PCC Residential Programs: Guidelines for Writing An Application for Level of Payment (ALP)

BEFORE YOU BEGIN WRITING AN ALP

Download the CRP-001 (Residential ALP) template from CRP's website. This has three benefits: 1) the form can be saved on your hard drive and the next time you submit an ALP you can update the data on the youth without having to retype everything, 2) typing into the form makes the information more legible to the reader, and 3) an electronic version ensures a backup copy in case the ALP is lost in the mail or not received.
Leave no fields on the form blank. When there is nothing to report, write "NA."
Report only behaviors and interventions that have occurred during the time period specified.
Submit a copy of the ALP to CRP and the worker at the same time.
If an attachment is checked, please make sure to include it with the ALP. Attachments should include (but not be limited to) Treatment Plans, Incident Reports, Psychological or Psychiatric Evaluations, etc. Do not submit Report Cards or Purpose of Medication Sheets. ALPS are limited to 20 pages.
Submit relevant incident reports.
New evaluation reports such as psychological, psychoeducational, neurological, psychiatric evaluations add valuable insight into youth's issues and should be included.
Avoid using or explain any program jargon i.e., "youth had 4 LOP'S (Loss of Privileges) this month".

HELPFUL HINTS FOR PROBLEMATIC ALP SECTIONS
The following are hints for completing sections on the Residential Application for Level for Payment for which there are frequent issues or questions.

Quarter Beginning & Quarter Ending Dates
Write the date that corresponds to the ALP reporting period. If an ALP is due 3/1/2009, your Residential Application for Level of Care Payment should cover a 3 month period prior to this date. Therefore, your Beginning Date would be 12/1/2008 and your Ending date would be 3/1/2009. Providers may submit an ALP up to 30 days prior to the ALP due date.

Section A. PCC Information
Write the name of your agency and the full program name in this field. For example, for the agency Kare for Kids, whose Youth Adventure Program submitted an ALP, the following would be written: Kare for Kids – Youth Adventure Program. Secondly, write the most recent Admission Date to this program.

Section B. Child Information
Identify the child's name (last, first, m.i.), D.O.B. (date of birth), Sex, Race, and Social Security Number.

Section C. DCBS Worker Information
Write the Name of the DCBS worker then indicate whether the DCBS worker is different from the previous worker listed on the last ALP completed, the county of the youth's current DCBS worker, Office Phone, and Fax.

Section D. Attachments
Include information that has not previously been submitted (such as incident reports) and assists in the understanding of a youth's services and issues.

Section E. DCBS Permanency Goal
Indicate the current DCBS Permanency goal. Secondly, identify the Projected Date of Discharge and any changes in the discharge plan in the last 3 months.

Section F. Parent/Guardian Information
If parental rights have been terminated check the "NOT APPLICABLE" box and continue to section G. Write the last name and first name of parent/guardian, Relationship to Child, Phone #, Mailing Address, City, State, Zip Code.

Indicate the amount of involvement this family member has in this youth's treatment.
If the youth's family receives services or treatment, please identify those in this section. If no services, check "NO SERVICES."

Section G. Progress Toward Treatment Goals

Identify goals established by the program as well as the youth and the youth's progress on those goals. The following are examples of how to identify progress toward goals:

Goal #	Goal	Progress
1	Youth will decrease talking back to direct care staff.	Youth has decreased the frequency of talking back to the direct care staff.
2	Youth will utilize self time-out when she becomes defiant to her on-campus teacher and she will process her anger with direct care staff afterwards.	Youth will place herself in time-out on occasion but continues to have difficulty with processing the feelings with direct care staff afterward.

Identify the current phase/level and the highest phase/level youth is capable of attaining.
Indicate whether the youth's behavior during this period has warranted a change in the treatment or level of supervision. If there were changes implemented, please provide details as to what was implemented.

Section H. Critical Incidents
Include specific brief details when identifying a behavior. Dates of incidents are important for clinical reviewers for identifying time lines and frequency of incidents. Utilizing the terms "ongoing" or "as needed" does not provide useful information. Only check "NO INCIDENTS" when none of the behaviors under critical incident have occurred. Please include any significant behaviors which might affect level assignment even if a formal critical incident report is not filed.

