Form PAIMI Report PAIMI Report PAIMI Reprot

OMB Approval: 0930-0169

Expiration Date: XX- XX- XXXX

The PROTECTION & ADVOCACY for INDIVIDUALS with MENTAL ILLNESS (PAIMI) PROGRAM - ANNUAL PROGRAM PERFORMANCE REPORT (PPR)
STATE		FISCAL YEAR 20__
The annual PAIMI Program Performance Report (PPR) is due by January 1st [PAIMI Rules at 42 CFR 51.8 and the PAIMI Act at 42 U.S.C. 10805(a) (7)]. The PPR contains information from the state P&A systems on its management and PAIMI Program activities during the preceding fiscal year (FY). The PPR includes the Advisory Council Report (ACR). The ACR is an independent assessment of the state P&A system’s operation of the PAIMI Program. The report is prepared by the PAIMI Advisory Council (PAC) in each P&A system and signed by the PAC Chairperson.
The annual PPR, including the ACR section, must be submitted electronically via the PAIMI Electronic Reporting System (PERS). The PAC Chairperson’s signature page must be uploaded as an attachment into the PERS.
PAIMI Electronic Reporting System (PERS): http://ppr.paimippr.com/
For PPR or ACR assistance on program issues, please contact the PAIMI Program Coordinator: Karen S. Armstrong, MSSW, JD Karen.Armstrong@samhsa.hhs.gov or 1 (240) 276 -1741	For PPR or ACR assistance with budget or financial issues, please contact the : SAMHSA Grants Management Officer: Virginia Simmons Virginia.Simmons@samhsa.hhs.gov or 1 (240) 276 – 1420.
Please read and follow the instructions in each section and use the attached glossary in to complete the form. Public reporting burden for this section of the annual PAIMI PPR is estimated to average 26 hours per response. This includes the time needed to review the instructions, to search existing data sources, to gather the data needed, and to complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to SAMHSA Reports Clearance Officer; Paperwork Reduction Project (0930-0169); CBHSQ, Room 2-1057; 1 Choke Cherry Rd.; Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0169).

ANNUAL PAIMI PROGRAM PERFORMANCE REPORT (PPR)
TABLE of CONTENTS
SECTION		PAGE
1	GENERAL PAIMI PROGRAM INFORMATION
2	PAIMI PROGRAM PRIORITIES (GOALS) & OBJECTIVES
3	INDIVIDUAL PAIMI-ELIGIBLE CLIENTS
4	CASE COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
5	INTERVENTIONS ON BEHALF OF GROUPS of PAIMI-ELIGIBLE INDIVIDUALS
6	NON-CLIENT DIRECTED ADVOCACY ACTIVITIES
7	GRIEVANCE PROCEDURES
8	OTHER SERVICES & ACTIVITIES
9	ACTUAL PAIMI BUDGET/EXPENDITURES
GLOSSARY

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1.A. Fiscal Year:	20XX
State:
Name of P&A system:
Mailing Address & Phone Number of Main Office:
Mailing Address & Phone Numbers of for each Satellite Office:
Name of PAIMI Program, if different from the state P&A agency:
Name, phone number, and e-mail address of the PAIMI Coordinator:
PPR Prepared by: Name: Title: Area Code & Phone Number: E-mail Address:
The name of the Director of the State mental health agency to whom copies of the PAIMI PPR & ACR were sent.*
Date (MM/DD/YYYY the PAIMI PPR & ACR was sent to the State mental health agency.*
*The PAIMI Act [42 USC at 10805 (a) (7) mandates that the head of the state mental health agency receive a copy of this report on or before January 1.

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. B. GOVERNING BOARD (GB)
1. B.1. Does the P&A have a multi-member governing board? If Yes, complete governing board (GB), Table 1.B.3. [See, PAIMI Rule - 42 CFR 51.22(b).].	Yes	No
1. B.2. Is the Chair of the PAIMI Advisory Council (PAC) a member of the GB? An explanation is required if the answer to this question is NO & the P&A IS private, non-profit system with a multi-member governing board.	Yes	No

1. B. 3. GB INFORMATION
In the following table, please provide the requested information for the GB members as of 9/30.
a. Total number of GB member seats available.
b. Total number of GB members serving as of 9/30.
c. Total number of GB vacancies on 9/30.
d. Term of appointment for GB members (number of years).
e. Maximum number of terms a GB member may serve.
f. Frequency of GB meetings.
g. Number of GB meetings held this fiscal year (FY).
h. Average percentage of GB members present at meetings during the FY.

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. B. 4 GOVERNING BOARD COMPOSITION
“The governing board shall be composed of members who broadly represent or are knowledgeable about the needs of clients served by the P&A system . . . .” [PAIMI Rule 42 CFR 51.22(b) (2). Count each GB member only once.
a. Number of individuals with mental illness (IMI) who are recipients/former recipients (R/FR) of mental health services or are or have been eligible for services.
b. Number of family members of individuals with mental illness who are R/FR of mental health services.
c. Number of guardians.
d. Number of advocates or authorized representatives.
e. Number of other persons who broadly represent or are knowledgeable about the needs of the clients served by the P&A system.
TOTAL
PAIMI Rule 42 CFR 51.22 (b) (2) – mandates GB positions for private, non- profit systems. Count each GB member only once. The Total of 1.B.3.a. must equal the subtotals of 1.B.3.b and 1.B.3.c.

