California Wraparound County Plan Approval and Provider Certification

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

EA staff will promptly engage with the family to introduce them to the HFW process, including its principles and stages, and to create the Plan of Care. The team will facilitate conversations and activities to identify individual strengths, needs, culture, and their vision for a better future. Policy & Procedures are outlined in the Program Statement and Policy #1050.01 Timely Engagement and Plan Development. A copy of the Strengths, Needs & Cultural Discovery, Team Agreement Template

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

EA Staff will prioritize the family’s voice and choice in developing the Plan of Care, building on the strengths of the youth, family, and other team members. Policy & Procedures are outlined in the Program Statement and Policy 1050.03, Program Principles; 1050.02, Plan Development & Implementation.

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will assess the functional strengths of youth, family, and community members to support the HFW process. Policy & Procedures are outlined in the Program Statement and Policy #1050.04 Individualized Strengths and Needs-Based Approach and #1050.03 Program Principles. The Additional Supporting Document includes the Wraparound Needs & Strengths Summary.

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Services and supports under HFW will target the most urgent underlying needs of youth and their families to create individualized strategies. IP-CANS will be utilized to identify needs. Policy & Procedures are outlined in the Program Statement and Policy #1050.04, Individualized Strengths and Needs-Based Approach. Additional Supporting Documents include the “Needs Egg.”

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW team ensures that the goals outlined in the Plan of Care are tailored to the individual’s needs and to the family, and that the family’s community assets are leveraged. Policy & Procedures are outlined in the Program Statement and Policy#1050.03 Program Principles; #1050.02 Plan Development and Implementation.

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will assist the family in identifying potential team members, including formal, natural, and community supports, and in prioritizing strategies in the Plan of Care that use these supports. The HFW team will prioritize identifying strategies within the family’s community to reduce reliance on formal supports and foster community sustainability. Policy & Procedures are outlined in the Program Statement and Policy#1050.03 Program Principles, #1050.05 Engagement of Formal, Natural, and Community Supports. The additional Supporting Document includes the Natural and Community Supports Inventory.

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency staff will recognize that a family’s traditions, values, and heritage are sources of great strength, and will use strategies that are relevant to and respectful of the youth and family’s culture, including Tribes in the case of an Indian child. Policy & Procedures are outlined in the Program Statement and Policy#1050.01 Timely Engagement & Plan Development, #1050.06 Culturally Respectful & Relevant Practices.

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency’s High Fidelity Wraparound teams will be comprised of formal and natural supports, who will work together to develop, implement, and monitor the Plan of Care that meets the unique needs of the youth and family. All team members will take ownership of their assigned tasks and collaborate to meet the needs of youth and families. Policy & Procedures are outlined in the Program Statement and Policy#1050.07 Team-Based Approach. Additional Supporting Documents include the Team Minutes Template and the Wraparound Team Agreement.

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency HFW team will monitor the Plan of Care’s success, including progress toward meeting needs, strategy implementation, and task completion. Policy & Procedures are outlined in the Program Statement and Policy#1050.03 Program Principles, 1050.08 Outcomes-Based Approach.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency HFW team will view setbacks and challenges not as evidence of a youth or parent’s failure, but as an indicator of a need to revise the plan. The HFW will be committed to implementing the Plan of Care that reflects HFW Principles, even in the face of limited system capacity. Policy & Procedures are outlined in the Program Statement and Policy#1050.09 Program Persistence.

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency HFW team will develop transitions in advance, and the facilitator will lead the team in identifying when the youth and family are ready for transition, based on benchmarks and indicators the team has been monitoring and adapting throughout the process. Transition will occur only when the youth’s and the family’s needs are met, not because of an adverse event or an administrative requirement. Transition will be celebrated with full youth and family participation. Policy & Procedures are outlined in the Program Statement and Policy#1050.10 Transition Planning & Graduation. Additional Supporting Document includes the Transition Planning Template.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate youth and family satisfaction. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate improved school functioning. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate improved functioning in the community. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate improved interpersonal functioning. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate increased caregiver confidence. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate stable and least restrictive living environment. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate reduction in inpatient, emergency department admission for behavioral health visits. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate the reduction in crisis visits. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will use evidence-based measures, such as IP CANS to assess and evaluate progress in needs and strengths, Wraparound Fidelity Index to measure satisfaction, Data Analysis and Reporting Tool (DART) to review records for adherence to standards, CFT meetings notes, post-HFW CFTs, and quality assurance phone calls and team observations to track and evaluate Positive Exit from HWF. Policy & Procedures are outlined in the Program Statement and Policy #1050.08

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

EA staff will promptly engage with the family to introduce them to the HFW process, including its principles and stages, and to create the Plan of Care. The team will facilitate conversations and activities to identify individual strengths, needs, culture, and their vision for a better future.. Each family will receive a “Wraparound Process User’s Guide” developed by the National Wraparound Initiative, which explains the Wraparound program to the family.
Policy & Procedures are outlined in the Program Statement and Policy #1050.01

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

The Wraparound Team will address immediate needs and concerns, enabling the family and team to focus on the Wraparound process during the engagement period. The individualized safety plan will be reviewed and revised to identify and prioritize safety needs, risks, and crises. EA staff will address initial crisis and safety concerns during engagement and develop an immediate crisis plan for intervention and stabilization to provide to the family, and document it in the youth’s chart, including how to access EA’s 24/7 on-call system for emergencies.
Policy & Procedures are outlined in the Program Statement and Policy #1050.13

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

During the engagement period, the team will learn the family’s story using the family timeline and the strengths, needs, and cultural discovery form to develop a vision statement. The form will be updated every 90 days, and the team will add new strengths, needs, and cultural preferences as they are discovered. The document will be provided to all team members.
Policy & Procedures are outlined in the Program Statement and Policy #1050.01; Additional Supporting Documents include a Strengths, Needs, and Cultural Discovery form.

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will assist the family in identifying potential team members, including formal, natural, and community supports, and in prioritizing strategies in the Plan of Care that use these supports. The HFW team will prioritize identifying strategies within the family’s community to reduce reliance on formal supports and foster community sustainability. Policy & Procedures are outlined in the Program Statement and Policy #1050.05; Additional Documents include Natural & Community Supports Inventory.

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

The team will ensure that meetings are held at times and locations that are convenient and accessible to all team members, and staff will have flexibility in working hours and scheduling to allow maximum participation
Policy & Procedures are outlined in the Program Statement and Policy #1050.01;

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator will establish team agreements, finalize the team mission statement, and guide the team in reviewing and prioritizing needs to set clear, measurable goals and outcomes. The Agency will assess the functional strengths of youth, family, and community members to support the HFW process.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Implementation and #1040, Individualized Strengths and Needs Approach. Additional Documents include the Wraparound Team Agreement and Wraparound Needs and Strengths Summary.

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

A comprehensive Plan of Care will be developed to prioritize needs, goals, and strategies for the youth and family. The team will help the family identify benchmarks for transitioning to less formal services, including the use of SMART goals, which are precise and quantifiable, enabling the team to track progress and outcomes. Services and supports under HFW will target the most urgent underlying needs of youth and their families to create individualized strategies. Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Plan Implementation, and #1050.04 Individualized Strengths and Needs-Based Approach. Additional Documents include the “needs egg.”

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

A comprehensive Plan of Care will be developed to prioritize needs, goals, and strategies for the youth and family. The facilitator will ensure the Plan includes highly individualized strategies tailored to each youth and family’s needs, strengths, values, and culture; reduces harm over time; aligns with the family’s vision and mission statement; addresses needs across multiple life domains; is coordinated with Children’s system of care partners; and is delivered in the community where the youth and family reside to ensure access.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Plan Implementation

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The individualized safety plan will be reviewed and revised to identify and prioritize safety needs, risks, and crises. Policy & Procedures are outlined in the Program Statement and in Policies #1050.13 Crisis Intervention; Additional Documents will include the Wraparound Safety Plan.

Procedures Ensure: (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The team will implement an individualized Plan of Care, track the completion of action items and strategies, and assess their effectiveness. The facilitator will engage the team to continuously evaluate progress, address emerging needs, modify strategies, and assign new action items.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Plan Implementation

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Plan Implementation

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator will engage the team to continuously evaluate progress, address emerging needs, modify strategies, and assign new action items. During the weekly meeting, the facilitator will lead the team to adjust the plan as successes occur, new needs are identified, or new strategies and action items are selected.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.02 Plan Development and Plan Implementation

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

The Agency HFW team will develop transitions in advance, and the facilitator will lead the team in identifying when the youth and family are ready for transition, based on benchmarks and indicators the team has been monitoring and adapting throughout the process.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.10 Transition Planning and Graduation. Additional Documents include the Wraparound Transition Plan.

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator will lead the team in developing a post-transition crisis and safety plan that reflects the transition and identifies potential crises that may occur after transitioning from formal services.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.10 Transition Planning and Graduation and 1050.10 Crisis Intervention.

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

Transitions out of the Wraparound process will be celebrated according to the child or youth and family’s culture, values, and preferences, and administrative structures are supportive of engaging in celebration, including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.10 Transition Planning and Graduation

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

EA Family Services aims to create efficient operational environments that foster the development of high-quality supports and services.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.11 Quality Supports and Services

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

EA will ensure that an Agency representative participates in Community Leadership Teams.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.11 Quality Supports and Services

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

Youth who meet the established eligibility criteria will receive services and will not be excluded based on the severity or nature of their needs.
The Agency will have appropriate caseload assignments to meet the individualized needs of the youth and family, considering the intensity and frequency of services, including 24/7 support for family crisis through the Agency’s on-call system.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.01 Timely Engagement and Plan Development

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

EA Family Services’ fiscal practices will be aligned with the values and principles of Wraparound to ensure standards are met. The Agency ensures the Wraparound budget allocates funding for direct services and supports to meet the individualized needs of youth and families
Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

EA will use the Flex Fund Request to request funds, and the Agency will use flex funds to meet urgent and individualized needs when other resources do not readily meet them; flex funds will not be requested or funded as a wraparound.
As outside entities allocate flex funds, the HFW facilitator and supervisors will strive to ensure the family quickly accesses these funds to meet urgent needs.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management. Additional Documents include Flexible Funding Request

Procedures Ensure: N/A (AAP funded Wraparound)

Description of Practice, Name of Supporting Documentation and Page #:

Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

As per standards, when requesting flex funding, the Agency will communicate to funding sources that:
-Flex funds and program resources can be supported by blending and braiding available System of Care funding to ensure their availability.
-When funding limitations exist within a single funding source, alternative funding options can be explored, or reliance on other sources can be increased to fill gaps.
-Requirements of any single funding source cannot prohibit families from accessing flexible funds to meet their needs.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.14 Fiscal Management

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

EA Family Services will employ staff who can appropriately meet the cultural, racial, and linguistic needs of youth and families.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

In the case of Indian children, EA staff will be trained in tribal sovereignty, traditions, values, respectful communication, collaboration, and advocacy.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

The Agency’s leadership (including managers and supervisors is committed to engaging staff in the following:
-Program quality and improvement through feedback, training, and coaching of staff.
-Open communication and a cohesive and positive team environment through collaboration and team building.
-A clear sense of mission and alignment with the Wraparound philosophy as outlined in the standards.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Each role in the HFW program has a job description that outlines the minimal requirements, necessary skills, functions, experience, and expectations. The Agency will use the role descriptions provided in the Wraparound Standards Toolkit.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

The Agency implements strategies to maintain a stable workforce and reduce turnover, including aligning wages with the community where the program operates.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

The Agency will implement a high-fidelity training plan that incorporates initial, annual, booster trainings, and ongoing training. Training will include both general HFW training and role-specific training. All Wraparound staff will be trained through Statewide Standardized Foundational Wraparound training provided by the UC Davis RCFFP. The training plan will include ICWA and Tribal Sovereignty training, as well as training for populations with specific and unique needs.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.16 High Fidelity Training Plan

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

EA will ensure that the youth, families, and peer partners who have current or prior Wraparound experience are meaningfully incorporated into any training the Agency provides.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.16 High Fidelity Training Plan

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

All staff will have the opportunity to job shadow and learn the program and role requirements, including skills and knowledge related to HFW principal phases and directives, as well as the effective use of flex funds to meet the families’ needs. EA Staff have access to supervision and coaching 24/7 as needed.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.15 Workplace Development and Supervision

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

EA Family Services recognizes the need for ongoing measurement and management of performance outcomes within its Wraparound program. This policy applies to all staff members involved in the Wraparound program, including program managers, coordinators, facilitators, and support staff.
Policy & Procedures are outlined in the Program Statement and in Policies #1050.12 Performance Outcome Management and Measurement.

Date Started: December 18, 2025

Date Submitted: December 22, 2025

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

TGC will utilize modified spreadsheet used to track FSP to monitor these timed items. Monitoring will be done by team lead and regular performance reviews (2x/year) as well as regular supervision and feedback on job performance. Supporting Docs: HFW Tracking Spreadsheet.

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

Agency values and staff training include focus on cultural diversity and inclusive practices. Preparation for CFT meetings include interview of the family to include their values, vision and goals; and will utilize CFT planning meeting matrix. HFW supervisor regularly sits in on CFT meetings and uses the Observation Tool to rate fidelity. We do service validation 4x/year in which we call families and get feedback on services and we have yearly county client surveys. We are also considering investing in the WFI or TOM. Supporting Docs: CFT Matrix, Staff Engagement for CFTs, CFT Meeting Observation Tool

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

CANS are conducted at intake and every 6 months (at least), per our DMH contracts and completion of this is monitored by our outcomes department. Staff are trained in the ICPM, Strength Based Need Identification and other trainings as part of their LACDMH training to facilitate CFT meetings. Ongoing coaching is provided in weekly supervision and during team meetings. Again, considering investment in WFI/TOM. Supporting Docs: CFT Matix

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

CANS completed at intake and every 6 months per LACDMH contracts; staff are provided Identifying Needs training to become CFT facilitator and review “The Needs Guide” with a supervisor. Needs are identified as part of the CFT meeting process. The Needs and Strengths Summary is used to guide this discussion utilizing information from the CANS. Supporting Documents: CFT Matrix, Needs Guide Article, Needs and Strengths CANS Summary

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Pre-work for initial CFT pulls individualized needs and strengths (Staff Engagement worksheet) and CFT meetings focus on individualized identified focus (CFT Matrix). We also use CANS data that is individualized. We will provide HFW booster fidelity review opportunities and access to the UC Davis HFW toolkit. Quarterly Service Validation calls and yearly client surveys give families way to give feedback formally and feedback is requested as part of every CFT meeting. Agency is considering investment in WFI and TOMS.

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Staff Engagement worksheet refers to formal and informal supports to ensure they are engaged and invited into the process. On going training and CFT Matrix includes Action plans for all members of the team to involve natural supports in the process as much and eventually more than providers to support transition at end of services.

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Agency has yearly cultural training requirement for all staff, active JEDI committee that does quarterly fish bowl style trainings and monthly lunch and learns with culture focus. On going access to lots of trainings through DMH, UCLA Training Hub, and UC Davis.

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

CFT Matrix document creates action items and at follow up CFT meetings these are followed up and problem solving addresses any barriers to accomplishing action goals. Team agreements will include norms for communication, process for decision making and expectations for contribution. Supporting Docs: CFT Matrix initial and follow up

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

CANS completed at intake and every 6 months. Summary of strengths and needs worked into CFT meetings to ensure that outcomes are driving decisions making. PSC (symptom checklist) is also used to determine with symptoms have reduced and family may be ready for transition stage.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

Staff and Supervisors have ongoing training and support on engagement strategies and challenging counter transference that may impact treatment. The Observation Tool is used to ensure that CFT meetings are utilizing principles of strengths focused and family’s needs to support engagement. Supporting Documents: Observation Tools and CFT Engagement Worksheet.

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Transition or Termination is planned with celebrations and transitional objects if appropriate. Families are linked to ongoing community supports including meds or lower level of care if needed. Supporting Documents: CFT Matrix.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Service Validation happens 4x/year in which families are contacted and asked about frequency and satisfaction with services. Supporting Documents: Service Validation Template

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is collected by our Parent Partner who is an essential part of the team. Any concerns in this area can be addressed by adding additional skills support including our Making Parenting a Pleasure group classes, Respite care, use of flex funds or other supportive services.

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

This is tracked in OMA forms by the county. OMA done at intake, every 3months, and when there is a Key Event Change (KEC). Supporting Documents: OMA forms (Baseline, 3m, KEC)

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

Currently this is tracked in our DMH Discharge Summary and on the FSP Disenrollment form. I am not sure how this will be tracked moving forward but reason for termination is tracked.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

At intake, DMH forms (Informed Consent, PFI, FOA, HIPPA) are reviewed. TGC documents of Attendance, Electronic Media Usage, Disclosure of licensure status/supervisor information, and document of what to expect in therapy are all reviewed. Specific to HFW, the Engagement activities leading up to the initial CFT, review all of these and this is reviewed at the start of the initial CFT and subsequent CFTs if needed.

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

TGC uses Assessment and Managing Suicide Risk (AMSR) to conduct ongoing risk assessments for all clients. The Columbia Suicide Scale is utilized at intake and when needed to assess for immediate harm to self or others and uses the DMH Safety Plan form when a Safety plan is indicated. Every program has an After-Hours number that are staffed 24hrs/day and this after-hours clinician is supported by an LPS certified to respond to crisis needs as a team.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

This is discussed in the preparation for the first CFT, in the initial CFT (see initial CFT Matrix), and in all follow up CFTs (see F/U CFT Matrix). Use the strengths needs and cultural discovery worksheet. Supporting docs: Strength needs and cultural discovery worksheet.

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

The team works to identify natural supports, Systems of Care partners, and any formal or informal support that should be involved in the treatment process. These team members are invited to all CFT meetings and provided with copies of the CFT matrix so that they can be active participants in the family plan.

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Staff are very flexible with scheduling and make every effort to accommodate the team’s needs. CFT meetings are offered in the clinic, in community settings (home, DCFS office, libraries ect.) and if necessary, using telehealth.

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

This is done in the initial CFT meeting and in every subsequent meeting. Supporting Docs: Initial CFT Matrix, Follow up CFT Matrix, CFT Agenda

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

This is done through use of the CFT Matrix (DMH) or Care Plan (UC Davis Template). Staff are provided additional training in identifying underlying needs and developing SMART goals. Brainstorming happens in CFT meetings and is documented on Matrix/Care Plan. Facilitators guide team to ensure a collaborative environment

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Plan of care is developed in collaboration with the family as well as formal and informal natural supports in the CFT meeting. Partners are included in the plan and individualized goals, and action plans are assigned to all team members Supporting Document: Care Plan Tool

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Agency utilizes Columbia Risk Screener at intake and Assessment and Managing Risk Tools (AMSR) to assess risk for all clients and develop individualized contingency plans. When a more formal safety plan is needed LACDMH has provided a standardized Safety Plan which is utilized. After Hours and LPS certified crisis team support is available 24/7 and all families are provided with program specific After Hours phone number. Supporting Documents: LACDMH Family Safety and Crisis Plan (in English and Spanish)

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

Plan of Care and CFT Matrix documentation will be reviewed by HFW supervisor as well as HFW supervisor conducting observations for CFT using Observation tool on a regular basis for all HFW facilitators. HFW Coordinator and HFW Supervisor also meets at least 1x/month as a group to support each other as peers. Per recommendations, CFT meetings with the whole team happen at least every 90days or more frequently if indicated. Supporting Documentation: CFT f/u matrix, CFT Observation tool

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

This process is indicated in the current CFT follow up matrix. Plan of care/CFT Matrix is updated at least every 90days in a CFT meeting or more frequently as indicated by the family needs. CFT matrix is uploaded into chart with in 72 hours for all clinical team and copies provided to family and other formal and informal supports. Supporting Documents: CFT follow up Matrix

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

Building of team is discussed in CFT meetings as well as treatment team meetings and new team members are welcomed in (especially natural supports that are identified during the process). CFT matrix guides involvement of team members and integration of them into the Care plan. Supporting Documents: CFT f/u Matrix and Plan of Care forms

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

Progress toward the family goals, family specific benchmarks, and outcome data (OMA, CANS, PSC ect.) are assessed at every CFT meeting and once achieved then HFW Facilitator moves the team into the transition phase of HFW. HFW team will utilize Wraparound Transition Plan form to identify needs and strengths addressed in treatment, needs met, and make plans for family to utilize natural supports for any ongoing needs. Support Documents: Wraparound Transition Plan form

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

If indicated Safety Plan will transition to include natural supports and 24 hr crisis lines to ensure ability for the family to get support in a crisis after HFW services are closed.

