shall be entitled to a hearing. The request for appeal shall be in writing and the party requesting the appeal shall cause the department to receive it within fifteen days of the date of the departments written notice of a determination of unreasonable risk. B. Any direct provider of care who is found ineligible after completion of background check may request an administrative review from the children, youth and families department. The request for an administrative review shall be in writing and the party requesting the appeal shall cause the department to receive it within fifteen days of the date of the departments written notice of a determination of unreasonable risk. C. The administrative review shall be completed by a review of the record by a hearing officer designated by the cabinet secretary. The hearing officers review is limited to: (1) whether the licensing authoritys conclusion of unreasonable risk is supported by any section of these regulations; and (2) whether the applicant has been erroneously identified as a person with a relevant conviction or substantiated referral. The review will be completed on the record presented to the hearing officer and includes the applicants written request for an administrative review and other relevant evidence provided by the applicant. The hearing officer conducts the administrative review and submits a recommendation to the cabinet secretary no later than 60 days after the date the request for administrative review is received unless the department and the applicant agree otherwise. The appeal that is a hearing under this

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section shall be pursuant to the departments administrative hearing regulations at 8.8.4 NMAC. [8.8.3.16 NMAC - Rp, 8.8.3.15 NMAC 03/31/06; A, 07/31/09] HISTORY OF 8.8.3 NMAC: Pre-NMAC History: The material in this part was derived from that previously filed with the State Records Center: HED 85-6 (HSD), Regulations Governing Criminal Records Check and Employment History of Licensees and Staff of Child Care Facilities, 8/30/85. History of Repealed Material: HED 85-6 (HSD), Regulations Governing Criminal Records Check and Employment History of Licensees and Staff of Child Care Facilities, filed - Repealed 7/30/2001. 8.8.3 NMAC, Governing Criminal Records Checks and Employment History Verification, filed 7/30/2001 - Repealed effective 3/29/2002. 8.8.3 NMAC, Governing Criminal Records Checks and Employment History Verification, filed 3/15/2002 - Repealed effective 10/30/03. 8.8.3 NMAC, Governing Background Checks and Employment History Verification, filed 10/16/2003 - Repealed effective 3/31/2006.

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