Texans Together – Support Survey
This is an opportunity for us to learn more about your organization and explore how we can build a strong, supportive partnership that meets the needs of children and families in our community.
ORGANIZATIONAL INFORMATION
Agency Name:
*
Is your agency name different than your Licensed Entity Name?
*
Yes
No
Licensed Entity Name (if different):
*
Mailing Address
*
Street Address
Street Address Line 2
City
County
Postal / Zip Code
Primary Contact Name
*
First Name
Last Name
Primary Contact Title:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Back
Next
Save
PROGRAM TYPE
Which services is your facility licensed to provide? (select yes for all that apply)
Child Placing Agency (CPA)
*
Yes
No
Child Placing Agency (CPA) - Adoption Only
*
Yes
No
General Residential Operation (GRO)
*
Yes
No
GRO operating as a Emergency Shelter
*
Yes
No
GRO operating as a Residential Treatment Center (RTC)
*
Yes
No
Supervised Independent Living (SIL)
*
Yes
No
Back
Next
Save
SAFETY, QUALITY, & RISK ASSESSMENT
Child Placing Agency (CPA)
CPA: Have you had any licensing actions, suspensions, or contract issues in the past 3 years?
*
Yes
No
N/A
CPA: Please explain:
CPA: How many corrective action plans did you receive in your most recent cycle?
*
CPA: How many improvement plans did you receive in your most recent cycle?
*
CPA: Do you have policies & procedures for runaway prevention?
*
Yes
No
CPA: Do you have policies & procedures for critical incident response?
*
Yes
No
CPA: Do you have policies & procedures for staff screening?
*
Yes
No
CPA: Do you have a written plan for the extended absence of key staff?
*
Yes
No
CPA: Do you maintain a written CQI plan?
*
Yes
No
CPA: Do you conduct internal record reviews?
*
Yes
No
CPA: Do you have a formal client satisfaction program?
*
Yes
No
SAFETY, QUALITY, & RISK ASSESSMENT
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Have you had any licensing actions, suspensions, or contract issues in the past 3 years?
*
Yes
No
N/A
GRO: Please explain:
GRO: How many corrective action plans did you receive in your most recent cycle?
*
GRO: How many improvement plans did you receive in your most recent cycle?
*
GRO: Do you have policies & procedures for runaway prevention?
*
Yes
No
GRO: Do you have policies & procedures for critical incident response?
*
Yes
No
GRO: Do you have policies & procedures for staff screening?
*
Yes
No
GRO: Do you have a written plan for the extended absence of key staff?
*
Yes
No
GRO: Do you maintain a written CQI plan?
*
Yes
No
GRO: Do you conduct internal record reviews?
*
Yes
No
GRO: Do you have a formal client satisfaction program?
*
Yes
No
SAFETY, QUALITY, & RISK ASSESSMENT
Supervised Independent Living (SIL)
SIL: Have you had any contract issues in the past 3 years?
*
Yes
No
N/A
SIL: Please explain:
SIL: How many corrective action plans did you receive in your most recent cycle?
*
SIL: How many improvement plans did you receive in your most recent cycle?
*
SIL: Do you have policies & procedures for critical incident response?
*
Yes
No
SIL: Do you have policies & procedures for staff screening?
*
Yes
No
SIL: Do you have a written plan for the extended absence of key staff?
*
Yes
No
SIL: Do you maintain a written CQI plan?
*
Yes
No
SIL: Do you conduct internal record reviews?
*
Yes
No
SIL: Do you have a formal client satisfaction program?
*
Yes
No
Back
Next
Save
ACCREDITATION
Child Placing Agency (CPA)
CPA: Are you currently accredited with the Council on Accreditation (COA)?
*
Yes
No
CPA: Are you currently accredited with CARF International?
*
Yes
No
CPA: Are you currently accredited with the Joint Commission?
*
Yes
No
CPA: Do you plan on becoming accredited?
*
Yes
No
CPA: If yes, what are your plans?
CPA: If no, what are your barriers?
CPA: Date of last accreditation survey:
-
Month
-
Day
Year
Date
CPA: Date of next accreditation review/renewal:
-
Month
-
Day
Year
Date
ACCREDITATION
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Are you currently accredited with the Council on Accreditation (COA)?
*
Yes
No
GRO: Are you currently accredited with CARF International?
*
Yes
No
GRO: Are you currently accredited with the Joint Commission?
*
Yes
No
GRO: Do you plan on becoming accredited?
*
Yes
No
GRO: If yes, what are your plans?
GRO: If no, what are your barriers?
GRO: Date of last accreditation survey:
-
Month
-
Day
Year
Date
GRO: Date of next accreditation review/renewal:
-
Month
-
Day
Year
Date
Back
Next
Save
ADMINISTRATIVE INFRASTRUCTURE & RISK MITIGATION
Information Technology (EHR, Data Security)
CPA: Does your agency use a Case Management System (Electronic Health Record)?
*
Yes
No
GRO: Does your agency use a Case Management System (Electronic Health Record)?
*
Yes
No
SIL: Does your agency use a Case Management System (Electronic Health Record)?
*
Yes
No
Please specify vendor/system:
Do you have formal policies for data privacy and security (HIPAA compliance)?
