Audit of Good Shepherd Services’ Compliance with Its Close to Home Contract with the Administration for Children’s Services
June 27, 2017 | MD17-066A
The objective of this audit was to determine whether Good Shepherd Services (GSS) is in compliance with the key terms of its “Close to Home” contract with the Administration for Children’s Services (ACS).
The Close to Home Program (CTH), started in 2012, is administered by ACS. It is intended to allow youths who are deemed juvenile delinquents by the Family Court to be placed in residential programs close to their families and communities. ACS contracts with non-profit providers to operate CTH Non-Secure Placement (NSP) group homes in or right outside of the five boroughs. Youths in the NSP program receive individualized educational services through the New York City Department of Education. They also receive medical, mental health and substance abuse services as needed, and participate in recreational, cultural and group activities within and outside of the group home.
ACS contracted with GSS to provide CTH NSP services to youths referred by ACS for July 1, 2012, through June 30, 2015. The contract with GSS was renewed for July 1, 2015, through June 30, 2018, with options to renew at the discretion of ACS through June 30, 2021. GSS currently operates two NSP residential facilities: the Barbara Blum residence (Barbara Blum) for boys, and Rose House for girls, both located in Brooklyn.
Audit Findings and Conclusion
The audit determined that GSS is not in compliance with some of the key terms of its contract with ACS. Among other things, we found limited evidence that GSS performed required assessments and provided certain services to the youths in our audit sample or that they provided them timely. Specifically, we found that: (1) behavior plans were not consistently prepared; (2) mental health assessments were not consistently obtained or conducted; (3) educational assessments were not performed timely; (4) monthly team treatment meetings were not consistently conducted; and (5) there was limited evidence that required appropriate recreation was provided to the youths in residence.
We also identified deficiencies in GSS’ reporting and recording of “reportable” and “critical” incidents. GSS did not consistently record incidents in the required three sets of records: (1) the Connection (CNNX) progress notes; (2) a hard-copy incident report; and (3) the communication log maintained at the NSP facility. Further, the hard-copy incident reports that GSS did complete were not consistently signed by supervisors and GSS’ communication logs were not consistently maintained in good order. The audit also found that GSS incorrectly billed ACS (both over and under the proper amounts) for care days for 3 of the 10 sampled youth.
Based on the audit, we make 15 recommendations, including:
- GSS should ensure that behavior plans are prepared for all youths.
- GSS should ensure that it obtains or performs mental health screenings for all youth in its care.
- GSS should ensure that educational assessments are performed timely.
- GSS should ensure that team treatment meetings are held monthly for all youths and that the minutes are maintained at all times in the youth’s case records.
- GSS should ensure that recreational schedules are posted in the residences and communication logbooks document recreational activities that take place.
- GSS should ensure that all incidents are properly reported to ACS; recorded in CNNX and the communication logbooks, including MCCU incident report numbers; and properly documented in hard-copy incident reports, signed by supervisors and maintained in the appropriate bound incident logs.
- GSS should ensure that communication logbooks are maintained in accordance with ACS policies.
- GSS should ensure that Change of Status forms are completed and submitted in all instances of youth movement from the youth’s assigned NSP facility so that care days are correctly billed and that care days and payments are adequately reconciled to ensure accurate payments.
In its response, GSS generally agreed with ten of the 15 recommendations addressed to GSS, disagreed with one recommendation, and did not specifically address four recommendations. In its response, ACS disagreed with the one recommendation addressed to ACS.
 A “reportable incident” is any event that might adversely affect the health, safet
y, and/or security of (1) youths in ACS physical or legal custody; (2) staff; (3) family; and/or (4) the community. A “Critical incident” is a reportable incident that is likely to have a serious impact that adversely affects the health, safety, and/or security of (1) youth; (2) staff; (3) family; and/or (4) the community (e.g., birth and death), or has a significant impact on a facility or the agency. Source: ACS’ Incident Reporting for Juvenile Justice Placement policy.