1. C. PAIMI PROGRAM STAFF
1. Provide the total number of P&A staff who are paid either partially or totally with PAIMI Program funds, including PAIMI Program income. Total: _____
a. How many of the staff listed above are attorneys? Total:___	b. How many of the staff listed above are non-attorney case workers/mental health advocates? Do not include support or administrative staff in this count. Total:_____

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
The minimum categories for data on race and ethnicity for federal program administrative reporting are defined in the Glossary:
1.D. 1. Ethnicity
	Governing Board	PAIMI Staff
1. D. 1. a. Hispanic or Latino
1. D. 1. b. Not Hispanic or Latino
TOTAL
1. D. 2 Race
	Governing Board	PAIMI Staff
1. D. 2. a. American Indian or Alaska Native
1. D. 2. b. Asian
1. D. 2. c. Black or African American
1. D. 2. d. Native Hawaiian or Other Pacific Islander
1. D. 2.e. White
1. D. 2.f. Two or more races
Vacancies on 9/30 (Identify each vacant position).
TOTAL

SECTION 1. GENERAL PAIMI PROGRAM INFORMATION
1. E. Gender
	Governing Board	PAIMI Staff
Male
Female
TOTAL

SECTION 2. PAIMI PROGRAM PRORITIES (GOALS) and OBJECTIVES

In the format provided, please list the program priorities (goals) and activities, as reported in the PAIMI Application (under Priorities and Objectives) for the SAME Fiscal Year (FY) that were used to achieve the annual objectives for this PPR.

The priorities shall be limited and consistent with the current mission and Government Performance Results Act (GPRA) mandates, accountability, and performance-based management requirements of SAMHSA/CMHS. Refer to the Guidance information included in the annual PAIMI Program Application.

For each priority (goal) identified for the FY, select one (1) case example that best illustrated the activities related to each priority (goal). Please provide in narrative form, one (1) example of an individual or systemic case and, if applicable, a legislative or regulatory activity. Remember case examples must illustrate the impact(s) and/or outcome(s) of PAIMI Program efforts.

Write the case example as though you were telling a story. As appropriate, Include the following information in your narrative: the presenting issue/complaint to be resolved; who (the parties involved); what the facts about the situation); where (the event occurred, such as, the type of facility, etc.); why the P&A program was involved; how the P&A program made a difference; and, the outcome(s) what resulted from this P&A activity? For example, “as a result of P&A intervention, this client lives independently in the community, goes to work every day . . . .”‘

Each narrative shall reflect the activities used to achieve the annual objectives; be brief, concise; use people first language; maintain confidentiality of the individual client; and, be consistent with the priorities and objectives submitted in the PAIMI Program application for same FY. Check narratives for redundancies, typographical, grammatical and syntax errors. In your narratives, please spell out the full name of an entity, etc. BEFORE using its acronym.

To facilitate review of this report, the priorities & objectives must be presented in the same order as those reported in the PAIMI application for the same FY.

See the GLOSSARY for definitions of priorities (goals) and objectives.

SECTION 2. PAIMI PROGRAM PRIORITIES & OBJECTIVES

SECTIONS 2.A., 2.B., & 2.C. were previously reported in the priority (goal)/objective table of the PAIMI Application for the same FY.

2. A. Priority (goal) - is a broad, general description of what the PAIMI Program hopes to accomplish. Each priority (goal) may have either a single or multiple objectives.

2. B. Objective - is the activity or activities undertaken to achieve a particular annual program priority (goal). Objectives have quantifiable targets and measurable outcomes. All objectives listed should be completed within the FY. Regulatory, legislative and/or litigation activities may span several FYs. Therefore, any objectives for these types of activities are to be divided into multiple steps that are achievable within the FY.

2. C. Target Population - Identification of a specific PAIMI-eligible population to be served (targeted) under each objective, such as, the elderly, adolescents, etc.

Items 2.D. & 2.E. are to be reported in this section of the PPR.

[Refer to the PAIMI Application for the same FY in which the information in items 2.A. 2.B & 2.C. was provided].

2. D. Target - A numerical statement of what is desired or expected as a result of the objective. [Note: Even narrative targets may be expressed in measurable terms/numbers, For example, “Development of one [1] protocol for facility monitoring.”]

2. E. Outcome - What was actually achieved as a result of the activity expressed in numerical terms? (See note in 2.D.).

2. F. Objective met or not met - A statement of whether the expected outcome (target) for this objective was met. If not met, an explanation is required as well as a description of future activities to address the unmet objective, if appropriate.

Insert additional pages into this section as needed.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS

Provide the number of individual PAIMI-eligible individuals for the categories listed below. Count an individual only once during each FY reporting period (even if the client returned for services many times or if many intervention strategies were provided. Include individuals carried over from the previous year but do not include individuals represented as part of a group or a legal class action, and individuals who receive only information or referral services.

Please complete each of the following sections. Do not leave any blank spaces. If no individuals were served in any category, list zero. Make sure that the total of individuals served in each sub-category is consistent. The total in 3.A.3. should equal the totals listed in each of the following categories: 3.C. Age of Individuals; 3.D. Gender of Individuals; and, 3.F. Individual Living Arrangements.

3. A. Number of Individuals Served with PAIMI Funds.

3. A.1. Total of PAIMI-eligible individuals who were receiving advocacy services at start of FY. _____ [This category reflects the number of individuals supported with either PAIMI Program funds or program income who had cases from the preceding FY still open on October 1. Do not report individuals served with non-federal dollars in this section, report these individuals in section 8].

3. A.2. Total of new/renewed PAIMI-eligible individuals served during the FY. _____

[This is the number of individuals who had a case opened during the reporting period (October 1 and September 30)]. Do not report individuals served with non-Federal dollars in this section, report these individuals in Section 8].

3. A. 3. Total of PAIMI-eligible individuals served in 3.A.1. & 3. A. 2. _____.

[This reflects the total number of individuals served with PAIMI Program dollars, including program income, during the fiscal reporting period and is an unduplicated count of all PAIMI-eligible individuals who received individual case representation].

3. A. 4. The number of PAIMI-eligible individuals who requested individual advocacy services who were not served within 30 days of initial contact either due to insufficient PAIMI funding 3.A.4.i. ______ or non-priority issues 3.A.4.ii ________.