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

HFW team will develop a meaningful way to celebrate the family’s success. Agency can provide materials (certifications, journals ect.) to provide transitional objects if necessary and flex funds can be used as needed to support this commencement.

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

We will gather feedback from families throughout treatment to inform agency HFW policies and procedures. This can be anonymous through suggestions boxes in waiting rooms or direct communication with providers. At the end of treatment (or any time during treatment when requested) the family will be given an opportunity to share their experience to HFW supervisor about their experiences and suggest any ideas for improving service delivery. We are hopeful that this is supported by LACDMH as well since much of the policy decisions happens at that level.

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

Upon notice of the county Community Leadership Team we will have regular representation (likely our HFW director or supervisor) who will be responsible for representing our agency and reporting back to the HFW team.

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

TGC centralized team, Program managers, supervisors, and direct staff will be trained on the eligibility criteria to ensure clients are appropriately identified and have access to HFW services. Staffing will be in alignment with DMH Program Service exhibit. All programs provide after hours support to clients in crisis with trained staff to respond to needs.

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

TGC will follow the Program Service Exhibit outlined by DMH to ensure service delivery, staffing, and data collection is followed with fidelity to the model.

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied., (c) N/A (AAP funded Wraparound)

Description of Practice, Name of Supporting Documentation and Page #:

TGC will utilize the flex funds allocated in our contract and follow limits of use to apply to HFW clients outlined in DMH Program Service Exhibit. Flex Funds requests are submitted by treatment team, reviewed by supervisor/manager/director and approved and processed. Requests are logged and tracked.

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

All requests for flex funds are logged by program managers/supervisors and reported to accounting department who submits to LACDMH for reimbursement tracked in spreadsheet. If amount is under allotted max amount as determined by LACDMH then approval is granted and purchase made. If amount is over allotted, then request is submitted to LACDMH with explanation of need and processed if approved by LACDMH. Supporting Documents: LACDMH Reasonable and allowable Purchase Limits; TGC Flex Funds Detail Report Tracking Spreadsheet

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

In addition to following the funding allocations and guidelines by DMH Program Service Exhibit. TGC will utilize fundraising dollars from sponsorship opportunities that are specifically for families in crisis.

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

TGC strategic plan includes goals and strategies for being the employer of choice and inclusive hiring practices. This includes partnerships with local universities, participating in job fairs, and accepting employment referrals from staff. To meet linguistic demands job posting include criteria specific to the language needs of the community we share. In addition, TGC utilizes Language Line to ensure we can provide for the diverse linguistic needs of the community.

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

TGC will leverage our JEDI strategies to ensure training and support is provided. We will seek appropriate community partnerships.

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

HFW will be promoted agency wide with a top-down approach of modeling and communicating the standards of HFW. Quarterly Clinical Leadership meetings will allow for training and program updates as needed. To enhance communication, shared language will be established to ensure shared mission and compliance.

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Job Descriptions will include necessary knowledge, skills, experience, and adherence to training to supports tasks of that role in HFW. All roles/function will be covered by staff on the HFW team.

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

HFW leadership in collaboration with the Human Resources Department will ensure that positions are compensated in a manner comparable to position and service area. As part of the TGC strategic plan hiring, promotion, and performance evaluation processes are assessed on an ongoing basis to ensure equity and stabilize staffing.

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

Staff will attend the HFW training provided by UC Davis and possibly in the future agency will work with UC Davis Training for Trainers to have an internal trainer due to limited availability of the UC Davis Trainings currently. HFW supervisor will utilize CFT Observational Tool to assesses adherence to the model quarterly and staff performance is reviewed twice per year. All training requirements determined by LACDMH and UC Davis for compliance with HFW will be completed.

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

Families and youth will be encouraged to participate in program evaluation and improvement as well as training upon graduation from HFW services. Community Partnerships will be strengthened to support HFW services and training.

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

All staff will be provided initial training through UC Davis or a UC Davis Train the Trainer graduate on all aspects of HFW. All staff have access to support 24/7 from direct supervisor, manager, or after-hours team supervisor/LPS.

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

Performance and service delivery is monitored regularly (frequency depends on task being monitored) and staff are provided regular feedback in supervision meetings and formal feedback twice per year. Data collected will be analyzed by HFW Supervisor, Director, and agency leadership to make any adjustments needed to improve service delivery. Agency representative will communicate with Community Leadership Team any barriers as well as share strategies utilized to successfully overcome barriers.

Date Started: December 8, 2025

Date Submitted: January 10, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for timely engagement, process documented in Program Manual pages 2-4 (Program Overview) and page 18 (Phase One – Engagement).

The Case Manager/Facilitator completes the initial Wraparound Plan of Care with family, Program Manager tracks timeliness, process documented in Program Manual pages 2-4 (Program Overview), page 18 (Phase One – Engagement) and pages 31-32 (Phase Three – Implementation).

The Case Manager/Facilitator schedules monthly Family Team Meetings (FTM) it is a standing agenda item at each FTM, process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development).

Care Plan Review is a standing agenda item for Family Team Meetings (FTM), Case Manager/Facilitator updates the Plan of Care after monthly FTM, Program Manager tracks timeliness, process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development) and in Family Profile Templates pages 8-9 (Child and Family Team Meeting Agenda)

Wrap Staff and supervisors are provided weekly supervision with opportunities for timeline feedback and engagement strategy, process documented in Program Manual pages 35-36 (Fidelity Monitoring Plan).

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the development and documentation of the Family Vision and Team Mission Statements, process is documented in the Program Manual pages 18-22 (Phase One – Engagement) and pages 27-28 (Phase Two – Plan Development).

The Case Manager/Facilitator seeks and records Family Voice data, process is documented in Program Manual pages 27-28 (Phase Two – Plan Development) with specifics in Family Profile Template pages 1-4 (Initial Child and Family Team Meeting agenda).

The Program Manager and the Support Specialist observe FTMs and review documentation every 90 days. Process documented in Program Manual page 35 (Fidelity Monitoring Plan).

Feedback from families is elicited every 6 months with the WFI-EZ and informally every 90 days. Process documented in Program Manual pages 33-34 (Data and Reporting) and pages 35-36 (Fidelity Monitoring Plan).

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the team to complete a Team Strengths Inventory and Natural Supports Inventory during Phase 2. Process is documented in Program Manual Page 27 (Phase Two – Plan Development) and Family Profile Template pages 6-7 (Natural Supports and Team Strengths Inventory)

The Strengths Inventory includes but is not limited to IP-CANS data. The HNH Intake Questionnaire expands on strengths exploration. Process is documented in Program Manual Page 18 (Phase One – Engagement) and Family Profile Templates Page 7 (Team Strengths Inventory).

The Training Plan includes ongoing opportunities for strengths-based, solution-focused services training and staff are provided weekly supervision. Process documented in Program Manual pages 51-54

The Program Manager is responsible for eliciting feedback from families on a routine basis. Process documented in the Program Manual pages 33-36 (Data and Reporting/Fidelity Monitoring Plan).

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager conducts an IP-CANS assessment during the Engagement phase. Process documented in Program Manual page 23-24 (Referral and Engagement).

All staff receive foundational training through UC Davis and are provided additional coaching and supervision on a regular basis. Process documented in Program Manual pages 51-54 (Training Plan)

The Case Manager/Facilitator is certified in IP-CANS assessments and utilizes the HNH Intake Questionnaire for further needs discovery. Process documented in Program Manual page 18-19 (Phase One – Engagement).

The Case Manager/Facilitator is responsible for tracking met and unmet needs and the care plan is updated with the progress. The Transition plan is reviewed with the family and then the entire team 90 days prior to the contract end date to ensure all needs are sufficiently met. Process documented in Program Manual pages 43-44 (Phase Four – Transition).

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Care plans are guided by IP-CANS assessment and thorough exploration of the family’s profile. Process documented in Program Manual pages 2-4 (Program Overview), pages 27-29 (Phase Two – Plan Development) and the Family Profile Templates pages 1-10.

All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training module. Process documented in Program Manual pages 51-54 (Training Plan).

Case Managers/Facilitators receive weekly coaching and supervision and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules. Process documented in Program Manual pages 35-36 (Fidelity Monitoring Plan).

Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. All care plans are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation).

The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator completes the initial Natural Supports Inventory during Phase 1 and updates are made during Care Plan updates. Process documented in Program Manual page 18 and in the Family Profile Templates page 6 (Natural Supports Inventory).

All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules and Skills Labs. Process documented in Program Manual pages 51-54 (Training Plan).

Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. All care plans are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation).

The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator guides the family through the creation of a Family Profile during Phase 1. Process documented in Program Manual page 18 (Phase One – Engagement), pages 27-29 (Phase Two – Plan Development) and the Family Profile Templates pages 1-10.

All HNH Staff receive weekly coaching and adhere to an agency specific training plan utilizing UC Davis Wraparound Training modules and Skills Labs. Process documented in Program Manual pages 51-54 (Training Plan).

The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan).

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator guides the creation of a team agreement in the initial Family Team Meeting. Process documented in Program Manual page 27 (Phase Two – Plan Development) and in the Family Profile Templates page 10 (Team Agreement Template).

The Program Manager utilizes monthly Parent Support group assessments and the 6 month WFI-Ez cycles to elicit family feedback. Quality assurance phone calls are conducted on a regular basis and utilized in monthly supervision and annual performance reviews. Process documented in Program Manual pages 33-34 (Data and Reporting Plan)

Feedback is collected using WrapStat and integrated into weekly supervision and annual performance reviews. Data is collected by Program Manager and reviewed by the Operations Director/Clinical Director for continuous quality improvement. Process documented in Program Manual pages 36-37 (Fidelity Monitoring Plan)

Care Plans are updated on a monthly basis and published by the Case Manager/Facilitator. Action items are reviewed at each Family Team Meeting. Care plans and Family Team Meeting minutes are reviewed by the Program Manager every 90 days. Process documented in Program Manual pages 31-32 (Phase Three – Implementation) and pages 36-37 (Fidelity Monitoring Plan).

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

The HNH Care Plan template documents specific strategies, their unit and rate of measure and assigned action items with timeframes for reassessment. Process documented in Program Manual pages 31-32 (Phase Three – Implementation) and the Child and Family Plan of Care template.

The Case Manager/Facilitator reviews action item completion as a standing agenda item at Family Team Meetings. HNH staff action items are reviewed weekly in supervision and in team meetings. Process documented in Program Manual page 2-4 (Program Overview), page 19 (Phase One – Engagement) and in the Family Profile Templates pages 8-9 (Child and Family Team Meeting Agenda template)

Strategies and action items are reviewed on a weekly basis in individual supervision and in all staff meetings. All forms are living documents in agency cloud storage. Process documented in Program Manual page 30 (Phase Three – Implementation).

Initial IP-CANS are completed in Phase 1 by the Program Manager. The Case Manager/Facilitator is responsible for facilitating the IP-CANS every 90 days throughout Phase 3 and 4. Process documented in Program Manual page 10 (Program Overview), pages 23-24 (Referral and Engagement), page 33 (Data and Reporting Plan).

HNH staff utilize Opeeka to support tracking and share information amongst team members. IP-CANS data informs plan of care updates every 90 days in addition to monthly review and updates throughout Phase 3 and 4. Process documented in Program Manual page 33 (Data and Reporting Plan).

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for monitoring and encouraging team persistence with the guidance of the Clinical Supervisor. Process documented in Program Manual page 35-36 (Fidelity Monitoring Plan).

Weekly supervision is provided to all staff by the appropriate organizational leader. Org chart documented in the 2026 Wraparound Organizational Chart. Access to flexible funding and additional support is requested in weekly individual supervision and all staff meetings. Process documented in Program Manual page 30 (Phase Three – Implementation), pages 35-36 (Fidelity Monitoring Plan).

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Sustainable transition of services is a priority throughout Phase 3 in preparation for Transition. The Case Manager/Facilitator is responsible for leading the team through identifying readiness for transition and planning for the end of services. Process documented in Program Manual page 4 (Program Overview) and pages 43-44 (Phase Four – Transition).

The Case Manager/Facilitator is responsible for organizing transition celebrations according to the youth and family’s preferences and flexible funds, staff time, and community partnerships are prioritized for celebrations. Process documented in Program Manual page 44 (Phase Four – Transition).

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate youth and family satisfaction with HFW. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved school functioning over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for school functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved functioning in the community over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for community functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved interpersonal functioning over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for interpersonal functioning needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate improved caregiver confidence over the course of HFW enrollment. The Case Manager/Facilitator tracks progress for caregiver confidence needs and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-EZ evaluation cycles. Additional feedback on caregiver confidence is collected monthly during the agency hosted parent group. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of and types of placement changes over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards stable and least restrictive living environments and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of hospital visits over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards fewer or no hospital visits and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the frequency of crises and level of involvement of professional support when crises occur over the course of HFW enrollment. The Case Manager/Facilitator tracks progress towards averting most crisis situations and manage impending crises without professional support and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan).

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

HNH utilizes the WFI-Ez managed through WrapStat to record and evaluate the when and why families exit HFW. The Case Manager/Facilitator guides the family through exploring transition readiness and updates the Plan of Care accordingly with the team at each Family Team Meeting, guided by quarterly IP-CANS. The Program Manager is responsible for the WFI-Ez evaluation cycles. Process documented in Program Manual page 31-32 (Phase Three – Implementation) and page 33 (Data and Reporting Plan), pages 43-44 (Phase Four – Transition).

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager initiates the orientation conversation during Phase 1 and reviews the Program Overview documented in the Program Manual pages 1-17 (Program Overview). The Case Manager/Facilitator deepens family understanding of HFW throughout HFW enrollment.

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator guides the family through developing and initial Family Safety Plan (crisis plan) in Phase 1. Process documented in the Program Manual page 18 (Phase One – Engagement) and in the Family Crisis and Safety Plan Template.

The Family Safety Plan (crisis plan) is kept updated in the family’s plan of Care through Phase 2 and into Phase 3. Process documented in Program Manual pages 27-29 (Phase Two – Plan Development) and pages 31-32 (Phase Three – Implementation).

The Program Manager with the support of the Case Manager/Facilitator ensures all Wraparound families are informed and able to access the agency 24/7 on call crisis response and provided with local community crisis response numbers as a backup. Process documented in Program Manual pages 16-17 (Program Overview) and in the Family Crisis and Safety Plan Template.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator is responsible for guiding the family through developing a Family Vision statement during Phase 1. Process documented in Program Manual page 18 (Phase One – Engagement) and in the Family Profile Templates pages 1-4 (Initial Family Team Meeting agenda).

The Case Manager/Facilitator is responsible for guiding the family through an initial Strengths/Needs/Culture discovery and is responsible for keeping the discovery updated in the Plan of Care as needed, at minimum every 90 days. Plans of Care are available and provided to all team members as they are added to the team and again every 90 days. Process documented in Program Manual page 27 (Phase Two – Plan Development) and Page 31 (Phase Three – Implementation).

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator guides the family through the completion of an initial Natural Supports inventory in Phase 1. Process documented in Program Manual page 18 and Family Profile Templates page 6 (Natural Supports Inventory).

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator is responsible for arranging meeting logistics. Process is documented in Program Manual page 27 (Phase Two – Plan Development) and page 30 (Phase Three – Implementation).

HNH Staff follow the agency specific training plan that utilizes the UC Davis Wraparound training modules and skills labs. Process is documented in the Program Manual page 51-54 (Training Plan).

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the Child and Family team through the development of team agreements, team strengths inventory, and mission statement in the development of the Family Profile in Phase 1 and into Phase 2. Process documented in Program Manual page 2 (Program Overview), pages 18-19 (Phase One), and page 27 (Phase Two).

All documents including the strengths inventory is guided by the IP-CANS and kept updated as additional strengths are identified and again every 90 days. Process documented in Program Manual pages 27-32 (Phase Two through Phase Three)

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager conducts the initial IP-CANS assessment during Phase 1.

The Case Manager/Facilitator guides the Child and Family team in developing measurable goals and outcomes from identified needs. These steps are utilized to develop the individualized HFW Plan of Care after the initial full Child and Family Team Meeting. Process documented in Program Manual pages 27-29 (Phase Two).

The HNH Plan of Care template allows for easy documentation of identified & brainstormed strategies and additional documentation is recorded in weekly team meeting notes and progress notes from HNH staff. Process is documented in the Program Manual pages 27-28 (Phase Two – Plan Development) and pages 30-32 (Phase 3 – Implementation).

Case Managers/Facilitators receive continual training in the development of Plans of Care to guide strategy and action item development. Process documented in Program Manual pages 51-54 (Training Plan).

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Case Managers/Facilitators follow the agency specific training plan and engage in weekly supervision to ensure the development of specific and individualized Care Plans. Process documented in Program Manual pages 51-54 (Training Plan).

The Case Manager/Facilitator guides the development and updating of the Plan of Care. The entire CFT team contributes to the Plan of Care and the living document is distributed to all team members. Process is documented in Program Manual pages 30-32 (Phase Three – Implementation).

The Program Manager reviews all care plans on a regular basis to ensure fidelity. Process documented in Program Manual page 35 (Fidelity Monitoring Plan).

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the Child and Family team in the development of the crisis and safety plan which is kept updated in the youth and family file. The Program Manager reviews all Family Safety Plan Process is documented in the Program Manual page 18 (Phase One – Engagement), page 27 (Phase Two – Plan Development) and in the Family Crisis and Safety Plan Template.

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the team in monthly team meetings. All HNH staff meet weekly to collaborate and track action items and strategy progress. Process documented in Program Manual pages 3-4 (Program Overview) and pages 30-32 (Phase Three: Implementation)

All HNH staff follow the agency specific training plan utilizing UC Davis Wraparound training modules and skills labs. Process documented in Program Manual pages 51-54 (Training Plan)

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads monthly review of the Plan of care progress and development as a standing agenda item. Plan adjustments are communicated to the entire team and kept on file. The Program Manager reviews all Plans of Care for accuracy and continuous quality improvement at least every 90 days. Process documented in Program Manual pages 27-32 (Phase 2 – Phase 3)

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator is responsible for and supported in developing team cohesion and trust. Support is provided in weekly supervision, coaching, and continual training. Process documented in Program Manual pages 27-32 (Phase 2 – Phase 3), pages 35-36 (Fidelity Monitoring Plan), and pages 52-53 (Training Plan)

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator leads the team in the identifying readiness for transition, the development of a formal transition plan, and a warm handoff to post adoption services when applicable. Process documented in Program Manual pages 43-44 and the Transition Plan template Pages 1 – 5

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator updates the Family Crisis and Safety Plan throughout the Transition phase in preparation for the end of formal HFW services. Plans are developed by the CFT and reviewed by the Program Manager. Process documented in Program Manual page 4 (Program Overview) and page 43 (Phase 4: Transition).

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

The Case Manager/Facilitator is responsible for planning and coordinating a celebration of commencement of HFW services that is specific and culturally relevant. Process is documented in Program Manual page 44 (Phase 4: Transition)

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

Families are central to the planning process. Their perspectives, preferences, and values drive decision-making. Family and youth /child perspectives are intentionally included throughout the wraparound process and the team strives to provide service options and choices that reflect the family values and preferences. Process is documented in the Program Manual page 5 (Program Overview) and pages 27-28 (Phase 2: Plan Development).

The Program Manager is responsible for eliciting family feedback through the WFI-EZ and quality assurance calls to be used in continuous quality improvement and workforce development. The Case Manager/Facilitator engages in weekly conversation at a minimum with the family to ensure ample opportunity to inform service planning and implementation. Process documented in Program Manual pages 9-10 (Program Overview) pages 33-34 (Continuous Quality Improvement – Data and Reporting Plan).

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : N/A (AAP funded Wraparound programs)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for determining eligibility during the engagement phase. All eligible youth are able to receive services. Process documented in Program Manual pages 23-24 (Referral and Engagement)

The HNH HFW staffing plan enforces case load limits to balance assignments in a way that supports families with complex needs. Process documented in Program Manual pages 45-50 (Staffing Plan).

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

With the support of the Operations Director and Executive Director, the Program Manager is responsible for fiscal management within the Wraparound program. Funding at all levels is allocated for the successful delivery of HFW services. Fiscal management documented in the Program Manual pages 37-38 (Support Service Costs) and Page 39 (AAP Fiscal Management Policy and Procedure).