*
Yes
No
Do you have formal policies for cybersecurity protocols (e.g., staff training, incident response plan)?
*
Yes
No
Has your agency experienced any data breaches in the past 3 years?
*
Yes
No
Please describe actions taken:
Are IT audits performed?
*
Yes
No
Date of last IT audit:
-
Month
-
Day
Year
Date
Accounting & Financial Practices
Does your agency utilize an Automated Accounting system?
*
Yes
No
Please specify system:
Are annual financial audits conducted by an external CPA firm?
*
Yes
No
Date of last financial audit:
-
Month
-
Day
Year
Date
Were there any significant findings in your most recent audit?
*
Yes
No
Please briefly describe any findings and resolution steps:
What was the actual annual revenue amount for your prior fiscal year?
*
What is the budgeted revenue amount for your current fiscal year?
*
Back
Next
Save
Human Resources & Staffing
Does your agency conduct pre-employment criminal background checks for direct care staff?
*
Yes
No
Does your agency conduct pre-employment FBI finger printing for direct care staff?
*
Yes
No
Does your agency conduct pre-employment child abuse/neglect registry checks for direct care staff?
*
Yes
No
Does your agency conduct pre-employment reference checks for direct care staff?
*
Yes
No
Does your agency conduct pre-employment education/credential verifications for direct care staff?
*
Yes
No
Does your agency conduct pre-employment drug screenings for direct care staff?
*
Yes
No
Does your agency conduct pre-employment National Sex Offender Registry checks for direct care staff?
*
Yes
No
Does your agency conduct annual criminal background re-checks for direct care staff?
*
Yes
No
Does your agency conduct periodic child abuse/neglect registry re-checks for direct care staff?
*
Yes
No
Does your agency conduct on going credential/license verifications for direct care staff?
*
Yes
No
Does your agency conduct regular training compliance checks for direct care staff?
*
Yes
No
Does your agency provide ongoing trauma-informed care training for all staff?
*
Yes
No
Does your agency provide ongoing cultural competency training for all staff?
*
Yes
No
Does your agency provide ongoing behavioral health/crisis intervention training for all staff?
*
Yes
No
Does your agency provide ongoing medical/medication administration training for all staff?
*
Yes
No
Does your agency provide ongoing emergency behavior intervention training for all staff?
*
Yes
No
Does your agency conduct ongoing updates/refresher trainings?
*
Yes
No
CPA: Current turnover rate (approximate %)
*
Please enter a number from 0 to 100. This will be recorded as a percent.
GRO: Current turnover rate (approximate %)
*
Please enter a number from 0 to 100. This will be recorded as a percent.
SIL: Current turnover rate (approximate %)
*
Please enter a number from 0 to 100. This will be recorded as a percent.
Do you conduct random drug tests or drug testing based on reasonable suspicion?
*
Yes
No
Do you conduct drug test post accident/injury?
*
Yes
No
Back
Next
Save
Insurance & Risk Mitigation
Child Placing Agency (CPA)
CPA: Does your agency maintain General Liability insurance?
*
Yes
No
CPA: Does your agency maintain Professional Liability insurance?
*
Yes
No
CPA: Does your agency maintain Worker's Compensation insurance?
*
Yes
No
CPA: Does your agency maintain Cyber Liability insurance?
*
Yes
No
CPA: Does your agency maintain Property insurance?
*
Yes
No
CPA: Has your agency had any claims filed against these policies in the past 3 years?
*
Yes
No
CPA: If yes, please briefly describe:
CPA: Do you maintain a formal risk management or mitigation plan?
*
Yes
No
Insurance & Risk Mitigation
General Residential Operation (GRO): including GRO operating as a Emergency Shelter (ES) and GRO operating as a Residential Treatment Center (RTC)
GRO: Does your agency maintain General Liability insurance?
*
Yes
No
GRO: Does your agency maintain Professional Liability insurance?
*
Yes
No
GRO: Does your agency maintain Worker's Compensation insurance?
*
Yes
No
GRO: Does your agency maintain Cyber Liability insurance?
*
Yes
No
GRO: Does your agency maintain Property insurance?
*
Yes
No
GRO: Has your agency had any claims filed against these policies in the past 3 years?
*
Yes
No
GRO: If yes, please briefly describe:
GRO: Do you maintain a formal risk management or mitigation plan?
*
Yes
No
Insurance & Risk Mitigation
Supervised Independent Living (SIL)
SIL: Does your agency maintain General Liability insurance?
*
Yes
No
SIL: Does your agency maintain Professional Liability insurance?
*
Yes
No
SIL: Does your agency maintain Worker's compensation insurance?
*
Yes
No
SIL: Does your agency maintain Cyber Liability insurance?
*
Yes
No
SIL: Does your agency maintain Property insurance?
*
Yes
No
SIL: Has your agency had any claims filed against these policies in the past 3 years?
*
Yes
No
SIL: If yes, please briefly describe:
SIL: Do you maintain a formal risk management or mitigation plan?
*
Yes
No
Back
Next
Save
Are you the Signature Authority?
*
Yes
No
Name of Signature Authority:
*
First Name
Last Name
Title of Signature Authority:
*
Your Name:
*
First Name
Last Name
Your Title:
*
Signature:
*
Date:
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: