ࡱ> %` 'bjbj"x"x ~@@X1<````QQQTpQ0,LpQX]J  Xt[[[[[[[$_hJbh\Q!$ "F !!\``]...!^`4Q[.![..KH<6QcLx PF!^JJO (]0X]AK"bA"( bcLbQcLH.v\\i.^X]!!!!pQpQpQĄ4dpQpQpQ4pQpQpQ`````` QUARTERLY CONTRACT MONITORING REPORT (QCMR) CLIENT MOVEMENT REPORT DMHS LICENSED BEDS - RESIDENTIAL SERVICES USTF PROJECT CODE:  FORMTEXT       REPORTING QUARTER: (CHECK ONE):NAME OF AGENCY:  FORMTEXT      JULY 1 TO SEPTEMBER 301  FORMTEXT       NAME OF PROGRAM:  FORMTEXT      OCTOBER 1 TO DECEMBER 312  FORMTEXT       PERSON COMPLETING FORM/PHONE #:  FORMTEXT      JANUARY 1 TO MARCH 313  FORMTEXT       DATE SUBMITTED:  FORMTEXT       APRIL 1 TO JUNE 304  FORMTEXT      CHECK AGENCY REPORTING QUARTER:1  FORMTEXT       2  FORMTEXT       3  FORMTEXT       4  FORMTEXT        1.  FORMTEXT      2.  FORMTEXT      3.  FORMTEXT      4.  FORMTEXT      5.  FORMTEXT       6.  FORMTEXT       Beginning Active Caseload (First Day of Qtr.)New Enrollees to Program Element During Qtr.Transfers to Program Element During QtrTransfers From Program Element During QtrTerminations From Program Element During Qtr.Ending Active Caseload (Last Day of Qtr.) TARGET GROUPS7. Number of Target Group Members:NEW ENROLLEESTRANSFERS7A.Clients who were Discharged from State Hospitals and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT      7B.Clients who were Discharged from County Hospitals and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT      7C.Clients who were Discharged from a Short-Term Care Facility/Involuntary Psychiatric Unit and Enrolled in this Program within 30 Days of Discharge.  FORMTEXT       FORMTEXT      7D.Clients who were Discharged from another Hospital and Enrolled in this Program Within 30 Days of Discharge. FORMTEXT       FORMTEXT      8.Of the Ending Caseload how many individuals are: A. Medicaid/Familycare Enrolled (8A. + 8B. must equal ending caseload)  FORMTEXT        B. Medicaid/Familycare Non-Enrolled  FORMTEXT       CLIENT MOVEMENT REPORT BEGINNING ACTIVE CASELOAD: Consist of clients who have had at least one face-to-face contact with your agency in the last 90 days and were active on the last of the previous quarter. The Beginning Caseload is equal to the Ending Caseload of the previous reporting quarter. NEW ENROLLEES: Clients who were newly enrolled in your agency during the reporting quarter and were enrolled in this program element prior to enrollment in any other program element within your agency. TRANSFERS TO: Refers to clients who are already registered within your agency in another program element, and are being transferred to this program element service. TRANSFERS FROM: Refers to clients who are registered within your agency in this program element, but for whom this program has ceased to provide services on an ongoing basis and for whom another program element of your agency is going to provide services on an ongoing basis. TERMINATIONS: Clients who are no longer receiving services at your agency. ENDING ACTIVE CASELOAD: Is the active caseload on the last day of the reporting quarter. It is calculated in the following manner: Add #1 (Beginning Active Caseload) + #2 (New Enrollees) + #3 (Transfers To). Subtract #4 (Transfers From) and #5 (Terminations) = Ending Caseload #6. DUPLICATED COUNT OF TARGET GROUP MEMBERS AMONG NEW ENROLLEES AND TRANSFERS TO: Refers to the count of clients who entered this program element within 30 days of their discharge from the hospital. The definitions of New Enrollees and Transfers To are the same as stated above. Therefore, the number of New Enrollees or Transfers To indicated in categories 7A, 7B, 7C, and 7D, should be the same or less than the number indicated in items #2 and #3 of this form. 7A. STATE HOSPITAL: Refers to the states five psychiatric hospitals located in New Jersey only: Greystone Park, Trenton, Ancora, Hagedorn, and Ann Klein. 7B. COUNTY HOSPITALS: Refers to the six county hospitals located in New Jersey only: Essex, Burlington, Camden, Hudson, Bergen, and Union. 