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: (c) N/A (AAP funded Wraparound)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: N/A (AAP funded Wraparound)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: N/A (AAP funded Wraparound)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for monitoring demographic information and population needs. Cultural, racial, and linguistic gaps in staffing are monitored and remedied by the Program Manager. Process is documented in the Program Manual page 45 (Workforce Development – Staffing Plan)

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager with support of the Operations Director is responsible for building relationship with local tribal representatives to ensure staff are culturally respectful, responsive, and ready to serve Native children. Process documented in Program Manual page 45 (Workforce Development – Staffing Plan).

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

Led by the Operations Director, the Program Manager is responsible for facilitating a flexible and creative work environment for all HFW staff. Process documented in Program Manual pages 45-47 (Workforce Development – Staffing Plan).

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Led by the Executive and Operations Director and supported by the Humboldt NeuroHealth HR department, the Program Manager is responsible for the hiring and evaluation of HFW staff and maintenance of the job descriptions in adherence to the HFW model. Process described in the Program Manual pages 45-46 (Workforce Development – Staffing Plan).

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

The Humboldt NeuroHealth HR department works to ensure workforce stability across the agency, including the HFW program. Process documented in Program Manual page 46 (Workforce Development – Staffing Plan).

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for tracking adherence to the Humboldt NeuroHealth HFW Training Plan. Process is documented in Program Manual page 51 (Training Plan).

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for tracking adherence to the HFW Training Plan. With the support of the Operations Director, the Program Manager is also responsible for identifying and facilitating community participation and collaboration to ensure lived experience is meaningfully incorporated into the HNH Wraparound training plan. Active engagement with community partners across Children’s Systems of Care strengthen community supports and strengthen partner participation in HFW teams. Process documented in Program Manual page 47 (Workforce Development – Staffing Plan) and pages 51-54 (Training Plan).

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for adherence to the Training plan and ensuring all staff have open access to coaching and supervision as needed. Process documented in Program Manual page 51 (Training Plan) and pages 35-36 (Fidelity Monitoring Plan).

Procedures Ensure:

N/A

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

The Program Manager is responsible for evaluating metrics and outcomes and integrating it into continual program improvement. Process is documented in Program Manual page 33-34

Date Started: November 26, 2025

Date Submitted: January 19, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures timely engagement and planning through clearly defined intake, engagement, documentation, and supervisory oversight procedures. Upon referral, families are contacted as soon as possible, and an intake is scheduled no later than 10 calendar days. Engagement activities prioritize immediate safety, orientation to the Wraparound process, and stabilization needs. Facilitators complete an initial Wraparound Plan of Care within thirty (30) calendar days of service start. Plans of Care are reviewed in Child and Family Team (CFT) meetings at least every 30–45 days and formally updated and redistributed to all team members no less than every ninety (90) days, or more frequently as needed.

Timeliness is actively monitored through supervisory chart reviews, internal quality record reviews, and CQI dashboards. Staff receive ongoing feedback regarding compliance with timelines, and corrective coaching is provided when standards are not met. Facilitators are trained in alternative engagement strategies to address barriers to contact, including flexible scheduling, community-based outreach, and use of natural supports.

Supporting Documentation
• Wrap Connections Process Checklist (Pg34)
• Documentation Certification Policy & Procedure (Pg 80)
• Internal Quality Records Review Policy (Pg 94)
• New Hire Orientation Checklist (Pg 189)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

The Wraparound process is explicitly led by youth and families, whose perspectives guide all planning and decision-making. Facilitators elicit, document, and continuously reference the Family Vision and Team Mission statements, ensuring services reflect family values, culture, strengths, and preferences. Youth and families are viewed as equal partners and primary decision-makers throughout engagement, planning, implementation, and transition.

In cases involving Indian children, Tribal representatives are actively engaged as equal members of the High-Fidelity Wrap (HFW) team, and Tribal voice is prioritized in accordance with ICWA principles. Supervisors routinely review Plans of Care, meeting minutes, and case documentation to ensure family voice is clearly reflected. Family feedback is gathered through satisfaction surveys, quality assurance outreach, and fidelity tools and is incorporated into CQI processes.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 &Pg 39)
• Training Policy & Procedure (Pg 153)
• Continuous Quality Improvement Plan (Pg 67)
• Performance Evaluation – Direct Care Staff (Pg 203)

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound utilizes a strength-based approach throughout the HFW process. Facilitators work collaboratively with youth, families, team members, and community partners to identify functional strengths that directly inform strategy development and decision-making. Strengths are documented in the Plan of Care and updated as new strengths emerge. The IP-CANS is used as a required tool for strengths identification and integration into planning.

Staff receive ongoing training and coaching in strength-based and solution-focused practices. Supervisory review and CQI audits ensure strengths are actively utilized in planning rather than merely listed. Family feedback regarding strength-based service delivery is routinely collected and used to inform training and coaching.

Supporting Documentation
• IP-CANS (Pg 96)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Training Policy & Procedure (Pg 153)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

All services and supports are driven by the identification of underlying needs rather than behaviors or service categories. Facilitators receive training and coaching on developing needs statements that reflect the root causes of challenges. Identified needs guide the development of goals, strategies, and outcomes, and the Wraparound process continues until those needs are sufficiently met.

The IP-CANS is required for needs identification and prioritization. Supervisors review Plans of Care and documentation to ensure needs statements are clinically sound, individualized, and appropriately linked to strategies and outcomes. Transition decisions are made collaboratively with the team and family when needs have been met.

Supporting Documentation
• IP-CANS (Pg 96)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Each Wraparound Plan of Care is uniquely tailored to the youth and family’s strengths, needs, culture, values, and preferences. Documentation tools are designed to allow flexibility and creativity in strategy development. Facilitators receive ongoing coaching to customize the Wraparound process and avoid formulaic planning.

Supervisors routinely review Plans of Care to ensure individualization is evident and strategies reflect community assets, informal supports, and family-identified priorities. Family feedback regarding the customization of services is collected and used for CQI and staff coaching.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Natural and community supports are considered essential members of the HFW team. Facilitators complete and update a natural supports inventory with each family and intentionally integrate natural supports into planning and strategy implementation. Plans of Care prioritize community-based strategies to promote sustainability and reduce reliance on formal services over time.

Staff receive training and coaching on identifying, engaging, and maintaining natural supports. Supervisory review and CQI monitoring assess the extent to which Plans of Care incorporate community and natural supports.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Training Policy & Procedure (Pg 153)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound recognizes culture as a source of strength. Facilitators complete strengths, needs, and cultural discovery activities prior to Plan of Care development and incorporate cultural values, traditions, and preferences into service delivery. Staff receive ongoing training in cultural responsiveness, including ICWA and Tribal sovereignty when applicable.

Family feedback regarding cultural respect and relevance is routinely collected and used to inform CQI, supervision, and training.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• Wrap Plan / Care Plan Templates (Pg 37 & 38)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

HFW teams include formal and natural supports across systems and operate collaboratively to implement and monitor the Plan of Care. Team agreements are developed and documented to guide participation and decision-making. Facilitators intentionally foster team cohesion, shared ownership, and accountability.

Feedback from families and team members is routinely collected through observations, surveys, and QA outreach and used for CQI and staff coaching. Plans of Care and meeting minutes are reviewed for follow-through and shared responsibility.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Continuous Quality Improvement Plan (Pg 67)
• Performance Evaluation – Direct Care Staff (Pg 203)

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

Plans of Care include measurable goals, strategies, and action items with defined timeframes. Facilitators track completion of action items and review progress at CFT meetings. Outcome data, including IP-CANS results, informs decision-making and plan adjustments.

Data is used to support planning and transition readiness but does not replace team-based monitoring of needs and outcomes. CQI dashboards and supervisory reviews ensure outcomes-based fidelity.

Supporting Documentation
• IP-CANS (Pg 96)
• Wrap Plan / Care Plan Templates(Pg 37 & 39)
• Continuous Quality Improvement Plan (Pg 67)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

Setbacks are viewed as indicators that plans require revision rather than evidence of youth or caregiver failure. Teams are supported to continue working with families until needs are met and the family agrees services should end. Clear processes exist for accessing additional coaching, supervision, flexible funding, and system supports.

Facilitators receive training in post-crisis planning, conflict resolution, and effective brainstorming. Persistence is monitored through supervisory review and CQI discharge analysis.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• Flex Funds Policy & Procedure (Pg 84)
• Continuous Quality Improvement Plan (Pg 67)

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Transitions are planned in advance and occur only when youth and family needs have been sufficiently met. Families do not experience sudden loss of services due to administrative reasons or adverse events. Transition planning includes preparation of natural supports, community resources, and post-Wraparound safety planning.

Transitions are celebrated in culturally relevant ways, and administrative structures support staff participation and use of flex funds for celebrations when appropriate.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Flex Funds Policy & Procedure (Pg 84)
• Continuous Quality Improvement Plan (Pg 67)

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound actively monitors youth, family, and (when applicable) Tribal satisfaction with the High-Fidelity Wraparound (HFW) process and perceived progress toward goals. Satisfaction data is collected at multiple points during service delivery and at transition, ensuring feedback reflects the family’s experience across all phases of Wraparound. Feedback mechanisms include structured satisfaction surveys, quality assurance follow-up, and team-based discussions. In cases involving Indian children, Tribal partners are engaged as appropriate to assess satisfaction with collaboration, communication, and cultural responsiveness.

Collected satisfaction data is reviewed through Continuous Quality Improvement (CQI) processes and shared with supervisors and leadership to inform practice improvements, staff coaching, and training priorities.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Internal Quality Records Review Policy (Pg 94)
• Documentation Certification Policy & Procedure (Pg 80)
• Wrap Connections Process Checklist (Pg 34)

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Educational and vocational functioning is monitored as a core outcome of Wraparound services. Facilitators collaborate with youth, caregivers, schools, and educational partners to track attendance, academic engagement, IEP/504 participation, and vocational development. Educational progress is reviewed during Child and Family Team (CFT) meetings and incorporated into the Plan of Care as goals, strategies, and outcomes.

School functioning data is documented in the youth’s record and reviewed through supervisory oversight and CQI outcome monitoring to identify trends, barriers, and opportunities for cross-system coordination.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound monitors youth functioning in the community, including engagement in pro-social activities and reduced involvement with the juvenile justice system . Facilitators work with families and community partners to identify meaningful community activities aligned with youth strengths and interests. Community functioning outcomes are discussed during team meetings and documented in Plans of Care.

Data related to justice involvement, community participation, and behavioral stability is reviewed through CQI processes to assess effectiveness of strategies and inform plan adjustments.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Wrap Connections Process Checklist (Pg 34)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Interpersonal functioning outcomes focus on reduced family stress, improved relationships, and strengthened peer connections. Facilitators support families in identifying relational needs and developing strategies that promote healthy communication, conflict resolution, and connection. Progress is reviewed during team meetings and documented in the Plan of Care.

Supervisors and CQI reviews assess whether interpersonal functioning outcomes are addressed through individualized strategies and whether progress is evident over time.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Wraparound services aim to increase caregiver’s confidence and capacity to manage future challenges independently. Facilitators support caregivers in identifying skills, resources, and supports that enhance confidence and crisis preparedness. Caregiver confidence is discussed during planning and transition and documented as an outcome within the Plan of Care.

CQI processes review caregiver-related outcomes to ensure services are building sustainable skills and connections to community resources.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Training Policy & Procedure (Pg 153)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound prioritizes permanency and stability in the least restrictive, community-based living environments. Placement stability is monitored throughout service delivery, with team-based problem-solving used to prevent unnecessary placement changes or institutionalization. Placement changes, when they occur, are documented and reviewed to identify contributing factors.

CQI dashboards and discharge reviews monitor trends in placement stability and inform program-level improvements.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Internal Quality Records Review Policy (Pg 94)
• Documentation Certification Policy & Procedure (Pg 80)

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Behavioral health stability is measured through monitoring inpatient admissions and emergency department visits. Facilitators coordinate with behavioral health providers and caregivers to identify triggers, enhance crisis planning, and implement preventative strategies. Hospital utilization data is reviewed during team meetings and incorporated into plan revisions.

CQI outcome analysis tracks trends in inpatient and emergency utilization to evaluate program effectiveness and guide training and service improvements.

Supporting Documentation
• Safety Planning (Pg 35)
• Continuous Quality Improvement (CQI) Plan(Pg 67)
• Documentation Certification Policy & Procedure (Pg 80)
• Incident Reporting Policy & Procedure (Pg 89)

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound emphasizes proactive crisis prevention and natural support utilization. Crisis frequency, intensity, and professional involvement are documented and reviewed. Facilitators work with families to strengthen natural supports and crisis response strategies, reducing reliance on professional crisis services over time.

Crisis data is reviewed through CQI processes and supervision to ensure crisis plans are effective and individualized.

Supporting Documentation
• Safety Plan (Pg 35)
• Wrap Connections Process Checklist (Pg 34)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Incident Reporting Policy & Procedure. (Pg 89)

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

Youth and families exit Wraparound services based on stabilization and sufficient progress in meeting identified needs. Discharges do not occur due to adverse events or administrative requirements. Transition readiness is determined collaboratively by the team and family and documented in the youth’s record.

CQI discharge reviews evaluate reasons for exit, outcomes achieved, and sustainability of supports to ensure fidelity to Wraparound principles.

Supporting Documentation
• Transition Planning Documentation (RTWB slide 12 )(Pg 12)
• Wrap Connections Process Checklist (Pg 34)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures that all youth and families receive a thorough orientation to the High-Fidelity Wraparound (HFW) process at the outset of services. Facilitators explain the principles and phases of Wraparound, legal and ethical considerations (including confidentiality, mandated reporting, and informed consent), and the roles and responsibilities of all team members. This includes a clear explanation of the family’s central role, the importance of natural supports, and, in the case of an Indian child, the role of the Tribe as an equal partner in the HFW team.

Orientation is conducted using developmentally appropriate and culturally responsive methods and is documented in the youth’s file. Supervisors review documentation to ensure orientation was completed and that families demonstrate understanding of the process, expectations, and their rights.

Supporting Documentation
• New Hire Orientation Checklist (Pg 189)
• Training Policy & Procedure (Pg 153)
• Wrap Connections Process Checklist (Pg 34)
• RTWB (Engagement, slide 11) (Pg 9)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

During the Engagement phase, facilitators address immediate safety and crisis concerns to ensure families can meaningfully participate in the Wraparound process. Initial safety and crisis needs are discussed with the youth and family, and when pressing concerns are identified, an immediate crisis response plan is developed, provided to the family, and documented in the youth’s chart.

Families are informed of and provided access to 24/7 crisis response resources. The initial safety plan supports stabilization and informs, but does not replace, the more comprehensive HFW Safety Plan developed during the Plan Development phase. Supervisors review crisis documentation to ensure responsiveness, clarity, and alignment with Wraparound principles.

Supporting Documentation
• RTWB (slide 24) (Pg 24)
• Safety Plan (Pg 35)
• Wrap Connections Process Checklist(Pg 34)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

Wrap Connections facilitators guide structured discovery conversations with youth and families to identify individual and family strengths, underlying needs, cultural values, traditions, and a shared vision for a better future. A Family Vision statement is completed with every family during the Engagement phase and documented in the youth’s chart.

A Strengths, Needs, and Culture Discovery document is initiated for every family, updated at least every 90 days, and revised as new information emerges. This document is shared with all team members and provided to new team members as they join the process. Discovery activities inform initial Plan of Care development and ensure continuity as teams evolve.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• RTWB (slide 13) (Pg 13)
• IP-CANS (Pg 96)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

Wrap Connections actively engages all relevant team members across Children’s System of Care partners, including formal providers, natural supports, and Tribal representatives when applicable. Facilitators collaborate with youth and families to identify individuals who care about and can support the family and clarify each member’s role and responsibilities on the team.

A natural supports inventory is completed and documented for every youth and family. Facilitators intentionally engage team members through inclusive communication, role clarification, and team-building activities that foster collaboration and shared ownership. Engagement efforts and team-building activities are documented in meeting minutes or case notes and reviewed through supervision and CQI processes.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• RTWB (slide 23) (Pg 23)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Wrap Connections prioritizes family voice and choice in arranging meeting logistics. Child and Family Team meetings are scheduled at times and locations that are convenient, accessible, and responsive to family needs, culture, and trauma history. Facilitators demonstrate flexibility in work hours and utilize community-based locations, telehealth, transportation support, and interpretation services as needed to maximize participation.

Staff are trained to collaborate with families and team members to schedule meetings that support engagement, equity, and full participation. Meeting logistics and accommodations are documented and reviewed through supervisory oversight and documentation certification.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• Wrap Connections Process Checklist (Pg 34)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Building on the Engagement phase, the Wrap Connections facilitator leads the Child and Family Team in establishing the foundational structures that guide collaboration and decision-making throughout the Wraparound process. Prior to development of the initial Wraparound Plan of Care, the facilitator supports the team in developing formal team agreements that outline how members will participate in meetings, communicate respectfully, resolve conflict, and make decisions.

In addition, the team identifies and documents additional strengths of the youth, family members, other team participants, and the broader community. Strengths identified during engagement are revisited and expanded as new strengths emerge through relationship-building and collaboration. The facilitator also guides the team in creating a clear Team Mission statement that aligns with and operationalizes the Family Vision, defining the shared purpose and direction of the HFW process.

Team agreements, updated strengths inventories, and the Team Mission are documented in the youth’s file and reviewed by supervisors to ensure fidelity to Wraparound principles and readiness for Plan of Care development.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• RTWB (slide 13) (Pg 13)
• Wrap Connections Process Checklist (Pg 340
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator guides the HFW team in reviewing needs identified during engagement, identifying any additional underlying needs, and collaboratively prioritizing those needs before developing goals or strategies. Needs statements focus on the underlying reasons for challenges rather than behaviors or service categories. The IP-CANS is utilized to support identification and prioritization of needs.

From prioritized needs, the team develops specific, measurable goals and outcomes that reflect youth and family priorities. Facilitators intentionally engage the team in brainstorming multiple individualized and creative strategies to address each prioritized need. Strategies are discussed, refined, and selected collaboratively before responsibility is assigned in the form of clear action items.

Facilitators receive training and coaching in needs-driven planning, collaborative goal development, and effective facilitation of strategy brainstorming. Documentation of needs, goals, outcomes, brainstormed strategies, and assigned action items is reviewed through supervision and CQI processes to ensure fidelity and quality.

Supporting Documentation
• IP-CANS (Pg 96)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW team develops a comprehensive, individualized initial Plan of Care that integrates the prioritized needs, goals, and strategies identified through team planning. The facilitator leads a high-quality, collaborative planning process that includes all relevant Children’s System of Care partners and, in the case of an Indian child, Tribal representatives. The planning process elicits multiple perspectives, builds trust and shared vision, and reflects Wraparound values and principles.

The Plan of Care is aligned with the Family Vision and Team Mission and addresses needs across multiple life domains. Strategies and action items are clearly documented, including assigned responsibility, timelines, and expectations. Plans reflect a balanced mix of formal services, natural supports, and community resources, with an intentional emphasis on increasing reliance on natural supports over time. Services are coordinated across systems and delivered in community-based settings that are accessible and responsive to family needs, culture, and trauma history.

Plans also include benchmarks for gradual transition from formal services to less intrusive and more sustainable supports, paced according to family readiness. Plans of Care are documented in the youth’s file, distributed to all team members, and routinely reviewed through CQI processes and supervisory oversight to provide feedback and guide training and coaching.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Wrap Connections Process Checklist (Pg 34)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80
• Continuous Quality Improvement (CQI) Plan (Pg 67

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator leads the HFW team in developing an individualized crisis and safety plan that identifies safety needs, potential high-risk and crisis situations, and proactive and reactive strategies to support the youth and family. Crisis and safety planning occurs in a collaborative, team-based environment and prioritizes strategies selected by the youth and family. Plans are culturally relevant and maximize the use of natural supports whenever possible.

The crisis and safety plan clearly documents warning signs, prevention strategies, response steps, and specific contacts for 24/7 support. Facilitators receive training and coaching in crisis and safety planning, including how to support families in developing realistic, strengths-based strategies. Crisis and safety plans are reviewed through supervision and CQI processes to assess individualization, progression of strategies, cultural relevance, and effective integration of natural supports.

Supporting Documentation
• Safety Plan (Pg 35)
• Wrap Connections Process Checklist (Pg 34)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure(Pg 80)
• Continuous Quality Improvement (CQI) (Pg 67)

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures consistent and high-fidelity implementation of the Wraparound Plan of Care through structured team facilitation, documentation, and supervisory oversight. The facilitator leads Child and Family Team (CFT) meetings using agendas and meeting minutes that explicitly review strategies, action items, assigned responsibilities, and progress toward outcomes. Action items are tracked over time, and facilitators check in with team members between meetings as needed to support timelines, remove barriers, and maintain momentum.