TOTAL ___________ equals the sum of 3. A. 4. i. & 3. A. 4. ii.]

[Refer to the Glossary for definition of I &R. Do not include individuals who received Information and Referral (I&R) services in this section – report them in Section 6.A.]

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS
3. A. 5. Identify populations, advocacy issues and activities (systemic, legislative, educational, training, etc.) from 3.A.4.i. and/or 3.A.4.ii. that will be addressed in the future.
3. B. Number of complaints/problems of PAIMI-ELIGIBLE individuals.						Total
[3.B. Refers to the total number of complaints/problems presented at the time the individual contacted the P&A for assistance. The number may be higher than the total number of PAIMI-eligible individuals served by the P&A because each individual may have more than one complaint/problem to be addressed].
3. C. Age of Individuals* [See. 42 U.S.C. 10804(a)(1)(4), 42 CFR 51.24 (a)]
0 – 4 __	5 – 12 ___	13 -18 ___	19- 25____	25 – 64 ____	64+ ____	Total
* 3.C. must equal the total number of individuals served in 3. A. 3.

3. D. GENDER OF INDIVIDUALS*
3. D. 1. Male ______	3. D. 2. Female ____	3. D. 3. Total* _____
*3. D. 3. Must match the total number of individuals served listed in sections 3. A. 3 and 3.C.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS

Please refer to the GLOSSARY for definitions. The following information is self-reported or self-identified and uses two separate questions. The data on race and ethnicity are collected separately; provision shall be made to report the number of respondents in each category who are Hispanic or Latino. Collection of greater detail is encouraged; however, any collection that uses more detail shall be organized in such a way, that the additional information can be aggregated into these minimum categories for data on race and ethnicity.

,

3. E. Ethnicity & Race of PAIMI-eligible Individuals
ETHNICITY
3. E.1. a. Hispanic or Latino
3. E.1. b. Not Hispanic or Latino
Total [This figure must match the numbers reported in sections 3.A. 3. and 3. C.]
RACE
3. E. 2. a. American Indian or Alaska Native
3. E. 2. b. Asian
3. E. 2. c. Black or African American
3. E. 2. d. Native Hawaiian or Other Pacific Islander
3. E. 2. e. White
3. E. 2. f. Two or More Races
3. E. 2.g. Unknown
3. E. 2.h. Total – This information is self-reported and may exceed the total clients served.
The data in 3.E. 2.h. Total is self-reported. Please do not question self-reported data. Each client may select one or more race categories. The totals in this section may exceed those listed in 3.A.3., 3.C.3, or 3.D.3. P&A staff must ask and report this information. Also, Ethnicity is not the same as race, so race must be reported for clients identify as Hispanic/Latino.

SECTION 3. PAIMI-ELIGIBLE INDIVIDUALS
3. F. Living Arrangements of Individuals at Intake.					Total
1. Independent [per the PAIMI Act of 2000 – these individuals DO NOT have priority over PAIMI-eligible individuals in residential care or treatment facilities, see 42 U.S.C. 10804(d), exception those within 90 days of discharge from a residential care or treatment facility, military families (off base), veterans, the homeless, veteran].
2. Parental or other family home - per the PAIMI Act of 2000 – these individuals do not have priority over PAIMI-eligible individuals in residential care or treatment.
3. Community residential home for children/youth (0-18 years), e.g., supervised apartment, semi-independent, halfway house, board & care, small group home (3 or less).
4. Adult community residential home, e.g., supervised apartment, semi-independent, halfway house, board & care, small group home (3 or less).
5. *Non-medical community-based residential facility for children & youth.
6. Foster Care
7. *Nursing facilities, including skilled nursing facilities(SNF)
8. *Intermediate care facilities (ICF)
9. * Public and private general hospitals, including emergency rooms.
10. * Other health facility.
11. Psychiatric wards (public or private)
12. Public (municipal or state-operated) institutional living arrangements, e.g., hospital treatment center/school or large group home 4+ beds).
13. Private institutional living arrangement.
14. Legal Detention/Jail/Detention Center
15. State Prison
16. Homeless
17. Federal facility*:	a. Detention	b. Prison	c. Veterans hospital	Other (describe
TOTAL
The total for 3. F. equals the total listed in 3. A. 3 *Expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 - 290jj(2).

SECTION 4.COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. A.1. Areas of Alleged Abuse. Report the number of complaints/problems from closed cases only within the following categories:	Outcomes
	Total	A	B	C	D
a. Inappropriate or excessive medication
b. Inappropriate or excessive
1. Physical restraint
2. Chemical restraint*
3. Mechanical restraint*
4. Seclusion
c. Involuntary medication
d. Involuntary Electrical Convulsive Therapy (ECT)
e. Involuntary aversive behavioral therapy
f. Involuntary sterilization
g. Failure to provide appropriate mental health treatment
h. Failure to provide needed or appropriate treatment for other serious medical problems
i. Physical Assault
1. Serious injuries related to the use of seclusion and restraint.*
2. Serious injuries NOT related to seclusion and restraint.
j. Sexual assault
k. Threats of retaliation or verbal abuse by facility staff
l. Coercion
m. Financial exploitation
n. Suspicious death
o. Other - [Make every effort to report within the above categories. Describe the type of PAIMI complaint on a separate sheet. [The number of complaints listed must be less than 1% of the total number of abuse complaints listed in this section].
Total [Sum of items a. - o.]
*Expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 -290jj-2]. See also, the PAIMI Act 42 U.S.C. 10802(1) (A) - (D).

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. A. 2. Abuse Outcome Statements

For each area of alleged abuse in 4.A.1., choose one or more outcome statements that best describe or relate to the complaint/problem area. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, and D).

A. Persons with disabilities whose environment was changed to increase safety or welfare.

B. Positive changes in policy, law or regulation re: abuse in facilities (describe facility where impact was made).

C. Validated abuse complaints that were favorably resolved as a result of P&A intervention.

D. Other indicators of success or outcomes that resulted from P&A involvement (explain).

4. A. 3. Abuse Complaints Disposition
For closed cases listed in Table 4.A.1., provide the number of abuse complaints/ problems for each disposition category.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problem favorably resolved in the client’s favor.
d. Number of complaints/problem not favorably resolved in the client’s favor.
e. Total - The number of complaints/problems addressed from closed cases. [The total for 4. A. 3. e. must match the total listed in Table 4. A. 1.].

SEC. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. B.1. Areas of Alleged Neglect – failure to provide for appropriate . . .: Report the number of complaints/problems from closed cases only within the following categories:	Outcomes
	Total	A	B	C	D	E
a. Admission to residential care or treatment facility
b. Transportation to/from residential care or treatment facility
c. Discharge planning or release from a residential care or treatment facility
d. Mental health diagnostic or other evaluation (does not include treatment)
e. Medical (non-mental health related) diagnostic or physical examination
f. Personal care (e.g., personal hygiene, clothing, food, shelter)
g. Physical plant or environmental safety
h. Personal safety (client-to-client abuse)
i. Written treatment plan
j. Rehabilitation/vocational programming
k. Other. [Make every effort to report within the above categories. Describe the type of PAIMI complaint on a separate sheet. [The number of complaints listed must be less than 1% of the total number of neglect complaints listed in this section].
Total [Sum of items a. - k.]

SECTION 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. B. 2. Neglect Outcome Statements

For each area of alleged neglect listed in Table 4.B.1. , choose one or more outcome statements that either best described or related to the complaint/problem. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, D, and E).

A. Validated neglect complaints that have a favorable resolution as a result of P&A intervention.

B. Positive changes in policy, law, or regulation regarding neglect in facilities

(describe facilities).

C. Persons with disabilities discharged consistent with their treatment plan after

P&A involvement.

D. Persons with disabilities whose treatment plans met selected criteria.

E. Other indicators of success or outcomes that resulted from P&A involvement

(explain).

4. B. 3. Neglect Complaints Disposition
For closed cases listed in Table 4.B.1., provide the numbers of neglect complaints or problem areas for each disposition category. [See, 42 U.S.C. 10802(5)].
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by the client.
c. Number of complaints/problem favorably resolved in the client’s favor.
d. Number of complaints/problem not favorably resolved in the client’s favor.
e. Total – The number of complaints/problems addressed from closed cases. [The total for 4.B.3.e., must match the total listed in Table 4. B.1.].

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS
4. C.1. Areas of Alleged Rights Violations ; Report the number of complaints/problems from closed cases only within the following categories:	Total	Outcomes
		A	B	C	D
a. Housing Discrimination
b. Employment Discrimination
c. Denial of financial benefits/ entitlements (e.g., SSI, SSDI, Insurance)
d. Guardianship/ Conservator problems
e. Denial of rights protection information or legal assistance
f. Denial of privacy rights (e.g., congregation, telephone calls, receiving mail)
g. Denial of recreational opportunities (e.g., grounds access, television, smoking)
h. Denial of visitors
i. Denial of access to or correction of records
j. Breach of confidentiality of records (e.g., failure to obtain consent before disclosure)
k. Failure to obtain informed consent (see also, involuntary treatment)
l. Failure to provide special education consistent with State requirements
m. Advance directives issues
n. Denial of parental/family rights
o. Other [Make every effort to report within the above categories. Describe the type of PAIMI complaint on a separate sheet. [The number of complaints listed must be less than 1% of the total number of rights violation complaints listed in this section].
TOTAL [Sum of items a. - o.]

SECTION. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. C. 2. Rights Violations Outcome Statements

For each category of alleged rights violation listed in Table 4.C.1., choose one or more outcome statements that either best described or related to the complaint/problem. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, C, or D).

A. Persons with disabilities served by the P&A whose rights were restored as a result of P&A Intervention.

B. Persons with disabilities whose personal decision making was maintained or expanded as a result of P&A intervention.

C. Policies or laws changed and other barriers to personal decisions making eliminated as a result of P&A intervention.

D. Other outcomes as a result of P&A involvement:

4. C. 3. Rights Violations Disposition
For closed cases listed in Table 4.C.1., provide the numbers of rights complaints/problem areas for each disposition category.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problems favorably resolved in the client’s favor.
d. Number of complaints/problems not favorably resolved in the client’s favor
e. Total - The number of complaints/problems addressed from closed cases. [The total for 4.C.3.a, must match the total listed in Table 4. C. 1.].

SEC. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. D. 1. Intervention Strategies

Report the number of intervention strategies and the outcomes used to address each individual complaint/problem area in Section 4. D.

Some clients may have more than one complaint/problem and each may require more than one intervention strategy, therefore, the total number of intervention strategies used may exceed the total number of individuals served.

Do not report each phone call, letter, meeting, or other action taken on behalf of a client as a separate intervention strategy. [Referrals, counseling, and negotiation are considered cumulative processes]. See Glossary for the definitions of “Intervention Strategies.

SEC. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. D. 2. Intervention Strategies

Outcomes

ABUSE

NEGLECT

RIGHTS VIOLATIONS

Strategy

Total

A

B

C

D

A

B

C

D

E

A

B

C

D

1. STA

2. A/NI

3. TA

4. AR

5. N/M

6. LR

Total

1. STA - Short Term Assistance

2. A/NI - Abuse/Neglect Investigations

3. TA - Technical Assistance

4. AR - Administrative Remedies

5. N/M - Negotiation/Mediation

6. L/R - Legal Remedies

• Please refer to the outcome statements listed in Section (Abuse) 4. A. 2., (Neglect) 4. B. 2. and, (Rights Violations) 4. C. 2.