7C. SHORT-TERM CARE FACILITIES: Refers to inpatient, community-base mental health treatment facilities that provide acute care and assessment services to the mentally ill. The Commissioner, Department of Human Services must designate the facility. 7D. OTHER HOSPITAL: Refers to any psychiatric hospital or psychiatric unit within a hospital that is not a State, County or STCF Hospital in New Jersey; include as Other any Facility located outside of New Jersey. QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT DMHS LICENSED BEDS - RESIDENTIAL SERVICES USTF PROJECT CODE:  REF Text1   REPORTING QUARTER: (CHECK ONE)NAME OF AGENCY:  REF Text2  JULY 1 TO SEPTEMBER 30 1  REF Text6   NAME OF PROGRAM:  REF Text3  OCTOBER 1 TO DECEMBER 312  REF Text7   PERSON COMPLETING FORM/PHONE #:  REF Text4  JANUARY 1 TO MARCH 313  REF Text8   DATE SUBMITTED:  REF Text5   APRIL 1 TO JUNE 304  REF Text9  CHECK AGENCY REPORTING QUARTER: 1  REF Text10   2  REF Text11   3  REF Text12   4 REF Text13   Insert Spcialized Program (see chart below)Supervised A+Supervised ASupervised BSupervised CFamily Care E = MICA; G = Crisis;  I = Deaf/Blind; J = Gero-Psych; K = DD FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      AptGHAptGHAptGHAptGHAptGH1. Capacity at Beginning of Qtr FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      2. Housing Units Beg. Of Qtr FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      3. Occupancy/Caseload at Beginning of Quarter FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      4. Clients Newly Enrolled/Transf. in During Quarter FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      5. Clients Terminated/Transf. out During Quarter FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      6. Occupancy/Caseload at End of Qtr. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      7. Housing Units End of Qtr. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      8. Capacity at End of Qtr. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      9. Actual Occupied Bed Days FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      10. Vacant bed days during bed hold period FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      11. Vacant bed days beyond bed hold period FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      12. All other vacant days FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      13. Individual Units of Service FORMTEXT       FORMTEXT       FORMTEXT      14. Group Units of Service FORMTEXT       FORMTEXT       FORMTEXT       DMHS LICENSED  RESIDENTIAL SERVICES  FOR ALL LEVEL GROUP HOMES AND APARTMENTS: Residential Care Days (Items 9-12 above): 1. Actual occupied bed days = where consumer was physically in the program for all or part of the day; Bed days relating to days the bed was held vacant during the 30 day bed hold period; Bed days relating to days the bed was held vacant beyond the 30 day bed hold period; All other vacant bed days. 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hs85CJhs8mHnHuhs85CJOJQJaJhD@OJQJhs8OJQJmHnHu'h`yhCJOJQJaJmHnHuhah=mHnHu+hh=CJOJQJ^JaJmHnHu7j *hahaCJOJQJU^JaJmHnHu=j *hahA CJOJQJU^JaJmHnHu??kdq$$Ifl4ִ xM$ #x)sRSRR t0    44 laytax??@@@@@@@@ @ @ @ @6@7@a@b@@AsAA $ & F]a$ $h]^ha$$]a$ $ ] ^a$ ! $ a$gdDgdDAAAABD  r t       F v  gdDgdD$a$gdD !