Implementation is grounded in Wraparound principles, with an emphasis on strengths-based practice, family voice and choice, cultural responsiveness, and use of natural and community supports. Teams intentionally acknowledge and celebrate successes as they occur—both large and small—to reinforce progress, build hope, and strengthen engagement. Staff receive ongoing training and coaching on effective implementation practices, including how to recognize progress and celebrate achievements in culturally relevant ways.

Supervisors review documentation and meeting records to ensure strategies are actively implemented, progress is monitored, and implementation remains aligned with the Plan of Care.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Wrap Connections Process Checklist (Pg 34)
• RTWB (slide 11) (Pg 11)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

The facilitator engages the HFW team in continuous review of the Plan of Care to assess progress, evaluate the effectiveness of strategies, and respond to changing needs. Reviews of strategies, progress, and action items occur within the context of HFW team meetings, where data, observations, and family feedback inform decision-making.

As successes occur, new needs are identified, or circumstances change, the facilitator leads the team in adjusting goals, strategies, and action items. Updates are documented in the youth’s file and communicated to all team members. Meeting minutes capture completion of tasks, new assignments, team attendance, use of formal and natural supports, use of flex funds when applicable, and updates to the Plan of Care.

Plans of Care are formally updated and redistributed to all team members at least every ninety (90) days and more frequently as needed. Documentation tools are designed to be flexible and individualized, allowing plans to evolve in response to youth and family needs. Supervisors and CQI processes review updated plans to ensure fidelity, clarity, and clinical appropriateness.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Wrap Connections Process Checklist (Pg 34)
• Documentation Certification Policy & Procedure (Pg 80)
• Internal Quality Records Review Policy (Pg 94)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

Throughout implementation, facilitators continually assess and support team cohesion, trust, and shared commitment. Team agreements developed during Plan Development are actively utilized and revisited during HFW team meetings to reinforce expectations for collaboration, communication, and decision-making.

Facilitators receive ongoing training and coaching on building and sustaining effective teams, including strategies for conflict resolution, engagement of diverse perspectives, and reinforcement of shared ownership. The use of natural supports is monitored over time, and facilitators receive feedback through supervision and coaching on strategies to strengthen and expand natural and community-based involvement.

When new team members—formal or natural—are added, facilitators orient them to the Wraparound process, review the current Plan of Care, clarify roles, and engage them in team-building activities. Team functioning and cohesion are reviewed through supervision and CQI processes to ensure effective collaboration in service of youth and family goals.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• Training Policy & Procedure (Pg 153)
• Performance Evaluation – Direct Care Staff (Pg 203)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures that transitions from formal High Fidelity Wraparound services are intentional, needs-driven, and collaboratively planned. Transition planning begins only after the youth, family, and HFW team have identified that pre-determined benchmarks and indicators demonstrate sufficient progress toward completing the Team Mission and meeting prioritized needs. These benchmarks are monitored and adapted throughout the Wraparound process and reviewed during Child and Family Team (CFT) meetings.

Once readiness for transition is identified, the facilitator leads the team in developing an individualized transition plan. The transition plan identifies ongoing needs, services, and supports that will remain in place after formal HFW concludes and outlines clear strategies to transfer any remaining responsibilities from HFW staff to natural supports, community partners, or other service providers. Transition planning occurs in a team-based, collaborative environment that prioritizes family voice and choice.

For adoptive families receiving Adoption Assistance Program (AAP) funding, facilitators provide education regarding available post-adoption services and supports and ensure these resources are incorporated into the transition plan when appropriate. The completed transition plan is documented in the youth’s file, distributed to all team members, and reviewed through supervisory oversight and Continuous Quality Improvement (CQI) processes to ensure sustainability and fidelity.

Supporting Documentation
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Wrap Connections Process Checklist (Pg 34)
• RTWB (slide 12) (Pg 12)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (pg 67)

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

As part of the transition process, the facilitator leads the HFW team in developing or updating an individualized crisis and safety plan that reflects post-transition needs. The post-transition safety plan identifies potential crisis situations that may occur after formal Wraparound services end and includes proactive and reactive strategies designed to prevent escalation and support stability.

Youth and family members play a central role in identifying strategies that are culturally relevant, realistic, and strength based. The plan prioritizes the use of natural and community supports and clearly identifies who to contact for support if concerns arise. Crisis and safety planning occurs in a collaborative, team-based environment, and facilitators receive training and coaching to support effective post-transition planning.

Post-transition safety plans are documented in the youth’s file and reviewed through supervision and CQI processes to assess individualization, progression of strategies, cultural relevance, and effective integration of natural supports. Feedback from these reviews informs ongoing staff training and coaching.

Supporting Documentation
• Safety Plan (Pg 35)
• Wrap Connections Process Checklist (Pg 34)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound recognizes transition from formal Wraparound services as a significant milestone and ensures that the conclusion of HFW is celebrated in a meaningful and culturally relevant manner. Celebrations are planned in collaboration with the youth and family and reflect their values, preferences, culture, and definition of success.

Administrative structures support celebration activities by allowing flexibility in staff time, facilitating community-based celebrations, and providing access to flexible funds when appropriate. Celebrations serve to honor the family’s progress, reinforce strengths and resilience, and support a positive and empowering transition from formal services. Documentation of transition celebrations is reviewed through supervision and CQI processes to ensure consistency with Wraparound values.

Supporting Documentation
• Wrap Connections Process Checklist (Pg 34)
• Flex Funds Policy & Procedure (Pg 84)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound intentionally elevates youth and family voice beyond individual service planning and integrates their feedback into program-level decision-making. Mechanisms are in place to gather youth and family input regarding their Wraparound experience, perceived outcomes, cultural responsiveness, and service accessibility. This feedback is reviewed by supervisors and program leadership and is used to inform service planning practices, workforce development priorities, policy and procedure refinement, and Continuous Quality Improvement (CQI) activities.

Youth and family perspectives are incorporated into program improvement efforts through satisfaction surveys, quality assurance follow-up, discharge feedback, and review of outcome data. Program leadership uses this information to identify strengths in service delivery, address barriers, and guide training and coaching initiatives. When appropriate, aggregated family feedback is shared with leadership forums to ensure accountability to families and alignment with Wraparound values.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Internal Quality Records Review Policy (Pg 94)
• Documentation Certification Policy & Procedure (Pg 80)
• Wrap Connections Process Checklist (Pg 34)

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : N/A (Counties with contracted providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound participates in the county-established Community Leadership Team (CLT), which provides collaborative, cross-system oversight to ensure High Fidelity Wraparound standards are implemented consistently at both organizational and system levels. The CLT engages in shared decision-making and includes representation from child-serving entities, contracted providers, and Tribes within the region, as applicable. Formal communication structures support coordination between the Community Leadership Team and Interagency Leadership Teams (ILTs).

The Community Leadership Team meets regularly and addresses key system-level responsibilities, including identifying and reducing interagency barriers, supporting cross-agency training, promoting culturally responsive and family-centered practices, reviewing family plans at a systems level, monitoring flex fund access and use, and reviewing HFW data to inform CQI efforts.

As a provider, Wrap Connections designates an identified representative who actively participates in the Community Leadership Team and brings program-level feedback, data trends, and implementation considerations to the forum. Information from CLT meetings is communicated back to program leadership to support alignment between system priorities and service delivery.

Supporting Documentation
• HFW Community Leadership Team (CLT) Charter Agreement (Pg 86)
• Statement of Work (SOW) (Pg 106)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Flex Funds Policy & Procedure (Pg 84)

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : N/A (Counties with contracted providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound implements eligibility and referral processes designed to ensure equitable access to High Fidelity Wraparound services. Youth who meet established eligibility criteria are not excluded based on the severity or complexity of their needs. Referral pathways are clearly defined and communicated to referring partners, and services are publicized to families and community stakeholders to promote awareness and access.

Program leadership plans staffing levels and caseload assignments to support the intensity and frequency of services required by families with complex needs, including the ability to provide 24/7 crisis response. Service access and caseload capacity are monitored through internal tracking and CQI processes to identify waitlist trends and ensure timely engagement. When access barriers are identified, leadership works collaboratively with system partners to address resource or capacity constraints.

Supporting Documentation
• Statement of Work (SOW) (Pg106)
• Wrap Connections Process Checklist (Pg 34)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Employee Retention Policy & Procedures (Pg 104)

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound maintains fiscal practices that are intentionally aligned with the values, principles, and operational requirements of the California High Fidelity Wraparound (HFW) model. Program budgets and contractual agreements allocate funding to support essential Wraparound operations, including required staffing roles, workforce development and training, data collection and data management systems, and the direct costs of services and supports identified in individualized Plans of Care.

Contracts and funding structures reflect rates that support high-fidelity service delivery, including intensive, community-based services responsive to individualized family needs; required workforce roles and supervision structures; and systems necessary to track fidelity, outcomes, and Continuous Quality Improvement (CQI). Fiscal oversight ensures that funding decisions directly support Wraparound principles and service integrity rather than limiting flexibility or responsiveness.

Supporting Documentation
• Statement of Work (SOW) (Pg 106)
• FF Organizational Code of Ethics Policy & Procedure (Pg83)
• Continuous Quality Improvement (CQI) Plan (Pg67)

County Procedures Ensure: (a) A system is in place for identifying federal, state, local or private resources that are potentially available across the Children’s System of Care, (b) These resources and funding streams are analyzed, and a plan/budget is created to leverage them to the maximum extent, (c) Cost sharing agreements between Child Welfare, Probation, and Behavioral Health are in place, (d) Multiple funding sources are explored and leveraged as much as possible to expand access to HFW services.

Description of Practice, Name of Supporting Documentation and Page #:

As a contracted provider, Wrap Connections collaborates with county and system partners to support equitable funding across the Children’s System of Care. Federal, state, local, and private funding sources are identified and leveraged to the maximum extent possible to ensure that High Fidelity Wraparound services are adequately funded and accessible to families with complex needs. Medi-Cal and other eligible funding streams are utilized when appropriate to support service delivery.

While county-level cost-sharing agreements are managed by the county, Fred Finch Wraparound participates in system-level collaboration to support resource alignment, service coordination, and expansion of access to HFW services. Program leadership communicates funding-related barriers or gaps to system partners through established governance and CQI forums.

Supporting Documentation
• Statement of Work (SOW) (Pg 106)
• HFW Community Leadership Team (CLT) Participation Documentation (Pg 86)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures that flex funds are available to meet urgent and individualized youth and family needs when such needs cannot be readily addressed through other resources. Flex funds are incorporated into the overall funding plan for HFW and are accessed through a clearly defined approval process.

Requests for flex funds are evaluated based on HFW team recommendation and alignment with established criteria, including whether the request supports the Team Mission and Plan of Care, builds on family strengths, addresses identified needs, is culturally relevant, strengthens natural or community supports, represents a responsible use of resources, and includes a sustainability plan. Families are supported in understanding the flex fund process, and when requests are denied, teams receive clear communication regarding the rationale and appeal options. In cases involving Indian children, flex funds may be used to compensate Tribes for culturally appropriate activities that address youth and family needs.

Supporting Documentation
• Flex Funds Policy & Procedure (Pg 84)
• Wrap Connections Process Checklist (Pg 34)
• Wrap Plan / Care Plan Templates (Pg 37 & 39)
• Documentation Certification Policy & Procedure (Pg 80)

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound participates in collaborative oversight processes regarding the use and availability of flex funds. Flex funds are managed to ensure equitable access for all families served. Tracking and accounting processes document flex fund requests—both approved and denied—including the amount requested, intended purpose, and HFW team recommendation.

Flex fund utilization data is reviewed through program oversight and CQI processes and shared with funders and system partners as required to promote transparency, accountability, and alignment with Wraparound values.

Supporting Documentation
• Flex Funds Policy & Procedure (Pg 84)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• FF Organizational Code of Ethics Policy & Procedure (Pg 83)

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound ensures that no single funding source or program requirement limits the availability or appropriate use of flexible funds to meet youth and family needs. Program leadership works collaboratively with system partners to broaden available funding sources and explore alternative options when restrictions exist within a specific funding stream.

When funding limitations arise, reliance on other funding sources is increased or additional resources are identified to prevent service gaps. Flex fund access decisions are guided by family needs and Wraparound principles rather than by the constraints of any single funding source.

Supporting Documentation
• Flex Funds Policy & Procedure (Pg 84)
• Statement of Work (SOW) (Pg 106)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound intentionally recruits, hires, and retains staff who reflect the cultural, racial, ethnic, and linguistic diversity of the youth, families, and communities served. Demographic data of the population served is routinely reviewed through referral information, case documentation, and program data to inform recruitment priorities and workforce planning. Hiring practices emphasize lived experience, bilingual capacity, cultural humility, and demonstrated ability to work effectively with diverse families.

When staffing limitations prevent direct cultural or linguistic matching, Wrap Connections ensures that families’ cultural needs are met through alternative strategies, including engagement of natural supports, culturally matched community partners, Parent Partners, Youth Partners, or other formal supports identified by the family. When a staff member who speaks the family’s primary language is not available, professional interpretation services or trusted natural supports are utilized to ensure full participation and informed decision making.

Supporting Documentation
• Job Descriptions (Youth Partner, Parent Partner, Facilitator, Clinical Supervisor, Program Director, Skills Coach) (Pg 159)
• Employee Retention Policy & Procedures (Pg 104)
• Training Policy & Procedure (Pg 153)
• Documentation Certification Policy & Procedure (Pg 80)

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

When serving Indian children, Fred Finch Wraparound prioritizes respect for tribal sovereignty, traditions, and cultural values in all aspects of service delivery. Staff receive training on ICWA requirements, tribal sovereignty, culturally respectful communication, and advocacy to ensure services are delivered in partnership with Tribes rather than in parallel to them. The program actively supports culturally rooted approaches that strengthen tribal identity and promote positive outcomes.

HFW teams collaborate with tribal representatives when applicable, encourage participation in tribal traditions and ceremonies as identified by the youth, family, and Tribe, and integrate tribal services and resources into the Plan of Care. Staff are trained to understand the value of tribal systems of care and to support tribal engagement as an equal and essential component of the HFW team.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• Statement of Work (SOW) (Pg 106)
• Care Plan / Wrap Plan Templates (Pg 37 & 39)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound fosters a flexible, creative, and collaborative work environment grounded in shared responsibility for program quality and fidelity to the HFW model. Leadership promotes cohesion, open communication, and alignment with Wraparound principles through structured supervision, team meetings, reflective practice, and continuous feedback loops. Staff are encouraged to exercise creativity in problem-solving and service delivery while maintaining accountability to fidelity standards.

Program leadership actively engages staff in CQI efforts, solicits input on program improvements, and reinforces a shared mission and commitment to HFW values, principles, phases, and activities. Structures are in place to support flexibility in scheduling, field-based work, and crisis response in order to meet the needs of families and communities.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Clinical Supervision Guidebook (Pg 41)
• Performance Evaluation – Direct Care (Pg 203)

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound maintains rigorous hiring practices and meaningful performance evaluation processes to ensure staff possess the skills, attitudes, and competencies required for High Fidelity Wraparound. All required HFW roles are fulfilled either through distinct positions or clearly defined combined roles, including Youth Partner , Family Partner, Facilitator, Family Specialist/Skills Coach, Fidelity/Quality Support, Clinical Supervisor, and Program Manager.

Job descriptions are specific to HFW and clearly articulate role purpose, core functions, required competencies, and performance expectations. Hiring processes include behavioral interviews, scenario-based questions, and opportunities for candidates to demonstrate alignment with Wraparound values such as family voice and choice, strengths-based practice, collaboration, and persistence. Employees receive clear expectations, regular feedback, and ongoing coaching through supervision and formal performance evaluations.

Supporting Documentation
• Job Descriptions (All HFW Roles) (Pg 159)
• Performance Evaluation – Direct Care (Pg 203)
• New Hire Orientation (NHO) Checklist (Pg 189)

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound implements multiple strategies to promote workforce stability and reduce turnover. Compensation structures are designed to be competitive within the local labor market and reflective of cost-of-living considerations. Caseload expectations are monitored to maintain manageable workloads that support service quality and staff well-being.

The organization provides clear promotion and advancement pathways that value lived experience and does not require staff to leave direct service roles to advance professionally. Opportunities for wage increases, leadership development, specialized roles, and skill advancement are offered to retain experienced staff and promote long-term commitment to the program.

Supporting Documentation
• Job Descriptions (HFW) (Pg 159)
• Training Policy & Procedure (Pg 153)
• Performance Evaluation – Direct Care (Pg 203)
• Employee Retention Policy & Procedures (Pg 104)
• Non-Employees Policy & Procedures (Pg 100)

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: (3) HFW staff are trained internally by utilizing internal curriculum. Counties and providers who choose to utilize their own curriculum are required to submit their internal curriculum that aligns with the Statewide standardized Foundational HFW curriculum.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound maintains a comprehensive High Fidelity training plan that includes initial onboarding, ongoing training, annual booster trainings, and role-specific instruction for all staff. All employees receive initial HFW training aligned with California Wraparound Standards and receive continued training through workshops, team meetings, supervision, coaching, and peer learning.

Clinical Supervisors and Program Managers receive specialized training in supervisory and leadership competencies specific to HFW implementation. The training plan includes ICWA and Tribal sovereignty education and is responsive to emerging population needs and system priorities. Training participation and completion are tracked and reviewed as part of CQI processes.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• RTWB / HFW Training Materials (Pg 1)
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Clinical Supervision Guidebook (Pg 41)
• RTWB Training PDF

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound administers its training program in collaboration with community members, families, and individuals with lived Wraparound experience. Youth Partners, Parent Partners, and peer mentors are meaningfully incorporated into training delivery to ensure that training reflects authentic family perspectives and real-world application of HFW principles.

Community partners and system stakeholders are invited to participate in Wraparound trainings or are offered targeted education to strengthen collaboration, shared understanding, and effective participation on HFW teams. This approach supports system-wide alignment and reinforces family-centered, culturally responsive practices.

Supporting Documentation
• Training Policy & Procedure (Pg 153)
• Youth Partner & Parent Partner Job Descriptions (Pg 179 & 175)
• RTWB / HFW Training Materials (Pg1)
• Community Leadership Team (CLT) Charter (Pg 86)

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound provides all staff with an initial apprenticeship period and ongoing coaching and supervision that emphasize Wraparound values, principles, phases, and activities. Supervision focuses on skill development, fidelity to the HFW model, effective use of flex funds, and responsive problem-solving to meet family needs.

Supervisory structures ensure staff have access to coaching or supervision as needed, including during crises, reflective of the flexible scheduling and 24/7 responsiveness required in HFW services. Coaching and supervision practices are monitored through CQI processes to ensure effectiveness and consistency.

Supporting Documentation
• Clinical Supervision Guidebook (Pg 41)
• Performance Evaluation – Direct Care (Pg 203)
• Training Policy & Procedure (Pg 153)
• Continuous Quality Improvement (CQI) Plan (Pg 67)

Procedures Ensure:

Fred Finch Wraparound implements a formal, written Continuous Quality Improvement (CQI) Evaluation Plan that operates at both the program level and the system level to routinely and reliably monitor the quality, fidelity, and effectiveness of High-Fidelity Wraparound (HFW) implementation. The CQI plan establishes a systematic process for the ongoing collection, analysis, reporting, and utilization of data to inform practice, ensure accountability for outcomes, and support continuous learning and improvement.

Data collection under the CQI plan minimally includes:
1. Demographic information for children, youth, and families served,
2. Wraparound fidelity data, aligned with Section 1 Fidelity Indicators, and
3. Outcome data, aligned with Section 2 Expected Outcomes.

CQI implementation is conducted collaboratively with system partners, including child welfare, probation, behavioral health, and contracted providers, to ensure shared accountability and alignment across the Children’s System of Care. Data-sharing protocols and interagency communication structures enable the appropriate exchange of information necessary to implement CQI activities while maintaining confidentiality and compliance with applicable regulations.

Data is collected at the level closest to the individual youth and family—through case documentation, standardized tools (e.g., IP-CANS), fidelity measures, meeting records, and service tracking—and is subsequently aggregated and uploaded in formats appropriate for higher-level program, organizational, and system analysis. Supervisors and program leadership routinely review CQI data to assess timeliness, accuracy, and completeness and to identify trends, strengths, gaps, and opportunities for improvement.

CQI findings are actively used to inform coaching, supervision, training priorities, fidelity monitoring, and program adjustments. Staff receive feedback on performance related to timelines, documentation quality, fidelity indicators, and outcomes as part of an ongoing learning and accountability process.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Internal Quality Records Review Policy (Pg 94)
• Documentation Certification Policy & Procedure (Pg 80)
• IP-CANS (Pg 96)
• Performance Evaluation – Direct Care (Pg 203)
• Statement of Work (SOW) (Pg 106)

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

Fred Finch Wraparound utilizes collected CQI data to drive evaluation and improvement at multiple levels, including direct practice with youth and families, overall program effectiveness, and system-level collaboration and supports impacting HFW implementation. Data is reviewed regularly by facilitators, supervisors, program leadership, and quality management staff to ensure it is actionable and directly informs service delivery.

At the practice level, staff receive timely feedback through supervision, coaching, and team meetings based on outcome data, fidelity measures, and case reviews. Data is used to identify strengths in practice, areas requiring additional support, and individualized training or coaching needs. This feedback loop ensures that data meaningfully enhances service quality rather than functioning solely as a compliance activity.

At the program level, aggregated data is analyzed to identify trends related to engagement, fidelity, outcomes, service utilization, transitions, and workforce development. Findings inform program planning, resource allocation, workflow adjustments, and target quality improvement initiatives designed to better serve families and improve overall effectiveness.

At the system level, CQI findings are synthesized and communicated to leadership structures, including the Community Leadership Team, to identify and address systemic barriers that impact HFW implementation. These may include service access gaps, cross-system coordination challenges, funding limitations, or policy barriers. Data-informed recommendations support shared problem-solving and system improvement aligned with HFW values and standards.

Evaluation metrics and outcomes are documented, reviewed, and incorporated into ongoing CQI cycles to ensure continuous alignment with the CA High Fidelity Wraparound model and to support sustained quality improvement over time.

Supporting Documentation
• Continuous Quality Improvement (CQI) Plan (Pg 67)
• Community Leadership Team (CLT) Charter (Pg 86)
• Internal Quality Records Review Policy (Pg 94)
• Performance Evaluation – Direct Care (Pg 203)
• Training Policy & Procedure (Pg 153)
• IP-CANS (Pg 96)

Date Started: September 3, 2025

Date Submitted: January 23, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

a) Upon receiving the referral, the facilitator assigned to the case contacts the family on the same day the referral was received and offers a same day appointment. We track initial contact using the community outreach services form and notify the referral party when the intake will take place. Community Outreach Services COS Form, page 1

b) The initial CFT Matrix (Plan of Care) is completed within the first 30 days from the day of enrollment, and the team ensures to use either an English or Spanish version depending on the family’s language preference. This would also include how the wraparound plan of care will be utilized once we become a high fidelity wraparound provider. English or Spanish CFT Planning Matrix, entire document

c) A CFT Matrix (Plan of Care) it is reviewed every 30-45 calendar days after its initial completion. English or Spanish CFT Planning Matrix, entire document

d) DCFS and the Probation department are invited to participate in these meetings depending on the type of open case the family’s or youths have. English or Spanish CFT Planning Matrix, Entire Document

e) Our plan is to increase the feedback that is given to staff and supervisors by providing them with continued individual supervisions and reviewing timelines.

f) Staff are trained in alternative strategies when contacting a family becomes difficult, by having the staff reach out to DCFS/Probation for assistance in consultations as well as DMH Liaisons (Parent Partner Advocate).

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

a) We ensure that youth and families have the opportunity to share about themselves and their perspectives from the beginning of services, by eliciting information during the assessment, family engagement, and during the first Child and Family Team (CFT) meeting.

b) Each team takes time to ask about the youth and family’s cultural considerations, Long-term view (future hopes and aspirations), and ground rules which can highlight some of their values and culture. English or Spanish CFT Planning Matrix, page 1

c) Supervisors routinely review documentation being generated by staff to support them in enhancing the support and guidance they are providing the youth and families. Supervisors also observe team meetings and provide staff with feedback to increase their confidence and skills.

d) Our agency gathers feedback from our youth and families using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) Each team keeps an inventory of the youth and families’ strengths using the CFT Planning Matrix, which is updated as needed. This assists each team member to ensure that they are developing strategies for needs based on the family’s strengths and following up during each monthly meeting to see how the strategy can continue to be modified to maintain a strength-based focus. English or Spanish CFT Planning Matrix, page 2

b) Strengths are also identified and highlighted using the IP-CANS which is also reviewed with the families. CANS 0-5 or CANS-IP, entire document

c) We also ensure that our staff go through on going coaching and training. Trainings through DMH Events Hub and internal agency trainings.

d) Our agency gathers feedback from our youth and families using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our teams provide youth and families with clarification on the difference between needs and goals to ensure that they have a better understanding of what underlying needs can be based on the information being gathered from the youth and family. These underlying needs are documented using the CFT Matrix where the family can choose up to 3 needs that they would like to focus on and develop strategies for. English or Spanish CFT Planning Matrix, pages 3-4

b) Our staff attend trainings where they learn about being able to identify needs and ensure that needs are being written using the youth and families wording.

c) Needs are also identified using the IP-CANS. CANS 0-5 and CANS-IP, entire document

d) Transition planning occurs when the team and family agree that needs are sufficiently met. English or Spanish CFT Planning Matrix, pages 3-4

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our team uses different forms/documentation that allows for sufficient flexibility when creating individualized plans for each child/youth and families we work with. English or Spanish CFT Planning Matrix, entire document

b) Staff receive continuous training and coaching through our agency and DMH Event Hub trainings to enhance their skills and creativity in the services and strategies they provide.

c) We also ensure that our facilitators attend trainings through DMH Event Hub and that all staff receive ongoing trainings and coaching in providing flexible, creative, and highly individualized services and strategies.

d) Our teams ensure that each strategy is individualized and customized to match each youth and family member’s needs, strengths, values, culture, and preferences. These strategies are identified and documented on the CFT Matrix. English or Spanish CFT Planning Matrix, page 3-4

e) Our agency gathers feedback from our youth and families using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

a) During the family engagement meeting each team uses the planning sheet to assist with identifying natural and community supports that the family might want to be a part of their Child and Family Team meetings. Family Engagement Planning Sheet, entire document

b) Our staff attend ongoing trainings on how to support the youth and families to develop a natural and community support to ensure that they will continue to receive continued support when services transition and services end.

c) Facilitators document all participates at each meeting using the CFT Planning Matrix and identify the role each natural supports and community supports will take through strategies being developed for each need. English or Spanish CFT Planning Matrix, page 1, 3-4

d) Our agency gathers feedback from our youth and families using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) We gather information regarding strengths, needs, and culture on the referral, during the assessment, and when meeting with DCFS or Probation for a staffing prior to the initial Child and Family Team Meeting. Staff Engagement Worksheet, entire document

b) Our staff receive ongoing training through our agency and through the DMH Event Hub on how to elicit and use family and culture in the planning and service delivery, as well as how to provide culturally respectful and relevant strategies based on what the youth and family is sharing.

c) Our agency gathers feedback from our youth and families using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

a) Teams agreements are documented using the CFT Matrix which highlights how each team member will be assisting the youth and family with a specific need by indicating the action being taken by each staff member. English or Spanish CFT Planning Matrix, pages 3-4

b) Feedback is obtaining from youth and families during individual sessions which are weekly or during the CFT meeting which varies depending on need, every week, bi-weekly, or monthly. Feedback is also obtained from our youth and families by using a Mental Health Perception of Care survey which is provided every 30 days. Mental Health Perceptions of Care POC English or Spanish, entire document

c) Feedback is reviewed by supervisors and ensure that appropriate training is completed if needed as well as the meeting minutes. Mental Health Perceptions of Care POC English or Spanish, entire document

d) CFT Matrix copies are provided to family, CSW, Probation Officers, and are routinely reviewed and assessed by the team members and supervisors to ensure that action items are being followed through and met. English or Spanish CFT Planning Matrix, entire document

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

a) Specific measurable strategies and actions items are tracked using the CFT Matrix, giving the family a varied timeframe depending on what the strategy is and how much time they believe they would need. English or Spanish CFT Planning Matrix, pages 3-4

b) Our teams provide an attainable timeframe for each action item based on the family’s feedback to ensure that enough time is provided and that there is consistent follow up if additional time is needed or if unexpected challenges are being faced to fulfill any action item which are documented by facilitators. English or Spanish CFT Planning Matrix, pages 3-4

c) If a team member is not present during the meeting, any changes to the strategies or action items are communicated to ensure that everyone is aware of the new plan in place.

d) Our agency has identified each therapist on the team to be the person responsible for completing the IP-CANS and share with the rest of the team members. CANS 0-5 or CANS-IP, entire document

e) The information gathered from the IP-CANS is use by the team to support tracking and decision-making on the strategies and actions plans that are being created to better support the youth and families.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

a) Each one of our teams works closely with the youth and families and continue to provide support and guidance until an agreement that services should end based on family voice and choice. We also document when any setbacks are occurring as part of worries on the CFT Planning Matrix and ensure that a new date is identified to address specific challenges. English or Spanish CFT Planning Matrix, page 2, 5

b) We participate in weekly case consultation with our DMH Liaison if challenges or setbacks are faced by any team to ensure that we are continuously modifying our approach.

c) Facilitator meets with a supervisor after a crisis to discuss steps taken and possible plan revision if needed to ensure all safety measures were effective and utilized by the youth and family. Safety planning is completed at the beginning of services, and it is updated upon each post-crisis situation. LACDMH Family Safety & Crisis Plan English or Spanish, entire document

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

a) Each team upon reviewing and observing that all needs have been met as indicated in the CFT Planning Matrix, develop a transitional plan in which the youth and family decide if they want to be linked to continued outpatient services or provide them with a list of potential Mental Health providers near their area if they opted to not be linked. English or Spanish CFT Planning Matrix, pages 3-4, 5

b) Our teams also consult with DMH prior to moving forward with a graduation. The youth and families decide how they would want to celebrate their achievements through food or recreational activity taking into account their culture and values, and flex funds are requested by the team. Their hard work is acknowledged with a transitional object to motivate them to continue using their coping skills and a certificate of completion.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our agency provides the youth and families a survey every month that assists in gathering information on how their experience with services is going thus far by allowing our agency to then evaluate how well our policies and procedures are doing in recording the youth and family’s satisfaction with their wraparound experience. Our agency is also in process of developing a policy and procedure to record and evaluate youth and family satisfaction once we begin implementing HFW by utilizing the wraparound standards. Mental Health Perceptions of Care POC English or Spanish, entire document

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The team uses the CFT Planning Matrix to track how a youth is performing in school and recording their attendance, participation in school, and changes to their educational plan. These improvements are documented either under non-negotiables if there is a meeting that is being scheduled (Student Success Meeting, 504 Panning Meeting, Individualized Education Plan IEP), strengths when increasing their academic performance, and under a specific school related need if identified by the youth and parents during the monthly CFT meetings. English or Spanish CFT Planning Matrix, page 1-4

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our agency has a policy and procedure in place to record and evaluate the level of justice involvement and engagement with community activities to ensure that there is record of the services probation referrals and clients that are on informal probation are receiving by documenting specific actions that need to be taken by the youth and families as part of the non-negotiables section. English or Spanish CFT Planning Matrix, page 1

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our teams have observed that families upon transitioning out of services have a better understanding of each of their family members needs and are more receptive to feedback and open to communicate how they are feeling without judgement or shame. PSC-35 LACDMH English or Spanish, entire document and IP-CANS 0-5 or CANS-IP, entire document

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

We document on the CFT Planning Matrix areas in which both the youth and caregivers might want to increase their confidence and knowledge on and based on that information we provide linkage and resources to community events, resources (food banks, job fairs, parenting classes, life skills), low cost no cost assistance (electricity, rent) to ensure that we are building on their ability to manage future problem solving skills. English or Spanish CFT Planning Matrix, pages 2-4

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our agency documents on the CFT Planning Matrix when a new placement occurs and conducts an initial CFT meeting at their new placement when transitioning from home to resource home or between resource homes. We update and review our safety plan with the new placement and make modification if needed to better support the youth and family. We are also in communication with DCFS or Probation when any changes occur and notify our DMH Liaison of any change in placements. English or Spanish CFT Planning Matrix pages 1-2 and 5, LACDMH Family Safety & Crisis Plan English or Spanish, entire document

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our team documents all hospitalizations through an Incident Report which includes details on the reason for hospitalization and steps taken by each staff prior to the youth being hospitalized. We update and review the safety plan to better support the youth and family based on the most recent hospitalization. LACDMH Family Safety & Crisis Plan English or Spanish, entire document, Special Incident Report SIR, entire document

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Our teams gather information during the enrollment, family engagement, and assessment to develop the safety plan and the team’s contact information as well as emergency numbers they can call if in need of professional support. The team provides a copy of the safety plan once it is completed and provides them with additional copies as the safety plan is updated or modified to ensure that they are able to fully respond to crisis situations. Upon the families becoming familiarized with the safety guidelines they can follow during a crisis, the level of professional support decreases. LACDMH Family Safety & Crisis Plan English or Spanish, entire document

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

Before a family is transitioned out from wraparound services, we schedule a final CFT meeting and document any transitional planning that will be taking place reflecting possible linkage to additional outpatient services or resources. English or Spanish CFT Planning Matrix, pages 2-4, 5

We document the reason why a family is transitioning out of services, family voice and choice, case closing, or meeting their Mental Health goals and needs. We also acknowledge their achievements in being able to complete their goals and meet their needs by celebrating through an activity, food, providing them with a transitional object, and certificate.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Our team ensures that they provide an overview to the youth and family of the services they will receive including principles and phases, legal and ethical considerations, the role of each of the team members including the family, natural supports, and Tribes in the case of an Indian child. This information is given to the youth and family during the initial contact, enrollment, family engagement, and initial Child and Family Team (CFT) meeting. We also provide the families with the wraparound guide in either English or Spanish, encourage them to ask questions and provide opportunities to ask questions regarding wrapround if they are unfamiliar with the program. Wraparound Process user’s guide English or Spanish

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

a) The safety plan is discussed during the initial engagement phase, and a safety plan is immediately created if concerns or a crisis is brought forward by the youth or family. A copy is provided to the family and a copy placed in the chart, the safety plan includes the Psychiatric Mobile Response Team (PRMT) contact information, 988 Suicide Line, local Sheriff’s department (MET), and information of the nearest hospital. LACDMH Family Safety & Crisis Plan English or Spanish, entire document

b) At the completion of the crisis planning the team ensures that the family understands the difference between the crisis plan that was just created and the safety plan that will be developed during the plan development phase.

c) Our team also provides the youth and the family with the teams contact information and reviews that the team is available 24/7 for crisis response.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our teams identifies a family vision during the family engagement and is documented during the first initial Child and Family Team (CFT) meeting. English or Spanish CFT Planning Matrix, page 1

b) Our teams are currently participating in the high fidelity wrapround training and moving forward we will be incorporating the strengths, needs, culture discovery document to assist in identifying for each team member strengths, needs, and future goals. This document will be included in the youth’s chart and will be updated at least every 90 days. Strengths, Needs, Culture Discovery, entire document

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

a) Our teams document any natural supports the youth and family have identified, or the team has identified during the family engagement and document it in the child or youth’s case file. Family Engagement Planning Sheet, entire document

b) We also assist in identifying children’s system of care partners that should be included and engaged. English or Spanish CFT Planning Matrix, page 1

c) The team works with the family to identify potential formal, natural supports, and Tribes and discuss their role on the team. With the youth and family’s permission and/or request after a release of information is obtained, the facilitator invites the identified natural supports, children’s systems, and Tribes to attend CFT meeting. Authorization for Release of Health Information ROI sheet, entire document

d) Engagement and team building activities are documented in the youths file to highlight who attend and what the activity was. English or Spanish CFT Planning Matrix, page 3-4

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our teams inquire about the family’s availability during the enrollment and establish a schedule during the family engagement. Once a schedule is finalized the team provides the family with a calendar highlighting when each session will be provided. Our teams are available 24/7 and the families are able to notify the team via phone call or message when a session time needs to be adjusted or changed due to a change in the family’s schedule to accommodate their needs.

b) Our staff collaborate with each family to ensure that scheduled meetings and individual sessions align with the family’s needs and preferences to maximize participation, taking into account, school, work, extracurriculars, and religious practices.

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

a) Part of the plan of care development is to ensure that the youth and family identify a mission statement which on the CFT planning document we use it is called a long-term view. English or Spanish CFT Planning matrix, page 1

b) We also make a list of the youth and family’s strengths which assist with the development of the plan of care. During each meeting that the team has with the youth and family these strengths might be different due to newly discovered strengths that are being identified by the family themselves or strengths the team has been observing since services began. English or Spanish CFT Planning matrix, page 2

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

a) We collaborate with the youth and family to identify underlying needs and are uniquely developed for each family.

b) After an underlying need is identified, measurable goals and outcomes are developed for each of the needs that the youth and family will be incorporating in the plan of care.

c) The team collaborates with the child/youth and family to develop the measurable goals and ideal outcomes.

d) The youth, family, and the team brainstorm on the strategies that could be best used to suffice each identified underlying need and they are document using the Child and Family Team (CFT) matrix. English or Spanish CFT Planning Matrix, page 3-4

e) Facilitators are trained to lead the team in identifying, prioritizing, and selecting strategies and developing actions items stating who will be responsible for each action step.

f) All of these steps are used to develop the individualized Plan of care ensuring that a team-based approach is taken and that it is completed in a collaborative environment.

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) Facilitators attend ongoing trainings and coaching sessions to learn about engaging the team in the planning process and how to elicit multiple perspectives, build trust and shared vision, and demonstrate the HFW principles.

b) The team ensure that any goals that are being worked on through any children’s system of care that might be involved in the youth or families life or might need linkage to a specific children’s system of care are being tracked using the CFT planning document. English or Spanish CFT planning matrix, page 3-4

c) The plan of care is completed for each youth and family and outlines their family vision, needs across multiple life domains, children’s system of care partners, strategies, action items, natural supports, and transitions. The plan of care is provided to all team members to ensure all needs and action items are being addressed and met.

d) We have procedures in place to review each plan of care for continuous quality improvement and feedback is provided to staff and supervisors/coaches for training and coaching purposes.

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) The crisis and safety plan are both documented in the youth’s file which indicates the potential safety, high risk or crisis situation with proactive and reactive strategies identified by the family. The team is also available 24/7 for crisis intervention support and their information is on both the crisis and safety plan.

b) The team develops a safety plan with the collaboration of the youth and the family by identifying the present safety concerns, possible triggers, and actions that can be taken by the youth and caregivers when these situations are happening. Those completing the plan receive training and coaching to this process. LACDMH Family Safety & Crisis Plan English or Spanish, entire document

c) These safety plans are reviewed every six months, and any time a new crisis or safety concern arises, the safety plan is revised to ensure that the family knows how to manage these new safety concerns. Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. In the safety plan the team list natural supports they can contact, Psychiatric Mobile Response Team (PMRT), 988 hotline, nearest hospital, and law enforcement information.

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

a) The facilitator leads the team to review each of the action steps that were developed, by using the meeting agenda and previous meeting minutes to track if an action step was completed. The facilitator makes modifications as needed based on the feedback they are gathering from the youth, family, and the team. English or Spanish CFT planning matrix, page 3-4

b) Our teams receive ongoing training through DMH event hub on how to implement the plan of care, and document successes as the action steps are being completed. English or Spanish CFT planning matrix, page 3-4

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

a) The team meets with the family every four to six weeks to update the CFT plan (plan of care) to review strategies, progress, and actions plans that were identified for the youth and family. English or Spanish CFT planning matrix, page 3-4

b) The Facilitator highlights action steps that have been successfully accomplished while working to identify any new needs or strategies that need to be incorporated to the plan of care.

c) The Facilitator documents and notes tasks that have been completed by assigning new action steps to the team members, in addition invites formal and informal supports to further support the youth and family and any use of flex funds.

d) The CFT Matrix (Plan of care) form is updated and individualized to meet the changing needs of the youth and family.

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

a) Each team member contributes to the team agreements which includes what each team member is responsible for completing, the progress that has been made, and any new changes to the timeframe. These team agreements are reviewed regularly, and updates are provided during HFW team meetings. English or Spanish CFT Planning Matrix, page 1

b) We ensure that facilitators receive ongoing training and coaching on how to build, engage, and maintain effective teams, and feedback is provided through coaching and supervision to further support this area of growth.

c) Natural supports are constantly being monitored on how they are contributing to the support of the family, how consistent they are, and if their relationship changes cause them to either be more involved or less involved depending on the feedback being obtained by the youth and family.

d) Upon a new formal or natural support being identified by the family the team ensures that the overall process of services, and current plans and strategies are being reviewed to increase their understanding of wrapround services. We also ensure that an Release of Information is filled out by the youth or family to ensure that the team is able to have these discussions or provide information to any new formal and natural supports. Authorization of Release of Health Information ROI, entire document

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

a) Upon a team evaluating that a youth and family have reached certain pre-determining benchmarks, the facilitator will meet with the entire team to identify where they are in each benchmark and gather additional supporting information.

b) The facilitator then organizes a meeting with the youth and family where an individualized transition plan is created, and the family’s perspective is obtained on how they feel they have meet each of the identified needs on the CFT Matrix. During this process services and supports are also identified to ensure that there will be appropriate linkage to additional resources and a smooth transition between wraparound and their new service if that is what the family identified. English or Spanish CFT Planning Matrix, pages 3-4

c) Each member of the team ensures that the development of the individualized transition plan is done in a team-based approach and that collaboration occurs between youth, family, and the team. Facilitators receive continued training for this process, and the team ensures that the family has been successfully linked to identified community resources before services conclude.

d) We remain in place until the youth and family have been linked to services to ensure supportive services are in place prior to the transition to maintain continuity of care and participate in a warm handoff if able depending on the service or support identified.

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our teams ensure that the safety plan is updated to reflect the upcoming transition and that on the safety plan they have identified possible crisis situations that may occur after transitioning from services. The safety plan highlights the proactive and reactive strategies to support the youth and families with managing how they react to certain triggers that could lead to a crisis and utilizing their identified natural supports. LACDMH Family Safety & Crisis Plan English or Spanish, entire document

b) The team gathers information from the family on what they identify could be a crisis within their family to collaborate in developing strategies that would support their upcoming transition to ensure safety. The Team also includes additional safety resources such as the FURS program (family urgent response system), contacting their local law enforcement, nearest hospital, and Psychiatric Mobile Response Team (PMRT) number.

c) Safety plans are reviewed every six months unless there is a crisis then it is updated following the crisis and as needed to support the youth and the family. A copy of the safety plan is provided to the family and identify an area within their home they will be able to easy have access to the safety plan. Each safety plan consists of individualized strategies, proactive and reactive steps, and the team takes into consideration cultural relevancy and natural supports for continuous quality improvement.

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

a) Transitions are celebrated by having the youth and family identify how and where they would like to celebrate the transition such as their favorite place to eat, a nearby recreational activity, or at home if that is where they would prefer. The plan is documented on the CFT Planning Matrix taking into consideration the family’s culture, values, and preferences. English or Spanish CFT Planning Matrix, pages 3-5

b) Facilitators request flex funds once a plan has been finalized, ensures that every team member is available and able to attend. As part of the celebration the team provides the youth with a certificate, transitional object (i.e., toy, coping skill related item), and reviews all of their accomplishments. Any informal, formal, or natural supports that were part of their journey in services are invited if the family would like for them to be part of their celebration.

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

a) The team encourages the youth and family to participate in decisions regarding implementation of strategies, actions steps, and timeframes surrounding their action plan and identified needs.

b) Each team ensures that the family provides feedback on how what will be implemented as part of their plan development, each team member provides the youth and family with opportunities to determine how and what steps will be taken to achieve each need identified. English or Spanish CFT Planning matrix, pages 3-4

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team, N/A (AAP funded Wraparound programs)

Description of Practice, Name of Supporting Documentation and Page #:

Our agency has numerous staff that participate on the Community Leadership team, two program managers, and two clinical supervisors.

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : N/A (Counties with contracted providers only)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

a) The team documents any immediate financial needs that are identified by the youth and the family during a meeting, such as bills, rent, and any daily living essentials. We look into low cost, no cost resources and depending on the availability of the resources or if these resources are not sufficient in addressing the current financial hardships, we document the amount that will be request through flex funds on the CFT planning matrix. English or Spanish CFT Planning Matrix, pages 3-4

b) Our agency has new staff attend trainings for their identified roles along with shadowing other staff with the same role that have been here longer to better understand their functions within the role. In addition, staff attend refresher trainings from external entities along with participating in supervisions that discuss each roles unique contribution to the team and the families they will be working with.

c) We utilize a excel spreadsheet that captures the amount utilized on each patient throughout each month and we provide it to our billing department who oversees wraparound funding budget. They ensure that the data matches the claims that are submitted on the case rate through the WTS for each client. Flexible Expenditure SFC 70-72 FY 25-26, tab August for example

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

N/A

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our agency has procedures in place to ensure that families have access to flexible funds in a timely manner and how soon they are needed. Facilitators document any need for flexible funds on the CFT planning matrix and indicate by when the funds will be received. We emphasize the importance utilizing community resources to ensure long-term accessibility after services have terminated. English or Spanish CFT planning matrix, pages 3-4

b) We sit with the family to identify the specific needs and after completing a budget we determine the most immediate need to ensure it meets the families action plans and needs. Our parent partners actively support each caregiver throughout this process and gathers all the necessary information to better support family for long term sustainability.

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

a) Facilitators indicate the amount of funds that are being requested, what the funds will be used for, and each team will be responsible for following up on the funds request. Families are given updates as soon as the funds become available and schedule a time and date for when the funds will be provided. English or Spanish CFT Planning matrix, pages 3-4

b) Our agency follows the guidelines in the wrapround tracking system (WTS). All funds being used for each client are linked to a specific category to ensure that there is accuracy in what is being claimed and tracked by the WTS.

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

a) The team works closely with the CSW or Probation Officer to determine how the team will be supporting a youth or family with a current financial hardship and how the department will also assist if certain limitations are identified during a CFT planning meeting to increase the success in addressing a specific need. English or Spanish CFT planning matrix, pages 3-4

b) Flex funds can be used in combination with other funding sources depending on what is needed and how soon funding can be available to ensure that a specific need is being addressed in a timely manner. English or Spanish CFT planning matrix, pages 3-4

c) Our agency utilizes flex funds when there is an identified need, and we do not prohibit families from accessing these flexible funds. English or Spanish CFT planning matrix, pages 3-4

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

a) Our staff are diverse and can appropriately meet the cultural, racial, and linguistic needs of the youth and families they are working with. We take into account the demographic composition of the community we serve by hiring staff to meet their needs.

b) Our agency is made aware of any cultural, racial or linguistic needs a youth or family might have upon receiving the referral from DMH. We engage natural or formal supports to assist with translation when needed to accommodate to the family’s language needs.

c) If our agency is unable to provide a staff member who can provide services in the youth or family’s language, we have access to a contracted language interpretation services or we utilize natural supports when available.

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

a) Our staff are trained on tribal sovereignty, traditions, and values. Facilitators document any upcoming events, tribal traditions, and ceremonies that the youth or family are participating in or plan to attend.

b) Our staff encourage the youth and family to invite tribal representatives to their meetings if they would like for them to be part of the planning process. Our team also assists the youth and families with linking them to their respective tribe to increase and strengthen their tribal roots. English or Spanish CFT Planning matrix, pages 1, 3-4

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

a) Our managers and supervisors monitor how services are being provided and obtain feedback from the family’s every 30 days indicating the quality of service and any improvements that might make the program better. Mental Health Perceptions of Care English or Spanish

b) Supervisors have supervisions with staff weekly and during group supervisions an activity is facilitated to foster a creative positive team environment and open communication amongst all staff.

c) Our managers and supervisors are currently participating in the high-fidelity wraparound training to ensure that a clear sense of mission and compliance with high-fidelity wraparound philosophy is clearly understood by all in our program.

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

a) In our agency we have a youth partner (Child and Family Specialist), Parent Partner/Family Specialist (Parent Partner), HFW Facilitator (Facilitator), Mental Health Therapist/Clinician, Clinical Supervisor, and HFW Supervisor/Manager/Fidelity Coach.

b) Each job description and responsibilities for each of the roles includes a position summary, duties/functions, and qualities which incorporates skills, competences, and attributes.
-The Child and Family Specialist work one on one with the youth providing emotional and behavioral support along with incorporating strategies identified by the youth and caregiver.
-The Parent Partner/Family Specialist works one on one with the resource parents/bioparents/relative caregivers providing them with support and guidance on navigating the child’s needs as well as their own needs. In addition, providing community linkage through identified natural and formal supports.
-The HFW Facilitator facilitates/schedules all meetings (i.e. CFT meetings, staffing’s), tracks and updates CFT matrix (plan of care), communicates with all team members including all children’s systems of care, and ensures all documentation including safety plans are current and constantly revised as needed.
-Mental Health Therapist meets with the youth for individual sessions and is able to provide family sessions when deemed appropriate, they also evaluate if additional support is needed such as psychiatry or TBS.
-Clinical Supervisors provide the wrapround team with clinical insight and support surrounding crisis and safety, along with navigating challenging situations that the clinicians may have with their one-on-one sessions.
-Supervisor/Manager/Fidelity Coach provides daily support and the necessary tools to the wraparound team, weekly check-ins/supervision, in-person attendance to challenging cases by going to meetings and staffing’s, case distribution, and ensuring staff are actively attending trainings to better support the families we serve.

c) Each of the job descriptions are created to identify individuals who will be successful in the position by reflecting the attitudes, skills, knowledge, and experience needed to thrive in their position.

d) Our hiring process allows each candidate the opportunity to demonstrate specific attitudes and skills essential to the position they are applying for by asking them related questions to that specific role. HR-148 Applicant Interview Questionnaire, page BLANK
(This application is utilized by all programs in our agency; questions are modified to the role each candidate is applying for)

e) Each of our employees are provided with clear expectations for their performance upon hiring and ongoing while in the positions they hold. All employees also receive supervisions weekly individually as well as a team where feedback along with coaching is given to support their successes, and an annual review is completed yearly. Supervisors also provide acknowledgement to staff by submitting what TTC calls “On the spot” highlighting a staff success (individually, team based).

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

(a) TTC performs routine compensation analyses to confirm that our pay rates are competitive within our service area. If a role is identified as being below market rate, an adjustment is made accordingly. Furthermore, all TTC positions have a starting rate of no less than $25 per hour. TTC employs independent compensation consultants that regularly benchmark TTC pay scales against market.

(b) Workload levels are regularly reviewed to ensure alignment with program needs, staffing ratios, and organizational priorities. Supervisors are expected to monitor team capacity, redistribute tasks when necessary, and escalate concerns so adjustments can be made in a timely manner. Additionally, we encourage employees to provide feedback and engage in collaborative problem-solving to maintain a healthy balance and support high-quality service delivery.

(c) We have implemented an internal Transfer and Promotion process that provides employees with visibility into all current openings and the opportunity to apply when they meet the qualifications. A Transfer Form is used to ensure appropriate follow-through, timely communication of status, and an efficient transfer process.

(d) Employees receive an annual performance evaluation and may be eligible for a performance-based increase of up to 3%. In addition, employees may be considered for committee participation, providing opportunities to utilize their skills, contribute to organizational initiatives, and lead team projects.

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

a) All of our staff are currently attending, are pending to attend, or have recently completed an initial high-fidelity wraparound training course through UC Davis RCFFP. Once all staff are trained in high-fidelity wrapround our agency intends to continue to use UC Davis RCFFP for continued training and booster trainings annually.

b) Currently our staff receive ongoing training through DMH EventHub in general wraparound and in their specific roles through formal trainings, meetings, coaching, and supervision.

c) Our staff receive booster trainings at least once a year through the DMH Event Hub, UCLA DMH training portal, and through our agency in general wrapround, their specific roles, and cultural competency. We will utilize UC Davis RCFFP for future trainings once all staff have concluded the high fidelity wraparound training.

d) Clinical supervisors and HFW supervisors/managers attend general wrapround trainings through DMH EventHub as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role.

e) As part of staffs ongoing training, they also attend tribal sovereignty training, and they are encouraged to attend trainings that supports populations with specific and unique needs as needed.

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

a) Although we do not do formal trainings we discuss and share with community partners and systems of care the wraparound mission, procedures, policies, and strength-based approach to increase their knowledge and understanding of wrapround services. We plan to incorporate youth, families, and peer partners with current or prior wrapround experience the opportunity to be a part of the wraparound trainings.

b) We provide information about wrapround services to patients that are currently receiving services through our other programs such as outpatient and SUD that might need more intensive mental health services. Moving forward once all of our staff have completed high-fidelity wraparound training we can identify how we can facilitate wrapround trainings or offer trainings on wraparound to strengthen community partners and systems of care participation. We plan to coordinate with DMH to collaborate with other agencies to formulate a rotation to ensure that more trainings are taking place on a monthly basis to community members and allow them to highlight specific topics they would want additional information on.

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

a) All staff upon hiring receive initial training that covers values, skills, and knowledge of wraparound principles, phases, and activities as well as how to effectively use and identify when flex funds are needed to meet the family’s needs. We have a binder that is accessible to staff with all the information above and anything pertaining to wraparound, we plan to update the binder once we become high fidelity wrapround and incorporate any new forms that might be given to us by Los Angeles County and DMH.

b) All our staff have access to supervision and coaching 24/7 as needed, and their supervisors and clinical supervisors provides support during challenging situations.

Procedures Ensure:

N/A

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

a) Monthly we distribute surveys to our families to obtain feedback on services being provided to the youth if over 12 years old and able to fully read and understand the questions on the survey and the family if a youth is under 12 years old or the youth opts to not fill it out. Our survey is currently undergoing a modification, and our QA department is aware of some of the questions that need to be added to ensure we are in compliance with high fidelity wraparound requirements. Mental Health Perceptions of Care POC English or Spanish, entire document

b) This feedback allows for us to make adjustments and address program needs to better serve the youth and families we work with which overall improves our program effectiveness.

c) This also assists with being able to identify any potential system barriers that would impact the implementation of wraparound services.

Date Started: August 29, 2025

Date Submitted: January 28, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound staff engages families early and often, including Tribes in the case of an Indian child. First contact with families is made as soon as possible, but no later than 10 calendar days after referral; teams complete a HFW Plan of Care within 30 calendar days; teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days; teams update the Plan of Care and distribute to all team members at least every 90 days and more often as needed.

(a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery

(b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery

(c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery

(d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed. Please see 1.1abcd Wrap Screening, Assessment, and Service Delivery

(e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes. Please see 1.1e Oversight and Audit Process and 1.1e Clinical Audit Tool.

(f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult. Please see 1.1f Wraparound Trainings

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team prioritizes the youth and family’s perspectives and voices in developing and modifying the mix of strategies and supports to ensure the best fit with their preferences. The youth and family’s values, culture, expertise, capabilities, interests, and skills are elicited, fully understood, and celebrated. They are viewed as critical to a successful process and are the basis for decision making and problem-solving. In the case of an Indian child, the HFW team prioritizes the perspectives and voices of the youth, family and Tribe. Tribes, in the case of an Indian child, must be an equal voice on the HFW team.

(a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements). Please see 1.2ab Service Philosophy.

(b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file. Please see 1.2ab Service Philosophy.

(c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence. Please see 1.2c Team Consultation Meeting and Supervision and 1.2c Clinical Supervision Form template.

(d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process. Please see 1.2d Feedback Process.

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Functional strengths of the youth, the family, all team members, and the family’s community are collectively reviewed and utilized throughout the HFW process. Identified strengths are functional in nature and drive decision making and service planning. Five Acres Wraparound team members remain focused on solutions, rather than dwelling on negative events. The Integrated Practice-Child and Adolescents Needs and Strengths (IP-CANS) is critical and required for strengths identification.

(a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings. 1.3ab Strength Based Approach and 1.3ab CFT Planning Matrix.

(b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS. Please see 1.3ab Strength Based Approach and 1.3ab CFT Planning Matrix.

(c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services. Please see 1.3c Strength Based Solution Focused Training and Supervision.

(d) Feedback from families regarding their experience of strengths-based services is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.3d Feedback Process.

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound services and supports are focused on addressing the high priority underlying needs of the youth, as well as their family members.

(a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family. Please see 1.4a Needs Driven Approach.

(b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning. Please see 1.4b Underlying Needs Training and Supervision.

(c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS. Please see 1.4c Use of CANS.

(d) Transition is planned according to team and family agreement that needs are sufficiently met. Please see 1.4d Transition Planning.

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound is committed to finding creative, highly individualized strategies that are customized to match each youth and family’s needs, strengths, values, culture, preferences and reduce harm over time. The Five Acres HFW plan is uniquely tailored to fit the family and capitalize on the assets of their community and informal networks and in the case of an Indian child, the Tribe.

(a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family. Please see 1.5a Individualized Care and 1.5a Safety Plan Form.

(b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies. Please see 1.5b Individualized Care-Training and Coaching.

(c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences. Please see 1.5c Facilitator Training and Supervision.

(d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks. Please see 1.5d HFW Plan of Care.

(e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.5e Feedback Process.

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound recognizes natural supports as integral team members. Five Acres HFW teams are strengthened by the contributions of natural supports. Five Acres HFW teams prioritize strategies in the HFW Plan of Care that utilize natural supports, and that take place in the family’s community, to reduce reliance on formal supports while fostering sustainability within the youth and family’s community.

(a) A natural and community supports inventory is developed and updated for every family. Please see 1.6a Natural and Community Based Supports.

(b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports. Please see 1.6b Use of Natural and Community Based Support- Training and Supervision.

(c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items. Please see 1.6c Plan of Care- Natural and Community Based Supports.

(d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.6d Feedback Process.

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound team recognize that a family’s traditions, values, and heritage are sources of great strength. Five Acres Wraparound team use strategies that are relevant to and respectful of the youth and family’s culture, including Tribes in the case of an Indian child. Five Acres Wraparound team work to connect families with individuals and organizations that provide culturally relevant support after the family transitions from formal HFW services.

(a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file. Please see 1.7a Culturally Respectful and Relevant Approach.

(b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies. Please see 1.7b Culturally Respectful and Relevant Service Delivery – Training and Supervision.

(c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.7c Feedback Process.

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound team is comprised of formal and natural supports across all Children’s System of Care partners who work together to develop, implement, and monitor the individualized Plan of Care that meet the unique needs of the youth and family. All Five Acres Wraparound team members take ownership over their assigned tasks and collaborate to meet the youth and family’s needs. Teams experience optimism, commitment, and energization.

(a) Team agreements are created for each HFW team and documented in the youth’s file. Please see 1.8a Team Engagement and Agreement, 1.8a Family Engagement Planning Sheet, and 1.8a Staff Engagement Worksheet.

(b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited. Please see 1.8b Feedback Process.

(c) Feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes. Please see 1.8c CQI Process.

(d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items. Please see 1.8d HFW Plan of Care Review Process.

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team monitors the success of the HFW Plan of Care—including progress toward meeting needs, strategy implementation, and task completion. These are measured objectively, reviewed routinely, and used to inform changes to the Plan as needed. Needs statements are linked to measurable outcomes and data from standardized instruments including the IP-CANS and are integrated into the planning process.

(a) The HFW plan of care includes specific, measurable strategies and action items with timeframes. Please see 1.9abc Outcome Based Process.

(b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed. Please see 1.9abc Outcome Based Process.

(c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members. Please see 1.9abc Outcome Based Process.

(d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members. Please see 1.9d CANS Administration, 1.9d Clinical Assistant Procedure, and 1.9d Clinical Assistant Procedure workflow.

(e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition. Please see 1.9e CANS Data.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team views setbacks and challenges not as evidence of a youth, or parent failure, but as an indicator of a need to revise the Plan. The Five Acres Wraparound team is committed to implementing a Plan that reflects the HFW Principles, even in the face of limited system capacity.

(a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end. Please see 1.10a Persistence.

(b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support. Please see 1.10b Accessing Additional Support and Flex Funds.

(c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision. Please see 1.10c Facilitator Trainings and Supervision.

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Transitions are planned for in advance and celebrated with full youth and family participation. Transitions only happen when the youth and family have had their needs met, not due to an adverse event or an administrative requirement.

(a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements. Please see 1.11ab Transition Planning.

(b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations. Please see 1.11ab Transition Planning.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres has policies and procedures in place to evaluate youth and family satisfaction. Please see 2.1 Youth and Family Satisfaction, 2.1 Five Acres Client Satisfaction Survey, and 2.1 Five Acres Caregiver Satisfaction Survey

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.2-2.8 Expected Outcomes, 2.2-2.8 Outpatient SIR Procedure, 2.2-2.8 SDOH Screening Tool, and 2.2-2.8 Special Incident Report (SIR) form.