SEC. 4. COMPLAINTS/PROBLEMS of PAIMI-ELIGIBLE INDIVIDUALS

4. E. Death Investigation Activities

See, the PAIMI Act 42 U.S.C. at 10801(b)(2)(B) and 10802(1), and PAIMI Program expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C. at 290ii- 290ii and 290jj-1 - 290jj-2.

4. E. 1. The number of deaths of PAIMI-eligible individuals reported to the P&A for investigation by the following entities:

4. E. 1. a. The State.

b. The Center for Medicaid & Medicare Services (Regional Offices).

c. Other Sources. Briefly list the source for each death reported in this

category, e.g., newspaper, concerned citizen, relative, etc.

d. Total

4. E.1.e. If the information requested in 4.E.1. was not available, please explain.

4. E.2. All P&A death investigations conducted involving PAIMI-eligible individuals related to the following:	Total
a. Number of deaths investigated involving incidents of seclusion (S).
b. Number of death investigated involving incidents of restraint (R).
c. Number of deaths investigated NOT related to incidents of S & R, e.g., suicides.
d. Total Number of deaths investigated [Sum of 4.E.2. a-c].

4. E. 3. If you reported deaths in categories 4.E.2.a., 4.E.2.b., and/or 4.E.2.c., then please

provide the following information on one (1) death from each category, as appropriate:

Provide a brief summary that includes the following information: the circumstances about the death, P&A involvement in the death investigation, and the outcome(s) that resulted, etc.

SEC. 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI- ELIGIBLE INDIVIDUALS
This section captures information, which is not reflected in previous sections of this report, on how the P&A program used its PAIMI Program funds (including program income) to support non-individual client activities. To complete Table 5.F. Types of Interventions, refer to the guidance in Sections 5.A. – 5.E.
Under each intervention, as applicable, report each annual program priority activities for the FY & the other information requested. The items listed in the table’s left column and the numbers reported for each category should relate to the narrative section that follows.
5. A. Guidance for reporting the numbers of PAIMI-eligible individuals potentially impacted by P&A interventions
Types of Intervention	Guidance for Determining the Number* of Individuals* [The number of persons potentially impacted within the fiscal year for which the PPR is submitted].
Group Advocacy (non-litigation)	Estimated number of people with disabilities impacted by this change, i.e., count of people with disabilities (PWD) who are normally impacted by this practice, policy, etc. .
Investigations (non-death related)	Estimated number of PWD impacted by this change.
Facility Monitoring Services	Estimated number of PWD impacted, i.e., count of PWD living in facility.
Court Ordered Monitoring (COM)	Estimated number of PWD impacted by this change,  (i.e., count of PWD impacted by the monitoring.
Class Litigation	Estimated number of PWD impacted by this change, i.e., count of PWD impacted by the class litigation.
Legislative & Regulatory Advocacy	Estimated number of PWD impacted by this change, i.e., count of PWD that are normally impacted by this legislative and regulatory advocacy.
Other	Estimated number of PWD impacted by this change, i.e., count of PWD impacted specified intervention.

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI- ELIGIBLE INDIVIDUALS

5. B. Guidance for determination of concluded successfully for interventions on behalf of groups of PAIMI-eligible individuals.

Interventions reported in the Table 5. A., are considered to be concluded successfully if they meet any one of the following six (6) positive outcome statements:

1. The intervention resulted in a positive change in a policy, law, regulation, or other barrier for persons with disabilities.

2. The intervention changed the environment to increase safety or welfare for persons with disabilities

3. The intervention resulted in a positive change through the restoration of client rights, the expansion or maintenance of personal decision-making, or the elimination of other barriers to personal decision-making for persons with disabilities

4. The intervention resulted in persons with disabilities securing access to administrative or judicial processes.

5. The intervention resulted in persons with disabilities securing information about their rights and strategies to enforce their rights.

6. The intervention resulted in persons with disabilities taking action to advocate on their own behalf.

5. C. Guidance for determination of concluded unsuccessfully* for interventions on behalf of groups of PAIMI-eligible individuals.

Intervention activities reported in Table 5.F. are concluded unsuccessfully, if they did not meet any of the outcomes statements in sections 5.a. or 5.b.

5.D. Guidance for determination of ongoing interventions on behalf of groups of PAIMI-eligible individuals

SAMHSA/CMHS recognizes that legislative, legal and/or other systemic reform activities (e.g., facility monitoring, litigation preparation, etc.) may take more than one fiscal year to complete and sometimes these types of interventions take years before they are completed successfully. It is these types of situations where the use of ongoing is most appropriate. The interventions reported in Table 5. F. are considered ongoing, if they were started in either a prior year or the current fiscal year (FY) and were not concluded by the end of the FY (9/30).

SECTION 5. INTERVENTIONS on BEHALF of GROUPS of PAIMI- ELIGIBLE INDIVIDUALS
5. E. Types of Interventions	Number of intervention types used	Number of individuals Impacted	Concluded Successfully	Concluded Unsuccess- fully	On-going
1. Group Advocacy non-litigation
2. Investigations (non-death related)
3. Facility Monitoring
4. Court Ordered Monitoring
5. Class Litigation
6. Legislative & regulatory advocacy
7. Other
Total

5. F. In the PAIMI Application [at Section IV.2.2.], you were instructed to provide information on the objectives for these types of interventions in sequential steps that are achievable within the annual reporting period, e.g., identifying legal issues, filing a class action, etc.

In the space below, provide at least one (1) example that reflected the outcome of each

Subcategory (items 1 – 7) listed in Table 5.E. For each example, briefly describe the PAIMI Program activity, include factual information (who, what, when, where, how) and the outcome(s) that resulted

from P&A intervention.