If you check "SEE ATTACHED INCIDENT REPORTS", make sure you have attached and referenced those items as they relate to the specific behaviors. The following provides definitions with examples for each of the behaviors under critical incidents. Only include those used for the time period being reported:

Behaviors	General Definition	Brief Description and # of behavior(s) in the past 3 months	Date of incidents
Aggressive (Physical) Acts	ACTS THAT ARE PHYSICALLY HARMING OR THREATENING IN TO A PERSON(S) OR ANIMAL(S)	(Name of youth) took a hammer and hit another resident in the arm. (1 time) (Name of youth) tried to stab the fish in the program's aquarium three times.	4-5-2008 3-5-2008, 6-15-2008 & 7-2-2008
Aggressive (Verbal) Acts	ACTS THAT INVOLVE VERBAL THREATS OR VERBAL ASSAULTS (E.G., CURSING, SWEARING, INSULTING, ETC.)	(Name of youth) called staff a S.O.B. and then threatened to cut his tires when he was not looking.	4-8-2008
Bizarre or Unusual Behaviors	BEHAVIORS THAT ARE ATYPICAL OR UNUSUAL IN NATURE. HALLUCINATIONS, ODD COMMENTS, DELUSIONS, EATING NON-FOOD ITEMS ARE EXAMPLES.	(Name of youth) licked all the door knobs of the home and said s/he wanted to marry the door knobs in the fall.	5-8-2008
Destroying Property (Implies Damage)	THREATS, GESTURES, OR ATTEMPTS TO BREAK, DAMAGE, OR SABOTAGE PERSONAL OR ANOTHER PERSON'S PROPERTY.	(Name of youth) broke the laptop computer by throwing it across the room during a tantrum.	6-1-2008
Homicidal Behavior, Threats, or Ideation	THREATS, GESTURES, IDEATION OR ATTEMPTS TO KILL OR PLACE ANOTHER PERSON'S LIFE IN JEOPARDY.	(Name of youth) grabbed a screwdriver and threatened to kill another resident if he came near his Nintendo DS again. (1 time)	5-6-2008
Impulsivity – Dangerous	ACTS THAT PLACE THE YOUTH OR OTHERS AT RISK OF BEING HARMED DUE TO THE LACK OF THINKING BEFORE ACTING	(Name of Youth) ran out in heavy traffic to cross the road. (Name of Youth) stuck a fork in the electrical outlet to see if he could melt the fork.	5-3-2008 6-1-2008
Runaway/AWOL	THREATS, ATTEMPTS OR SUCCESSFUL AWOLS/RUNS --- DOES NOT INCLUDE BEING OUT OF THE AREA OR UNACCOUNTED FOR BRIEF PERIODS.	(Name of Youth) threatened to AWOL from the program after receiving consequences. (Name of Youth) ran from staff at Wal-Mart. He was later found on 6-10-2008 hiding at one of his best friend's home 240 miles from our program.	6-5-2008 6-8-2008 to 6-10-2008
Self-Abusive/Self-Mutilating Behavior	THREATS, GESTURES, IDEATION OR ATTEMPTS TO HARM SELF THAT MAY INCLUDE CUTTING, PAIN INFLICTION, PICKING SCABS TILL THEY BLEED, HITTING, HEAD BANGING, ETC.	(Name of Youth) took a paper clip and scratched his arm till it bled and then wiped the blood on his pillow.	7-4-2008
Sexual Acting Act	PROMISCUOUS/SEDUCTIVE BEHAVIORS, SEXUAL INTERACTIONS WITH OTHERS, PUBLIC OR COMPULSIVE MASTURBATION, SEXUAL COMMENTS, ETC.	(Name of Youth) made sexual comments about staff's breast and having sex with older men while on the field trip to the zoo. (Name of Youth) went to the bathroom with another male peer and they were caught touching each other's private parts.	6-3-2008 4-8-2008
Sexual Perpetrator	ATTEMPTS OR SUCCESSFULLY ENGAGING IN A SEXUAL ACT WITH A PERSON OR PERSONS UNABLE TO GIVE CONSENT EITHER BY FORCIBLE COMPULSION, COERCION, MENTAL ABILITY, OR OF SUFFICIENT AGE DIFFERENCE.	(Name of Youth) who is 16 years old was found attempting to coerce a female peer into having sexual intercourse.	5-6-2008
Suicidal Behavior (specify attempt, threat, etc.)	THREATS, GESTURES, IDEATION OR ATTEMPTS TO KILL SELF. THIS MAY OR MAY NOT INCLUDE A PLAN.	(Name of Youth) made a threat to overdose on their medication at their next home visit.	6-4-2008
Substance Use (Do not include tobacco use)	THREATS, GESTURES, OR ATTEMPTS USE OF A SUBSTANCE	(Name of Youth) talked about smoking pot with his high school friends. (Name of Youth) was caught with some prescription pills (unknown) and a joint of marijuana.	4-8-2008 5-6-2008
Other	MAY ENTAIL BEHAVIORS NOT DEFINED IN ABOVE BEHAVIOR CATEGORIES.	(Name of Youth) tried to intimidate a peer by standing close and telling him he is a mama's boy. (Name of Youth) tried to manipulate the program rules to get out of doing chores. (Name of Youth) exhibited disrespectful body language.	5-9-2008 6-5-2008 6-8-2008