$]a$AAAAADr*t 4 r          F v      ӿ廮yl`h2CJOJQJaJhs85CJOJQJaJ hs8CJhDhs8@CJOJQJhDhD6CJOJQJaJhD56CJOJQJaJhs8OJQJmHnHuhs8h h OJQJh 5OJQJh OJQJh8UOJQJUhs8OJQJhs85OJQJh8U5OJQJ"with one consumer for 15 continuous minutes. If a contact exceeds more than 15 continuous minutes, count as multiple contacts. If two staff members simultaneously serve one client, count as one staff contact. Travel time to and from contact is to be excluded from overall contact time. Group Units of Service: face to face contact where one staff member serves between two and six clients simultaneously for 15 continuous minutes, count as one group contact per client (group contacts of seven or more clients by one staff member are not reportable). Travel time to and from contact is to be excluded from overall contact time. SUPERVISED RESIDENCE A+: Refers to housing with on-site staff coverage 24 hours per day, seven days per week. SUPERVISED RESIDENCE A: Refers to housing with on-site staff coverage of less than 24 hours per day, but at least 12 hours per day of on-site coverage, Monday through Friday and at least 12 hours on-site coverage on weekends and holidays. SUPERVISED RESIDENCE B: Refers to housing with on-site supervision by program staff at least 4 hours, but less than twelve hours a day within each 24 hour period. SUPERVISED RESIDENCE C: Refers to housing with on-site staff coverage at a minimum of one hour per week. Typically, staff is on-site providing services three to four hours per week. FAMILY CARE: Refers to private home or apartment in which an individual resides and provides services to as many as five clients who also reside in the home. SPECIALIZED PROGRAMS: If a program is designed for one of the specialized services listed, enter the appropriate code in row G; otherwise, leave blank. QUARTERLY CONTRACT MONITORING REPORT (QCMR) LEVEL OF SERVICE REPORT DMHS LICENSED BEDS - RESIDENTIAL SERVICES USTF PROJECT CODE:  REF Text1   REPORTING QUARTER: (CHECK ONE)NAME OF AGENCY:  REF Text2  JULY 1 TO SEPTEMBER 30 1  REF Text6   NAME OF PROGRAM:  REF Text3  OCTOBER 1 TO DECEMBER 312  REF Text7   PERSON COMPLETING FORM/PHONE #:  REF Text4  JANUARY 1 TO MARCH 313  REF Text8   DATE SUBMITTED:  REF Text5  APRIL 1 TO JUNE 304  REF Text9  CHECK AGENCY REPORTING QUARTER: 1  REF Text10   2  REF Text11   3  REF Text12   4  REF Text13    15. Number of Clients Transferred within the Residential Program: A. Who moved to less Supervised Housing  FORMTEXT       B. Who moved to more Supervised Housing  FORMTEXT       16. Number of Clients who Graduated and were Placed in Non-Contract Housing:  FORMTEXT       17. Total Units of Service Provided: Individual  FORMTEXT       Group  FORMTEXT       18. Of the Individual Units of Service Provided (for B Apt. and C Apt./GH ONLY) how many are: A. Medicaid/Familycare Enrolled  FORMTEXT       B. Medicaid/Familycare Non-Enrolled  FORMTEXT       (18A. + 18B. must equal total individual units of service for B Apt. and C Apt./GH) 19. Of the Group Units Of Service Provided (for B Apt. and C Apt./GH ONLY) how many are: A. Medicaid/Familycare Enrolled  FORMTEXT       B. Medicaid/Familycare Non-Enrolled  FORMTEXT       (19A. + 19B. must equal total group units of service for B Apt. and C Apt./GH)     7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Division of Mental Health Services, PO Box 727, Trenton, NJ 08625-0727 7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Page 2 of 3 Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Page 1 of 3 Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 7/07 Submit Forms 30 days after the close of a Quarter to the QCMR Coordinator at the following address: Page 3 of 3 Division of Mental Health Services, PO Box 727, Trenton, NJ. 08625-0727 DMHS-licensed supervised residential options offering on-site staff support and assistance with activities of daily living according to clients needs. Housing opportunities include supervised apartments, group homes, and family care homes. 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RiesserRoseann A Moran"                           ! Oh+'0 ,8 X d p |Gayle G. Riesser QCMR Residential Services FormRoseann A Moran27Microsoft Office Word@F #@\j@6Y@rF])՜.+,0 hp  Dept. of Human ServicesY?1'  Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry FPFData Q1TableFcWordDocument~SummaryInformation(DocumentSummaryInformation8CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q