Use examples that illustrate the impact of PAIMI Program activities, especially how the activities made a difference to the clients served, such as, improved quality of life, etc.

If PAIMI Program funds were used to support any of the above activities, then describe how their availability furthered the purposes of the PAIMI

Act.

Insert additional pages into this section as needed.

SECTION 6. NON-CLIENT DIRECTED ADVOCACY ACTIVITIES
6. A. INDIVIDUAL INFORMATION AND REFERRAL (I&R) SERVICES. Refer to the Glossary for the definition of I& R. [See also, PAIMI Rules, 42 CFR 51.24].
Provide the number of PAIMI Program I&R services.	TOTAL
6.B. STATE MENTAL HEALTH PLANNING ACTIVITIES
Briefly list P&A collaboration/involvement in State Mental Health planning activities.
6. C. EDUCATION, PUBLIC AWARENESS ACTIVITIES AND/OR EVENTS [Refer to the Glossary].
6. C. 1. a. Number of public awareness activities or events.		Total
6. C. 1. b. Number of individuals who received the information.		Total
6. C. 2. Number of education/training activities undertaken.		Total
6. C. 2. Refers to either the number of training programs sponsored by the P&A or the number of events sponsored by another organization where P&A staff were the trainers. The training must have provided specific information to participants regarding their PAIMI rights. If the P&A only provided general program information, then report the number of individuals trained in section 6.C.1.b. [See, PAIMI Rule 42 CFR 51.31(c)].		Total
6. C. 3. Number (approximate) of persons trained. [Only include those individuals who attended a 6.C.2. type education/training program(s), [See PAIMI Rule 42 CFR 51.31].		Total

Section 6. Non-Client Directed Advocacy Activities

6. C. 4. Education, Public Awareness Activities and/or Events

Dissemination Activities.

Provide the number of articles, films, reports, etc. developed/produced. Provide an estimate for the number of people who received the information. For example, an article published about the P&A in a newspaper with a circulation of 200,000 readers; a television appearance on a station with 100,000 viewers in that time spot, etc.

6. C. 4. Outcome Statements for Dissemination Activities

For each non-client directed advocacy activity listed in the Table 6.C.5., choose one or more outcome statements that either best describe or relate to the TYPE of ACTIVITY. Enter the appropriate letter(s) and provide the number of outcomes per category selected in the “outcome” columns (A, B, and C).

A. Persons who received information about the P&A and its services.

B. Persons disabilities (or their family members) who received education or training about their rights, enabling them to be more effective self advocates.

C. Other outcomes that resulted from PAIMI Program involvement.

6. C. 5. Types of Dissemination activities	Number of:	Number of persons receiving the information	Outcomes
			A	B	C
a. Radio/TV appearances.
b. Newspaper articles (Attach copies of articles).
c. Public Services Announcements (PSA), videos, films, etc.
d. Reports
e. Publications, including articles in professional journals.
f. Other P& A disseminated information, includes general training, outreach activities or presentations, brochures and handouts that were not included/counted under training activities).
g. Website hits.
h. Other media activities. Describe in the space below total.
Total

SECTION 7. GRIEVANCE PROCEDURES [42 CFR Section 51.25]
7. The PAIMI Rules mandate that the P&A system shall establish procedures to address grievances from: 1) Clients or prospective clients of the system to assure that individuals with mental illness have full access to the services of the program [42 CFR 51.25(a)(1)]; and, 2) Individuals who have received or are receiving mental health services in the State, family members of such representatives, or representatives of such individuals or family members to assure that the eligible P&A system is operating in compliance with the Act [42 CFR 51.25(a)(2) - a systemic/program assurance grievance policy.]
7. a. Do you have a systemic/program assurance grievance policy, as mandated by 42 CFR 51.25(a) (2)? Yes ___ If No, please develop one ____
7.1. The number of grievances filed by PAIMI-eligible clients, including representatives or family-members of such individuals receiving services during this fiscal year. Total ____
7.2. The number of grievances filed by prospective PAIMI-eligible clients (those who were not served due to limited PAIMI Program resources or because of non-priority issues. Total _____
7.3. Total [Add 7.1 & 7.2] _____ [42 CFR Section 51.25(a)(1), (2)]
7.4. The number of grievances appealed to:
7. 4. a. The Governing Authority/Board	Total	7. 4. b. The Executive Director	Total
c. Total = 7. 4. a. & 7.4. b. _____
7.5. a. The number of reports sent to the governing board AND the Advisory Board mandatory for private non-profit P&A systems, at least one annually) that describe the grievances received, processed, and resolved. [A report is required, even if no grievances were filed. [PAIMI Rule 42 CFR 51.25(b)(2)] Total _______
7.6. Please identify all individuals (by name & title) responsible for grievance reviews.

SECTION 7. GRIEVANCE PROCEDURES [42 CFR Section 51.25]

7.7. What is the timetable (in days) used to ensure prompt notification of the grievance procedure process to clients, prospective clients or persons denied representation, and ensure prompt resolution? __________ [PAIMI Rule 42 CFR 51.25(b)(4)]

7.8. a. Were written responses sent to all grievants? YES ____, NO ___ If no, explain below.

7.9. Was client confidentiality protected? YES____, NO____. If no, explain below [42 CFR 51.25(b) (6)].

SECTION 8. OTHER SERVICES AND ACTIVITIES
The PAIMI Rules [at 42 CFR at 51.24(b)] mandate that “Members of the public shall be given an opportunity, on an annual basis, to comment on the priorities established by, and the activities of, the P&A system. Procedures for public comment which must provide for notice in a format accessible to individuals with mental illness, including such individuals who are in residential facilities, to family members and to representatives of such individuals and to other individuals with disabilities. Procedures for public comment must provide for receipt of comments in writing or in person.”
8. A. 1. Does the P&A have procedures established for public comment?
a. Yes __ Briefly describe how the notice is used to reach persons with mental illness and their families. b. No __, If no, briefly explain.
8. A. 2. Were the notices provided to the following persons?
a. Individuals with mental illness in residential facilities?	YES	NO*
b. Family members and representatives of such individuals?	YES	NO*
c. Other Individuals with disabilities?	YES	NO*
d. *Brief explanation is required for each NO answer in 8. A.2. a., b., or c.