When reporting behaviors and interventions, the reporter should ensure that descriptions are consistent and provide clear details to the reader. If you were a person outside of your agency, would you understand the information?

Section I. Methods of Interventions
The following provides examples with definitions for each of the methods. Only include those used for the time period being reported:

Method	General Definition	Frequency	Has the use of these methods become more frequent?
Use of Time-Out	Youth is given a time-out by self, staff or foster parent.	8	Yes. The youth only had 4 time outs last ALP reporting period.
Physical Management/Restraint	Youth is physically restrained or managed due to an out-of-control behavior.	3	No. This is what the youth averages per ALP reporting period.
Calling Outside Assistant	Staff/Caregivers contacted additional assistance to manage or address youth's behaviors.	10	Yes. Youth's behavior has escalated since admission requiring foster parents to rely on staff's after hour's assistance.
Other	This encompasses methods not utilized above. This may include seclusion, loss of privileges, groundings, loss of allowance, etc.	2	No. Youth averages two privilege losses per reporting period.

Section J. Social Skills
Identify the youth's strengths and areas in need of improvement as it relates to social interactions with adults and peers; level of supervision needed in public; daily living skills (e.g., personal hygiene care, ability to complete chores, etc.), employment and extracurricular endeavors. This section should correspond with the MEDICAID REHABILIATIVE SERVICES living skills development goals when applicable. For example:

How well does the child interact with peers and staff on campus? Ken is capable of meaningful relationships with peers and adults. He is sensitive to the needs of others and shares his feelings and concerns for their well-being.
How well does the child interact in a public setting away from the program (e.g., furloughs, home visits, etc.)? In public, Ken must be accompanied by a staff due to problems wondering off without informing staff of his location. Ken may also steal items from stores if not watched closely. Home visits are 4 hours every 2 weeks and are supervised by staff and the DCBS social worker.
How well does the child take care of personal hygiene needs and what type of staff intervention is required, if any? Ken has an acne issue and needs to be reminded to use his prescription medications to treat this condition, but otherwise can shave, clean, and dress appropriately without assistance. He is capable of cooking his own meals with limited supervision and understands how to plan meals.
If the child is employed at the program, how well does the child complete tasks and how much staff time is required? Youth works at a local Humane Society once a week for 3 hours. He walks and waters the dogs. He seems to enjoy this and needs little or no assistance with this job. However, staff must remain with him at the Humane society due to his tendencies to wonder off.

Section K. Education

Identify the type of educational status of youth.
Indicate the school type
Write the youth's current grade
Identify the staff and child ratio in the classroom
Indicate the number of staff interventions at the school
Identify the behavior problems at school during this reporting period and what interventions were necessary
Summarize progress and lack of progress in academics

Section L. Medical
Identify any medical condition that requires ongoing treatment or that was a result of a serious injury. What agency time and resources did this entail?

Section M. Medications
List the name of the prescribed medications, dosage, and purpose. If additional space is needed, please list other medications underneath section.

Section N. DSM-IV Diagnosis
List current DSM-IV diagnoses for Axis I and Axis II.

Section O. Mental Health Therapy/Substance Abuse Treatment
Record the frequency of each modality of treatment utilized for the time period the ALP covers.

Identify whether the child is receiving sexually reactive treatment or sexual offender treatment, when applicable.
Do not count the same treatment sessions twice by identifying it under more than one treatment modality

Section P. Visitation
Only include visits child has with state worker, relatives, friends, etc.

Section Q. Additional Information/Comments
Address any additional services or needs not addressed in the ALP form or attach an additional sheet referencing this section.

Section R. Signature of PCC Representative
The PCC representative completing the ALP should sign and print his/her name for legibility.

REMEMBER: Total Packet is limited to 20 pages.