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound Team has policies and procedures in place to record and evaluate school attendance and performance. Please see 2.9 Discharge Information.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound team orients youth and families to the HFW process, including explaining the HFW principles and phases, addressing legal and ethical considerations, and explaining the role of each member on the team including the family’s role and the role of natural supports. Please see documents 3.1 Child and Family Team Meeting Agenda, 3.1 Child and Family Team Planning Matrix, 3.1 Debrief Meeting, 3.1 Family Engagement Planning Sheet, and 3.1 Staff Engagement Worksheet.

(a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child. Please see 3.1 (a) Orientation

(b) An overview of the HFW principles and phases can be found in 3.1 (b)

(c) An overview of legal and ethical considerations can be found is 3.1 (c)

(d) The role of each team member including the family and natural supports and Tribes in the case of an Indian child can be found in 3.1 (d)

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres Wraparound team addresses pressing needs and concerns so that the family and team can focus on the HFW process. If immediate response is necessary, the HFW team formulates a plan for immediate intervention and stabilization, including development of a written crisis plan and ensures access to 24/7 crisis response when needed. Please see 3.2 Safety and Crisis Stabilization and 3.2 Safety Plan Form Example.

(a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the Five Acres Wraparound team develops an immediate crisis response plan which is provided to the family and is documented in the chart. Please see 3.2 (a) Safety and Crisis Stabilization.

(b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase. Please see 3.2 (b) Safety and Crisis Stabilization.

(c) All families are provided with information regarding how to access 24/7 crisis response when needed. 3.2 (c) Safety and Crisis Stabilization.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team facilitates conversations and activities with the youth and family to identify individual and family strengths, needs, culture, and their vision for a better future. The facilitator prepares a written summary document to clearly communicate strengths, needs, culture and vision to all team members, to orient new team members as they are added to the process, and to support the initial plan development process. Please see 3.3 Strengths, Needs, Culture and Vision Discovery, 3.3 CFT Planning Matrix, 3.3 (a) Family Engagement Planning Sheet.

(a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase. Please see 3.3. (a)

(b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified. Please see 3.3 (b).

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team engages the participation of team members across all Children’s System of Care partners (including formal, natural supports, and Tribes, in the case of an Indian child), who care about and can aid the youth and family. The Five Acres HFW team encourages and facilitates their active participation by clarifying their roles and responsibilities on the team. The facilitator intentionally engages the team in activities to ensure a positive and collaborative team culture. Please see 3.4 (a) Family Engagement Planning Sheet and 3.4 (b) Staff Engagement Worksheet.

(a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file. Please see 3.4 (a).

(b) Children’s System of Care partners who should be included on the HFW team are identified and engaged. Please see 3.4 (b).

(c) The Five Acres HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team. Please see 3.4 (c).

(d) Engagement and team building activities are documented in the youth’s file. Please see 3.4 (d).

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team ensures that meetings take place at a time and in a location that is convenient and accessible to all team members with priority given to family needs and family voice and choice, taking into consideration family schedules, culture, and history of trauma, and ensuring equitable access for all youth and families. The Five Acres HFW team plans for and arranges meeting logistics such as transportation, interpretation, telehealth capability, etc. Please see 3.5 Arrange Meeting Logistics.

(a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs. Please see 3.5 (a).

(b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation. Please see 3.5 (b).

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Building upon the activities completed during engagement, the Five Acres facilitator leads the team in developing formal agreements on how the team will engage during meetings and make decisions, identifying and documenting additional strengths of the youth and family, other team members, and the community, and
creating a team mission statement that defines the overall purpose of the HFW team in alignment with the family vision.

(a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file. Please see 4.1 (a).

(b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file. Please see 4.1 (b).

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres facilitator guides the team in reviewing needs identified during engagement, adding any additional needs, and prioritizing them. The Five Acres HFW team uses the prioritized needs to develop specific, measurable goals and outcomes. The Five Acres facilitator engages the team in brainstorming multiple creative strategies to meet the prioritized needs, goals, and outcomes before selecting strategies and assigning responsibility in the form of action items.

(a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file. Please see 4.2 (a).

(b) Measurable goals and outcomes are developed from these identified needs. Please see 4.2 (b).

(c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team. Please see 4.2 (c).

(d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed. Please see 4.2 (d).

(e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items. Please see 4.2 (e).

(f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment. Please see 4.2 (f).

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team develops a comprehensive initial Plan of Care that is based on the prioritized needs, goals, and strategies of the family and youth. This is accomplished via a high‐quality team process across all Children’s System of Care partners, including the Tribe in the case of an Indian child, that elicits multiple perspectives, builds trust and shared vision amongst team members, and demonstrates the HFW principles.

(a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles. Please see 4.3 (a).

(b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners. Please see 4.3 (b).

(c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined in items 1-6. Please see 4.3 (c).

(d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes. Please see 4.3 (d).

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres facilitator leads the team in developing a crisis and safety plan that identifies and prioritizes safety needs, potential risk and crisis situations, as well as highly individualized proactive and reactive strategies for the youth, family, and team members to respond effectively. Identified strategies should be chosen by the youth and family, should be culturally relevant, and should maximize the use of natural supports wherever possible.

(a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7. Please see 4.4 (a).

(b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 4.4 (b).

(c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. Please see 4.4 (c).

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound team carries out the initial Plan of Care, monitoring completion of action items and strategies and their success in meeting needs and achieving outcomes in a manner consistent with the HFW principles. Teams celebrate successes as they occur.

(a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed. Please see 5.1 (a)

(b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur. Please see 5.1 (b).

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres facilitator engages the team to continually review the Plan; assess the progress and the effectiveness of strategies; and update the Plan as needed, including changing goals and strategies if the needs of the youth and family change. The Five Acres facilitator documents and communicates, via meeting minutes and other forms of communication, completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the Plan. The Plan of Care is updated in an HFW team meeting and distributed to all team members at least every 90 days, and more frequently, as needed

(a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting. Please see 5.2 (a).

b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file. Please see 5.2 (b).

(c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes. Please see 5.2 (c).

(d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs. Please see 5.2 (d).

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres facilitator continually assesses and addresses team cohesion, trust, and commitment to ensure effective collaboration. When appropriate, teams seek and develop potential natural supports and add them to the team. Teams orient and engage new team members as they are added.

(a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings. Please see 5.3 (a).

(b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams. Please see 5.3 (b).

(c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision. Please see 5.3 (c).

(d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises. Please see 5.3 (d).

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

When the family has reached pre-determined benchmarks indicating sufficient progress towards completing the team mission and goals, and the youth, family, and team agree the family is ready for transition, the Five Acres Wraparound team will begin developing a formal individualized transition plan. Led by the facilitator, the Five Acres HFW team will outline a purposeful transition process which identifies needs, services, and supports that will persist past formal HFW and includes strategies to transition any remaining support being provided by Five Acres Wraparound staff to those ongoing supports. For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are educated on post adoptive services that can assist with transition.

(a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process. Please see 6.1 (a).

(b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file. Please see 6.1 (b).

(c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 6.1 (c).

(d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable. Please see 6.1 (d).

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres facilitator leads the team in developing a crisis and safety plan (or adjusting the current crisis and safety plan) that identifies potential crisis situations that may occur after transitioning from formal HFW. The crisis and safety plan includes individualized, proactive, and reactive strategies for the youth, family, and other supports who will remain after HFW concludes. The youth and family play a pivotal role in identifying these strategies, which should be culturally relevant, and maximize the use of natural and community supports.

(a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family. Please see 6.2 (a).

(b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process. Please see 6.2 (b).

(c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes. Please see 6.2 (c).

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres team ensures that the conclusion of formal HFW is celebrated in a manner that reflects a positive transition, is culturally relevant, and is meaningful to the youth and family.

(a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences. Please see 6.3 (a).

(b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.). Please see 6.3 (b).

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

Youth and family feedback is utilized to inform all levels of the HFW Program, including service planning and implementation, policy and procedure development, workforce development, and quality improvement of the Wraparound model.

(a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation. Please see 7.1ab Youth and Family as Key Decision-Makers, 7.1a Consent to Participate in Wraparound, 7.1a Wraparound DCFS Intake Packet, Wraparound Policies and Procedures Manual (Pg. 20, 23, 26, 44, 45), and 7.1a Wraparound Warm Line.

(b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement. Please see 7.1ab Youth and Family as Key Decision-Makers, 7.1b Satisfaction Survey Training, and 7.1b CANS IP Manual.

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres Wraparound Team works collaboratively and engages in shared decision-making to ensure the CA Wraparound Standards are met at the organizational and systems level.

(a) There is an identified representative who actively participates on the Community Leadership Team. Please see 7.2a Community Leadership Team and Wraparound Policies and Procedures Manual (Pg. 23).

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres HFW eligibility and referral criteria and processes ensure adequate, appropriate, and equitable access to HFW services and do not exclude families because of the severity or nature of their needs. Five Acres HFW is adequately publicized, available, and accessible so that youth and families who would benefit are able to participate. There is adequate program planning to ensure that once enrolled, families have access to an adequate array of services and 24/7 support to meet complex needs.

(a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs. Please see 7.3ab Eligibility and Equal Access and Wraparound Policies and Procedures Manual (Pg. 6-8, 27, and 46).

(b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis. Please see 7.3ab Eligibility and Equal Access, 7.3b CBS Division Crisis Response Protocol and Wraparound Policies and Procedures Manual (Pg. 6-8, 27, and 46).

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres HFW Program has fiscal practices that are aligned with the values and principles of Wraparound and ensure the CA Wraparound Standards are met. Budgets and contracts at all levels, regardless of county or provider-based service provision allocate funding for essential Wraparound operations which include required staffing, workforce development data collection, and data management systems and the costs of services.

(a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families. Please see 8.1abc SE 1129 SOW Wraparound Pg. 5 and
8.1abc Wraparound FY26 Budget.

(b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3. Please see 8.1abc SE 1129 SOW Wraparound (Pg. 5-6) and 8.1abc Wraparound FY26 Budget.

(c) Required data collection and/or data management systems. Please see 8.1abc SE 1129 SOW Wraparound (Pg. 19-20) and 8.1abc Wraparound FY26 Budget.

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres HFW Program has a process to ensure families have timely access to flexible funds to meet their urgent and individualized needs when these needs are not readily met by other resources. There is a defined approval process that ensures requests for flexible funds are evaluated based on approval/recommendation of the team.

(a) Flexible funds are available and included as a part of the funding plan for HFW. Please see 8.4ab Availability, Access, and Approval of Flex Funds and Wraparound Policies and Procedures Pg.48 and Pg.57.

(b) Processes to access and manage flexible funds are articulated. Please see 8.4ab Availability, Access, and Approval of Flex Funds and Wraparound Policies and Procedures Pg.48 and Pg.57.

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

There is collaboration and shared oversight amongst funders and providers regarding the use and availability of flexible funds. A process is in place to ensure flexible funds are pooled and held to meet the needs of all families served. Tracking and accounting for flexible funds whether approved or denied includes the amount, purpose, and HFW team recommendation of the request.

(a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request. Please see 8.5ab Collaborative Oversight of Flex Funds, Wraparound Policies and Procedures Pg. 48 and Pg.57, 8.5a Reasonable and Allowable Purchase Limits, 8.5a CSS Expenditure Coding Guide, and 8.5a Fillable CCS Supplemental Info Request Form.

(b) Flex funds are pooled and held to meet the needs of all families served. Please see 8.5ab Collaborative Oversight of Flex Funds and Wraparound Policies and Procedures Pg. 48.

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

The Five Acres HFW Program ensures the requirements of any single funding source shall not limit the availability of flexible funding or the resources developed to meet the needs of the youth, families, Tribes and communities served by HFW.

(a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.

(b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.

(c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs. Please see 8.6abc Funding Sources and Program Requirements do not Limit Flex Funds and Wraparound Policies and Procedures Pg. 48 and Pg.57.

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres hires staff that can appropriately meet the cultural, racial and linguistic needs of youth and families. Staffing reflects the cultural, racial and linguistic diversity of the youth, families and communities served.

(a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (pg. 22) and Wraparound Policies and Procedures Manual (Pg. 15).

(b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (Pg. 22) and Wraparound Policies and Procedures Manual (Pg. 15).

(c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized. Please see 9.1abc Culturally Responsive Workforce, Employee Handbook (Pg.22) and Wraparound Policies and Procedures Manual (Pg. 15).

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

In the cases of Indian children, Five Acres team shall prioritize respect for tribal sovereignty, traditions, and values and ensure respectful communication, collaboration, and advocacy. The team has the goal of promoting positive outcomes through culturally rooted support systems and services, and the team is responsible for building partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

(a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy. Please see 9.2a Indian Child Welfare Act Training.

(b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer. Please see 9.2b Tribal Partnership.

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

There is a high degree of collective responsibility for program quality and improvement, cohesion among staff members, open communication, and a clear sense of mission and compliance with HFW. Programs and its leaders create structures that promote staff creativity and flexibility.

(a) Program quality and improvement. Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).

(b) Cohesion (minimally including creating a positive team environment). Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).

(c) Open communication. Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).

(d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities). Please see 9.3abcd Flexible and Creative Work Environment and Employee Handbook (Pg. 8 and Pg. 16).

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Programs have rigorous hiring practices and use meaningful performance assessments. Job descriptions for all positions reflect best practices regarding Wraparound skills and expertise and have clear expectations for performance. The following are roles or functions on a Five Acres HFW team.

(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities. Please see 9.4abc Job Descriptions.

(b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit. Please see 9.4abc Job Descriptions.

(c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position. Please see 9.4abc Job Descriptions.

(d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position. Please see 9.4d LCM – Sample Job Posting, 9.4d Career Opportunities 5A, 9.4d Recruitment, Selection and Compensation Pg. 3 & Pg.6, and 9.4d Sample Interview Questions- Clinicians and Other Standard Positions.

(e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success. Please see 9.4e Employee Self-Evaluation, 9.4e Performance Evaluation Part I, 9.4e Performance Evaluation Part 2, and 9.4e Supervision Template, 9.4e Workflow for Online Performance Evaluations.

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres implement strategies to maintain a stable workforce and reduce turnover, including matching wages according to the community the program is in, maintaining manageable workloads for staff, implementing promotion/advancement structures, and providing wage increases or leadership opportunities that do not require a position change to achieve.

(a) Matching wages to cost of living in the location of the organization/service implementation area. Please see 9.5a Compensation Guide and 9.5ad Philosophy-Objectives.

(b) Maintaining manageable workloads for staff. Please see 9.5b Maintaining Manageable Workloads for Staff.

(c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience. Please see 9.5cd Stable Workforce and 9.5cd 5A RIA Plan.

(d) Providing wage increases or leadership opportunities that do not require a position change to achieve. Please see 9.5cd Stable Workforce, 9.5cd 5A RIA Plan, 9.5cd Stable Workforce, and 9.5d Promotion Ladder Job Aid.

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres has a high fidelity training plan that incorporates initial, annual, booster trainings, and ongoing trainings. The training plan includes both general HFW training and role-specific training for all roles, including specific training for all Clinical Supervisors and Wraparound Supervisors/Managers.

(a) All staff receive an initial HFW training using the Statewide Standardized Foundational HFW training through the UC Davis RCFFP. Please see 9.6a High Fidelity Wrap Training.

(b) All staff receive ongoing training both in general Wraparound and in their specific role through formal trainings, meetings, coaching, peer shadowing, and/or supervision. Please see 9.6b Wraparound Initial Trainings.

(c) All staff receive booster trainings at least annually in general Wraparound and in their specific roles. Please see 9.6c Wraparound Annual Trainings.

(d) Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound training as well as receive initial, ongoing, and booster trainings specific to their leadership/supervisory role. Please see 9.6d Wraparound Program Supervisor Trainings.

(e) All staff receive ICWA and Tribal sovereignty training and mechanisms are in place to identify and provide training that supports populations with specific and unique needs as needed. Please see 9.6e Wraparound Trainings for ICWA and Unique Needs.

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

Five Acres administer the training plan in collaboration with community members and families with HFW experience as part of the training team. Ensure efforts are inclusive of and promoted to system and community partners to ensure comprehensive support within the Children’s System of Care and that team members from other systems have a context for HFW participation.

(a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings. Please see 9.7ab Community-Based Training Program and Wraparound Policies and Procedures Manual (Pg.22).

(b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care. Please see 9.7ab Community-Based Training Program and Wraparound Policies and Procedures Manual (Pg.22).

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

Programs provide team members with initial apprenticeship and ongoing coaching that emphasizes Wraparound values, principles, phases and activities, as well as the effective use of flex funds to meet family needs. Leaders will ensure that staff have access to coaching and supervision 24/7, reflective of the flexible scheduling and crisis response needs of families and the community.

(a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs. Please see 9.8ab Coaching and Supervision and Wraparound Policies and Procedures Manual (Pg.20, 27, 46).

(b) Staff have access to supervision or coaching 24/7 as needed. Please see 9.8ab Coaching and Supervision and 9.8b CBS Division- Crisis Response Protocol.

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

By integrating data into every facet of its operations, from clinical practice to workforce development, community collaboration, and organizational strategy, Five Acres cultivates a resilient, adaptive, and outcomes-focused service model. This commitment to data-driven excellence ensures that youth and families receive the highest quality care in a compassionate, responsive, and continuously improving environment.

(a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs. Please see 10.2abc Evaluation Metrics & Outcomes.

(b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness. Please see 10.2abc Evaluation Metrics & Outcomes.

(c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation. Please see 10.2abc Evaluation Metrics & Outcomes.

Date Started: August 11, 2025

Date Submitted: February 18, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

Engagement: Once referrals are identified by the county-referring body, initial face-to-face contact with the family is made by the Wraparound team. The Wraparound team attempts initial contact with the family within 24-48 hours of receipt of referral and schedules a face-to-face intake as soon as possible, within 10 calendar days of the referral. Documentation of the first contact attempt and outcome are entered in the client record. The program is explained, questions answered, and appropriate intake paperwork is completed. Interviews are then conducted with all stakeholders involved in the youth’s life. Initial strengths and needs are identified as the facilitator establishes the beginning relationship, which demonstrates that the Wraparound program is different from other care systems they may be involved with. Victor is highly experienced in adapting the engagement strategies to meet the unique and specific needs of the populations we serve.

Planning Services: An Individualized Child and Family Plan (ICFP) is an important component of the Wraparound services delivery system. An ICFP is developed for each participant and family and is updated frequently throughout the provision of Wraparound services. The parents and children/youth are an integral part of this process and are seen as the driving force in the treatment and planning process. CFT Meetings ensure that services involve families as full participants, with service plans based on the unique values, strengths, norms, and preferences of the family. The multidisciplinary wraparound team provides the services, which are continually monitored for effectiveness and appropriateness through submitting plans to the County for review and approval. The Facilitator guides the CFT to explore and prioritize all life domain areas—starting with safety—by collaboratively developing a Family Team Mission Statement and facilitates the definition of concrete goals and assigned tasks among members of the wraparound team. The CFT process ensures the family, in partnership with their family Facilitator, is “in the driver’s seat”. The ICFP includes specific needs being addressed, clear responsibilities of team members, clearly defined goals and timelines, a description of existing resources (strengths), needed services and resources, funding requests, and safety procedures.

The ICFP functions as the CFT’s Plan of Care and is inclusive of goals, strategies, roles/responsibilities, timelines, safety/crisis elements, and documentation/distribution standards. The initial ICFP is completed within 30 calendar days from the start of services and filed in the client record. The ICFP is distributed to team members, family, and the referral party, is reviewed every 30-45 days within the context of the CFT Meeting and updated every 90 days or more frequently if needed. IP CANS findings are incorporated into the ICFP and reviewed during CFT Meetings to prioritize needs/goals, and to monitor outcomes over time. Each CFT Meeting documents attendance, strengths acknowledgements, strategy/action items, responsible parties and due dates, progress and completion checks, flex fund use (if any), and plan adjustments.

Wraparound Approach to Services SOP, pages 7-8
Victor Wraparound Manual, pages 15-16; 21-22

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

Victor’s practices ensure family and Tribal perspectives are elicited, centered, and documented throughout engagement, planning, and review. Families are full and active partners, their voice and choice leading the fully informing throughout beginning to end of services. Tribal sovereignty and inclusion of the child’s Tribe as an equal voice on the CFT are required under ICWA; and the Family Mission Statement guides Safety Planning and goal development.

Family culture, strengths, and skills are elicited and recorded using structured tools: Strengths Assessments, the Connection Map (natural supports and relationships), IP‑CANS, and the individualized Child and Family Plan (ICFP). The Wraparound Approach to Services SOP further details Victor’s cultural/linguistic access (bilingual hiring and translation).