8. A. 3. Do the procedures provide for receipt of the comments in writing or in person? YES* ____; NO _____.

8. A. 3. a. If NO, briefly explain why the agency does not have such procedures in place.

SECTION 8. OTHER SERVICES AND ACTIVITIES
8. B.1. Was the public provided an opportunity for comment?	YES	NO
8. B. 2. If you answered YES to 8.B.1., then briefly describe the activities used to obtain public comment, e.g., public forums, constituent surveys, etc.
8. B. 3. What formats and languages (as applicable) were used in materials to solicit public comments? Briefly list/describe.
8. B. 4. If you answered NO to 8.B.1., briefly explain why the public was not provided an opportunity to comment [PAIMI Rule 42 CFR 51.24(b)]. N/A

8. C. List Groups ( Provide a sample listing of any state, consumer, and advocacy organizations, and other entities, i.e., professional, national and local organizations involved in mental health and/or other disability related issues, current and former recipients of mental health services and their family members with whom the P&A system coordinated systemic activities, etc. [PAIMI Act 42 U.S.C. 10824 (a) (D)].

8. D. Briefly describe the outreach efforts/activities used to increase the numbers of ethnic and racial minority clients served and/or educated about the PAIMI Program. [The Demographic/State Profile information submitted with your PAIMI Application for the same FY will be used in the evaluation of your PPR data].

SECTION 8. OTHER SERVICES AND ACTIVITIES
8. E. Did the activities described in 8.D. result in an increase of ethnic and/or minorities in the following categories?
1. Staff	Yes	No
2. Advisory Council	Yes	No
3. Governing Board	Yes	No
4. Clients	Yes	No

8. F. PAIMI Program Implementation Problems

8. F.1. External Impediments

Describe any problems with implementation of mandated PAIMI activities, including those activities required by Part H of the Children’s Health Act of 2000 that pertain to requirements related to incidents involving seclusion and restraint and related deaths and serious injuries (e.g., access issues, delays in receiving records and documents, etc.).

SECTION 8. OTHER SERVICES AND ACTIVITIES

8. F.2. Internal Impediments

Describe any problems with implementation of mandated PAIMI activities, including any identified annual priorities and objectives (e.g., lack of sufficient resources, necessary expertise, etc.).

8. G. Accomplishments

Briefly describe the most important PAIMI-related accomplishment(s) that resulted from PAIMI Program activities. Provide a website reference as to where any supporting documents describing these achievements may be found, e.g., case citations, news articles, legislation, etc.

SECTION 8. OTHER SERVICES AND ACTIVITIES

8. H. Recommendations

Please provide a brief list of recommendations for activities and services to improve the PAIMI Program. Include a brief explanation as of why such activities and services are needed. [42 U.S.C. 10824(a) (4)].

8. I. Please identity any training & technical assistance requests. [PAIMI Act 42 U.S.C. 10825]

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 2012
In this section, provide actual expenditures for the FY. You may also submit in on an Excel spreadsheet. Refer to the PAIMI Application [Appendix C] submitted to SAMHSA/CMHS for the same FY.
9. A. PAIMI Program Personnel –. ++ List vacancies by position, annual salary, percentage of time & costs that will be charged to the PAIMI Program grant when the position is filled.
Position Title	Annual Salary	Percent/Portion of Time Charged to PAIMI	Costs Billed To PAIMI
insert additional rows as needed
Subtotal
++Vacant positions
Volunteer positions
Total Positions

9. B. CATEGORIES	COST
Fringe Benefits (PAIMI Only)
Travel Expenses (PAIMI Only)
Subtotal

9. C. Equipment - Type (PAIMI only)	COST
Subtotal

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 2012
9. D. Supplies - TYPE (PAIMI only)						COST
Subtotal
9. E. Contractual Costs (including Consultants) for PAIMI Program Only
Position or Entity	Service Provided	Salary/Fee	Fringe Benefit Cost	Travel Expenses	Other Costs
Subtotal

9. F. Training Costs for PAIMI PROGRAM only
Categories	# of Persons/ Travel Costs	# of Persons/ Training Costs	# of Persons/ Other Expenses
Staff
Governing Board
Pac Members
Volunteers
Subtotal

9. G. Other Expenses (PAIMI PROGRAM only)	Cost
Subtotal

SECTION 9. ACTUAL PAIMI BUDGET/EXPENDITURES FOR FY 2012
9. H. Indirect Costs (PAIMI only):	Cost
1. Does your P&A have an approved Federal indirect cost rate?	Yes	No
If Yes, what is the approved rate?	Rate:
2. Total of all PAIMI Program costs listed in 9.A. - 9.G.	$
3. Income Sources and Other Resources (PAIMI Program Only)	$
4. PAIMI Program carryover of grant funds identified by FY.	$
5. Interest on Lawyers Trust Accounts (IOLTA).	$
6. Program income (PAIMI only).	$
7. State	$
8. County	$
9. Private	$
10. Other funding sources. [IDENTIFY each source]. - UNRESTICTED	$
11. Total [All PAIMI Program resources listed in items 9. H.3 - 10]	$

GLOSSARY

Closed case - is when the advocate/attorney closes the client record or case file after providing advocacy interventions on behalf of a client, and determining that the client either has no need of further intervention services or that the agency has no other services available to address the issue(s) or complaint(s) for which the case was initially opened.

Grievance Procedures – are policies and procedures developed by the P&A system to ensure that its clients and prospective PAIMI-eligible clients, their family members, or representatives have full access to the system services and that the system is fully compliant with the provisions of the PAIMI Act and Rules.

Information and Referral (I&R) Services - is the provision of brief written or oral information, such as generic information about the P&A, including information about additional programs and resources external to the P&A that relate to the individual’s service needs and statutory or constitutional rights as a person with a disability. I &R services are generally of short duration, typically range from a few minutes to an hour, do not involve direct advocacy intervention by staff, and any type of staff follow-up. I &R services may include mailing generic agency information. Individuals receiving I &R services are not counted as PAIMI clients.

Intervention Strategies:

• Abuse/Neglect Investigations - a systemic and thorough examination of information, records, evidence and circumstances surrounding an allegation of abuse and neglect. Investigations are undertaken to determine if there is a basis for administrative or legal action on behalf of the client. Investigations require a significant allocation of time to interview witnesses, gather factual information, and to issue a written report of findings.

• Administrative Remedies - includes the use of any systems for appeal within an agency or facility, or between agencies, which does not involve adjudication by a court of law.

• Legal Remedies - the legal representation of clients in litigation in court processes concerned with rights, grievances, or appeals of such rights or grievances.

• Legislative/Regulatory Advocacy activities involve monitoring, evaluating, and commenting upon the development and implementation of Federal, State, and local laws, regulations, plans, budgets, taxes and other actions which may affect individuals with mental illness. [The PAIMI Rules at 42 FCR at 51.24 mandates that legislative activities shall also be addressed in the development of program priorities].

• Negotiation/Mediation - is an informal, non-legal intervention by a PAIMI representative, attorney or case manager used to resolve problems with facility staff or other agency representatives; (does not involve a formal appeal).

• Short Term Assistance - Time limited advice and counseling assistance, which may include reviewing information, counseling a client on actions one may take, and assisting the client in preparing letters, documents or making telephone calls to resolve the issue.

• Technical Assistance - includes the provision of information, referral or advice to clients by a PAIMI Program representative, attorney, or advocate, (e.g., coaching the client in self-advocacy, explaining service delivery system(s) available to meet needs, dissemination of information and materials to client, etc.). Follow-up is required.

Objectives - are activities undertaken to achieve annual program priorities (goals). All objectives required to have measurable outcomes and the use of numerical targets is encouraged. Each objective must clearly state why the activity was undertaken, who will benefit from the objective (the target population), how the activity will be accomplished, and what is the expected outcome for the activity? Generally, with the exception of litigation, legislative or regulatory activities, objectives shall be attainable within the fiscal reporting period (within one (1) fiscal year).

Open Case - is when a PAIMI-eligible individual with a complaint is accepted as a client by the P&A system. A case record or case file is opened for that individual. System staff maintains all intervention services provided to the client and other information t are maintained in this case record/file.

Outreach - is an activity that targets information on PAIMI Program activities to specific populations (e.g., cultural, ethnic and racial minorities, and other underserved or un-served populations, etc. The activity is linked to an objective of a specific annual priority.

PAIMI Clients (for purposes of this report) - are individuals who meet the PAIMI eligibility criteria as defined in the PAIMI Act [42 U.S.C. 10802(4) and its Rules at 42 CFR 51.2 Definitions, who have a complaint, for whom demographic data is collected, and for whom the PAIMI Program, or any of its subcontractors, provides an intervention (as reported under Intervention Strategies in this form).

Priorities (Goals) – are broad general descriptions of short term activities for the P&A system to accomplish within one (1) fiscal year (FY). [The exceptions are generally regulatory, legislative, and litigation activities]. The priorities must be directly related to the purpose of the enabling Federal legislation and the requirements of the Federal-funding agency and consistent with the priorities included in the PAIMI Application for the same FY. [See PAIMI Act at 42 U.S.C. 10801, PAIMI Rules at 42 CFR 51.24 (a) – Program Priorities, and the Children’s Health Act of 2000 at 42 U.S.C. at 290ii-ii-1 and 290jj-jj-2].

Public Awareness Activities - provide general information on disability rights and the purpose and mission of the P&A system. Public awareness activities include public service announcements, newsletters, radio or television, publications in legal journals, web site services, general distribution of agency brochures, etc.

Public Education and Constituency Training - is the dissemination of information to one or more persons through an interactive event, which often promotes a greater understanding of the constitutional or statutory rights of persons with disabilities. Contrasted to Public Awareness Activities, education and training must be specifically targeted to meet the unique need of the group(s) trained.

Racial/Ethnic Background - The following minimum standards shall be used for all federal administrative reporting and grants reporting or record keeping requirements that include data on race and ethnicity - http://www.whitehouse.gov/omb/fedreg_1997standards/.

Categories and Definitions:

Ethnicity:

Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American descent.

Not of Hispanic Origin:

Race:

American Indian or Alaska Native (include tribal affiliation for the Alaska native when possible). - A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

Black or African American - A person having origins in any of the Black racial groups of Africa.

Native Hawaiian or other Pacific Islander - A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.

White - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Respondents have the option of selecting one or more racial designations.

Resolution of Complaint/Problem Area – is in a client’s favor when (1) the client is satisfied with the result of the intervention or (2) the expressed wish or stated goal of the client is either fully attained or negotiated to an agreeable outcome, or (3) the violation in the stated case complaint/problem area was remedied.

Systemic Advocacy Activities – are the efforts taken to implement changes in policies and practices of systems that impact persons with mental illness. These "systems" include, but are not limited to, State agencies, various public and private residential care and treatment facilities, and other service providers, etc. [The PAIMI Rules at 42 CFR 51.24 (a) PAIMI Priorities state that systemic activities shall be addressed in the development and implementation of program priorities].