HFW Supervisors/Fidelity Coaches provide on‑site supervision, field coaching, and feedback; they observe CFT meetings using TOM to assess fidelity, and they review documentation through QA audits and CQI processes.

Feedback is routinely collected via Satisfaction Surveys, Net Promoter Score (NPS), Focus Groups (current/former clients/caregivers), Wraparound Fidelity Index (WFI/WFI‑EZ) interviews, and TOM observations; designated staff conduct surveys and QA calls with families and stakeholders.

Wraparound Approach to Services SOP, pages 5-8, 11-13, 15-17, 18
Victor Wraparound Manual, pages 12, 16-19, 21-22, 35

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

A formal Strengths Assessment is completed with the child/youth and family early and revisited; it captures interests, talents, and skills. The Connection Map identifies and updates natural supports and community resources within 30 days of services, and is revisited at every CFT Meeting. CFT meetings use posted visual materials and include strengths acknowledgments at each meeting.

IP‑CANS is administered before the 30 day care planning which identifies needs and strengths across life domains, and is used for plan development and outcome monitoring. Strength identification goes beyond IP‑CANS via the Strengths Assessment and other family‑driven tools.

Ongoing coaching and supervision in strengths‑based practice are provided by HFW Supervisors and Fidelity Coaches (field supervision, coaching, feedback). Structured training includes: 3-day Wraparound 101 and annual Wrap 102, in‑vivo coaching, and ≥16 hours/year of ongoing training, aligned to strengths‑based, family‑centered practice.

Family feedback on strengths‑based services is gathered through Satisfaction Surveys, WFI/WFI‑EZ, TOM, NPS, and Focus Groups and used for CQI and staff coaching

Wraparound Approach to Services SOP, pages 13, 16-18
Victor Wraparound Manual, pages 17-19, 26-27, 29-30
Victor Wrap 101 and Wrap 102 Curriculum

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

During Assessment, the team gathers information across multiple life domains, including the youth’s and family’s underlying reasons for service involvement (e.g., social/emotional needs, placement risks, independent living skills, natural supports, financial stability). The ICFP (Individualized Child & Family Plan) is built from needs first, before goals and action steps. It explicitly includes specific needs being addressed, priorities identified through the CFT process, strategies assigned only after needs are clarified and agreed on. The CFT explores and prioritizes life‑domain needs before establishing goals, starting explicitly with safety as the foundational need. Victor model reinforces the plans must focus on underlying needs rather than problem behaviors and strategies must address “root causes.”

Victor training requirements for all staff and leadership include Wraparound 101 (3‑day training) and Wraparound 102 (annual training) include that focus on assessment of underlying causes and needs‑driven planning, planning based on needs rather than behaviors. Staff receive a minimum of 12 hours of individualized in‑vivo coaching (shadowing, mentoring, strengths/needs practice), specifically reinforcing correct needs statements and needs‑based planning. HFW Supervisors provide ongoing coaching about how to identify underlying needs, write effective needs statements, avoid “behavior‑only” plans. Fidelity Coach monitors and guides training and requirements of staff and program.

Victor uses the IP‑CANS to identify child and family needs and strengths across core domains and is required for case planning and monitoring. Victor’s Wraparound Model outlines that the ICFP integrates IP‑CANS findings and reviews them at CFT meetings to prioritize needs/goals. The Wraparound process includes additional needs identification through assessment interviews, safety planning, needs/strengths assessments, family/natural support input.

Transition planning begins early and continues throughout services, with CFT agreement guiding decisions. Transition occurs only when underlying needs have been addressed, skills and supports are in place, and the family and team agree the youth is ready. The Victor Wraparound Manual reinforces that the CFT uses outcome tracking and needs completion to guide graduation decisions. Aftercare planning occurs when families have achieved sufficient independence and stability.

Wraparound Approach to Services SOP, pages 4-5, 7-10, 15, 17-18
Victor Wraparound Manual, pages 12, 16-18, 28
Victor Wrap 101 and Wrap 102 Curriculum

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Victor’s Wraparound practice ensures services are family‑centered, strength‑based, culturally relevant, and needs‑driven, explicitly requiring individualized services customized to each family’s situation. The ICFP (Individualized Child & Family Plan) is tailored to the family’s unique values, strengths, norms, and preferences; it documents needs, roles, strategies, timelines, funding, and safety procedures, enabling high flexibility in planning and revisions. Documentation cadence is built for adaptability: initial ICFP within 30 days, reviewed every 30–45 days, and updated at least every 90 days or as needed—so plans can be quickly individualized and adjusted. “Individualized Services” is a core Family Vision principle.

Victor’s Training plan requires a three‑day “Wraparound 101,” annual “Wraparound 102,” and 16 hours/year of ongoing training; content aligns to individualized, needs‑driven, culturally responsive practice (including phases/activities of Wraparound and individualized resource planning). In‑vivo coaching (minimum 12 hours) includes shadowing and one‑on‑one mentoring focused on strength‑needs practice—i.e., tailoring services to each family. HFW Supervisors provide on‑site supervision and oversight of teams, reinforcing individualized, flexible practice in day‑to‑day work.

Training covers phases and activities of Wraparound and Wraparound role definitions/skills (including facilitator functions), preparing facilitators to lead CFTs in individualized planning. In practice, the Facilitator guides the CFT to explore/prioritize life domains (starting with safety), co‑develop a Family Team Mission, and write concrete goals/tasks—explicitly customizing to the family’s unique context. Routine supervision/coaching by the HFW Supervisor supports facilitators in maintaining fidelity while adapting the process to family values, culture, and preferences.

ICFP review cadence ensures routine assessment of needs/goals/strategies, with documented attendance, strengths acknowledgments, action items, due dates, progress checks, and plan adjustments every CFT cycle. By emphasizing and leveraging natural supports and community‑based interventions; the program builds bridges to informal and formal community resources (e.g., schools, faith groups, neighborhood orgs), and tracks flex‑fund use—evidence that plans intentionally capitalize on community assets.

A designated representative conducts surveys with families and stakeholders regarding service quality, meeting frequency, and how needs are being met; supervisors respond to corrective actions and grievances. WFI/WFI‑EZ and TOM are administered on an ongoing basis to measure fidelity and family experience; data are entered into WrapStat for feedback. CQI processes (quarterly reviews, outcome monitoring) use survey and fidelity data to improve practice and identify training needs, providing feedback to staff and supervisors.

Wraparound Approach to Services SOP, pages 5-6, 8, 10-13, 15-18
Victor Wraparound Manual, pages 8-9, 11, 15-16, 18-19, 21-30, 35
Victor Wrap 101 and Wrap 102 Curriculum

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Victor’s Wraparound model requires a balance of formal and informal (natural) supports, emphasizing development of enduring community resources. The Safety Plan and ICFP explicitly include identification of natural supports to maintain safety, and this list grows over time as additional supports join the CFT. Resource Development procedures require staff to build community linkages (schools, churches, neighborhood orgs, businesses, donors), effectively building a community supports inventory. The Connection Map is a formal tool used to inventory natural supports, both biological and non‑biological. It is required at 30 days, reviewed within every CFT Meeting, and updated at least six‑month intervals. Connection Maps help identify existing natural supports, lost connections that can be rebuilt, and peer-based supports (friends, neighbors, significant adults).

Staff receive Wrap 101 and Wrap 102 training, plus in‑vivo coaching, all of which emphasize leveraging natural supports and community-based planning. Supervisors provide weekly supervision and coaching to ensure staff apply strengths-based, community‑linkage, natural‑support practices. Natural Supports are a core Wraparound principle: staff are trained to gradually shift the family’s support system from formal to informal, natural, and enduring supports. The Victor Wrap Manual details strategies for identifying natural supports through Strengths Assessments, Connection Maps, engagement strategies, and CFT facilitation, all of which staff receive training and coaching for. Staff receive coaching in “meeting the family where they are,” building trust, and helping families reconnect with extended family, friends, and community resources.

ICFP reviews every 30–45 days must assess natural supports, strengths, needs, progress, task assignments, and plan adjustments. Community-Based and Natural Supports principles require that strategies and action items prioritize informal supports over professional services. Flex Funds and community resource guidance reinforce that all natural/community supports must be explored and documented before using formal supports.

CFT meeting structure includes strength acknowledgments, review of natural supports, review of tasks assigned to natural/community supports, visual elements reminding teams to capitalize on strengths & supports. Connection Maps and Strength Assessments (updated at least every six months) are used to ensure natural supports are integrated into strategies. Natural supports are expected to increase as the family moves toward self‑sufficiency.

Surveys are sent to families and community stakeholders to evaluate service quality, including natural support engagement and satisfaction. WFI, WFI‑EZ, and TOM provide structured measurement of family experience, team function, fidelity to natural-support principles, and quality of engagement. CQI processes analyze survey and fidelity results to guide supervisor coaching, staff training, and practice improvements. NPS (Net Promoter Score) surveys ask families about satisfaction with team support—including natural support engagement. Focus Groups (≥50% current/former wrap clients) provide feedback on program design, fidelity, and the effectiveness of natural support integration.

Wraparound Approach to Services SOP, pages 5-6, 8, 10-13, 15-18
Victor Wraparound Manual, pages 8-9, 15-19, 25-27, 29-30, 35
Victor Wrap 101 and Wrap 102 Curriculum

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

During Assessment, Wraparound teams gather information on strengths, needs, cultural considerations, natural supports, life domains, and ICWA status before planning begins. All of these elements are documented and must meet licensing standards. Planning requires that the initial ICFP be built after strengths, needs, values, and cultural factors are documented, incorporating IP‑CANS findings and family priorities. Cultural and linguistic needs are included in service planning, ensuring cultural discovery occurs before plan development. Engagement phase includes Strengths Assessment, Connection Map, and exploration of family history and culture before developing goals. These tools form the foundation for the Child & Family Plan. The ICFP cannot be developed until the team has identified the family’s strengths, needs, culture, values, beliefs, and prioritized domains.

The Victor Wrap Practice requires training in ICWA, cultural competence, respectful communication, collaboration, and tribal inclusion, ensuring staff understand cultural obligations and tailoring services accordingly. Ongoing training includes modules on cultural competence, individualized resource planning, and service adaptation. Supervisors provide regular coaching reinforcing culturally respectful and individualized practice. Cultural respect is a core Wraparound principle requiring staff to understand, honor, and incorporate family beliefs, traditions, and cultural identity into planning. The Engagement process trains staff to listen empathically, understand cultural history, and use that information in planning—this includes culturally influenced strengths, values, and relationship patterns. Goal development & ICFP creation are explicitly based on the family’s culture, values, and worldview. Facilitators receive coaching to ensure this alignment.

Families receive satisfaction surveys evaluating service quality, responsiveness, cultural respect, team functioning, and family experience. Fidelity tools (WFI, WFI‑EZ, TOM) collect feedback on family experience, including cultural relevance, respect, and adherence to principles. CQI uses survey and fidelity feedback to guide staff coaching, training needs, and program improvements. NPS (Net Promoter Score) surveys gather family impressions of support, respect, cultural acceptance, and overall service quality. Focus Groups (≥50% current/former wrap clients) provide culturally informed feedback on services and strategies, used to improve program design and training.

Wraparound Approach to Services SOP, pages 6-8, 11-13, 15-17
Victor Wraparound Manual, pages 35

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

The Victor Wrap Model requires CFT/ICFP documentation that captures roles, responsibilities, timelines, safety/crisis elements, and distribution standards—functionally establishing the team’s shared agreements and recording them in the client record; the ICFP is completed within 30 days and placed in the file, then reviewed and updated on cadence. The Wrap facilitators co‑create a Family Team Mission Statement, use visual tools/posters in meetings, and transcribe/retain minutes so the family and team can reference commitments week‑to‑week—these meeting minutes operationalize team agreements and are retained with the case record. CFT meetings minutes are documented by the Facilitator outlining assignments and accountability (who does what by when), which are reviewed at each meeting, meetings are uploaded to the client’s file in Victor’s EHR.

Victor Wraparound Approach to Services SOP outlines and mandates routine satisfaction surveys to families and stakeholders and describes a grievance/response process—capturing perspectives on team engagement and collaboration. SOP requires fidelity tools—Wraparound Fidelity Index (WFI / WFI‑EZ) interviews (caregivers, youth, facilitators, and team members) and Team Observation Measure (TOM)—to routinely capture multi‑perspective feedback on teaming quality and collaboration. Manual adds Net Promoter Score (NPS) and bi‑annual Focus Groups (≥50% current/former clients/caregivers) to solicit family voice about the team process and collaboration.

Victor Wraparound Approach to Services SOP details a CQI framework: quarterly reviews of outcomes and fidelity/satisfaction data to (a) provide timely feedback to staff, (b) identify training needs, and (c) drive program improvements; participation with county leadership teams supports system‑level CQI as well. SOP links WFI/WFI‑EZ/TOM and survey results to practice improvement and coaching, ensuring supervisors use results to reinforce expectations and build skills. Manual notes leaders (e.g., Licensed/Clinical Supervisors and HFW Supervisors) review program data (including WFI) and use it to target additional training and reinforcements for staff—explicitly tying feedback to coaching.

Victor Wraparound Approach to Services SOP outlines the requirement of CFT meetings every 30 days with meeting minutes that document attendees, strengths acknowledgments, strategy/action items, responsible parties & due dates, progress checks, any flex fund use, and plan adjustments—a direct audit trail of shared ownership and follow‑through; the ICFP is updated at least every 90 days. Victor Wrap Manual prescribes a standard CFT structure (agenda, task review, IP‑CANS check‑ins, review of goals and assignments) and stresses documenting and transcribing the meeting information for family reference and accountability at the next meeting.

Wraparound Approach to Services SOP, pages 8, 13, 15-17
Victor Wraparound Manual, pages 13, 21–22, 25–28, 32-35

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

The ICFP (Individualized Child and Family Plan) must include: Specific needs being addressed, clear responsibilities for team members, clearly defined goals and timelines, strategies and action items assigned to individuals, safety procedures, this structure ensures plans contain measurable steps and timeframes. In CFT meetings, agenda components include: Review of goals “as written in the ICFP”, review of assigned tasks, progress, and reassignments, setting time‑bound tasks and expectations, using written/visual tools (poster boards, minutes) to document measurable actions.

Every CFT meeting must document: Action items, responsible parties & due dates, progress checks, completion status, updates must be recorded every 30 days and more frequently if required. Wrap Facilitator must review: Each goal, tasks assigned to each team member, progress made, re-assignment of tasks when needed. This occurs at every CFT and is written in the meeting minutes.

The ICFP is: Reviewed every 30–45 days, updated at least every 90 days, updated more frequently as needed, adjusted based on progress, new risks, and new team input, distributed to all CFT members after each revision. Facilitators use visual tools and meeting minutes to ensure updates are understood and shared. New needs or action items are added to the “parking lot” and integrated into the plan as appropriate. Plans evolve as the family’s trust builds and new information emerges; updates are required and documented.

The IP‑CANS is incorporated into the ICFP and reviewed at CFT meetings to guide prioritization and decision‑making. Wraparound Facilitators and Mental health clinicians perform assessments and the clinicians contribute diagnostic/clinical input used in planning. The IP‑CANS is described as a team-driven tool completed within the first 30 days during Milestone #1. It is used by the CFT collectively, with primary responsibility typically held by the Wraparound Facilitator. Scores and domain priorities are reviewed with all team members to guide goal setting. The IP-CANS is completed by the Mental Health Clinician for clinical responsibility, scoring, interpretation, the Wraparound Facilitator in some non-Medi-cal programs complete the IP-CANS and integrate into planning, reviewed at every CFT by the Facilitator. CFT team members participate in domain discussions and prioritization. The IP-CANS is presented during CFT meetings, incorporated into the ICFP, used to prioritize needs and support decisions, updated at minimum every 6 months and reviewed with the team.

IP‑CANS findings are integrated into the ICFP and reviewed in CFT meetings to prioritize needs and monitor progress, but all final planning and transition decisions require tracking: Goal completion, task completion, strengths and risk assessments. Transition planning requires reviewing progress in skills, resources, and goal attainment, not just CANS scores. IP‑CANS is used to identify needs and strengths but is one tool in a larger process that also includes: Strengths Assessment, Connection Map, Safety Plan, ICFP domain-level tracking. These are used together to determine readiness for transition. Transition and graduation require CFT review of task follow‑through, natural support engagement, need resolution, and skill development, not IP‑CANS alone.

Wraparound Approach to Services SOP, pages 8-11, 14,
Victor Wraparound Manual, pages 16-17, 21, 29-32

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

Persistence is a named Wraparound principle: teams address challenges with a “can‑do” stance, adding services as needed to maintain safety and achieve outcomes—explicitly promoting continuation through setbacks rather than ejecting the family. Family Voice and Choice is foundational; families are full and active partners at every level, and teaming continues with their voice centered in decisions—including about graduation/ending services. The Victor Wrap Manual reinforces these same principles (Voice & Choice, Persistence) and clarifies that individualized services and natural supports increase over time to sustain progress, aligning with continued work through limited progress. Transition occurs when needs are sufficiently met and the CFT (including the family) agrees; before then, teams continue to adjust plans rather than end services prematurely.

Coaching & Supervision: The Victor Wraparound Approach to Services SOP specifies an HFW Supervisor who provides on‑site supervision, program oversight, interagency liaison, and ensures weekly individual supervision for all wrap staff; this is the pathway to request additional coaching/supervision when challenges arise.
Fidelity/Practice Support: Teams can be observed with the TOM and supported via WFI/WFI‑EZ feedback—formal mechanisms that trigger targeted coaching and skills reinforcement.
Flexible Funding: The SOP details Flex Funds—criteria, tracking, approvals/denials, and an appeal path—including expectations to braid funds and prioritize natural supports; this is the documented process for requesting/accessing flex funds to overcome barriers.
Additional Support / After‑hours: A 24/7 crisis response system is in place with a published on‑call number, 15‑minute response window, and escalation to a designated administrator/clinical supervisor—concrete access to extra help during crises.
Facilitator & Team Help‑seeking: The Victor Wrap Manual describes the Facilitator’s leadership (coordinating the CFT, keeping the process on track) and provides detailed CFT structures (agenda, parking lot, reassignment of tasks), giving teams practical tools to seek help, escalate issues, and adjust plans.
Program‑level Coaching: The Victor Wrap Manual notes HFW/Clinical Supervisors review WFI and other data to initiate additional training or reinforcements—another route for teams to get extra help.

Training & Coaching Requirements: The Victor Wraparound Approach to Services SOP mandates Wrap 101/102, ≥16 hours/year ongoing training, and ≥12 hours of in‑vivo coaching (shadowing/mentoring), with curriculum covering phases/activities of Wraparound, individualized resource planning, safety/crisis planning elements within the ICFP, and role skills—directly supporting post‑crisis planning and continuous plan revision.
Supervision for Skill‑building: Weekly individual supervision by HFW or Clinical Supervisors provides ongoing coaching to strengthen facilitation skills (including conflict resolution and adapting plans after crises).
Post‑Crisis Safety Planning: The SOP requires the Safety Plan to identify high‑risk situations and proactive/reactive strategies, to be updated after crises and again at transition—practice that facilitators are trained/coached to lead.
Facilitator Techniques (brainstorming & revision): The Wrap Manual provides detailed CFT facilitation guidance—using visual tools, parking‑lot management, reviewing tasks, re‑assigning responsibilities, and checking IP‑CANS to inform revisions—codifying how facilitators lead effective brainstorming and ongoing plan updates (including after conflict or crisis).
Conflict‑tolerant Process & Persistence: Manual principles (Voice & Choice, Persistence, Natural Supports) and implementation guidance (re‑evaluation, re‑entering prior milestones) train facilitators to work through disagreements/conflict and iterate plans rather than stall progress.

Wraparound Approach to Services SOP, pages 5-6, 8-12, 16-18
Victor Wraparound Manual, pages 8-11, 13, 25-32
Victor Wrap 101 and 102 Training Curriculum

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Transition planning is built in from the start and continues throughout services: the Victor Wraparound Approach to Services SOP requires early and ongoing transition planning as the ICFP is implemented, modified, and goals are achieved—preventing abrupt service changes. Titration—not termination—of intensity: as milestones are met, service intensity decreases gradually; the CFT closely monitors progress and engages in the decision to transition, keeping families from experiencing sudden loss of support. Aftercare is provided to ensure continuity: families are offered telephone contact with Wraparound staff for up to 30 days post‑graduation for brief linkage and support—an explicit buffer against abrupt discontinuation. Operational safeguards during staffing changes: the SOP specifies that Executive Directors/HFW Supervisors ensure proper staffing and, in turnover cases, another staff member in the same position covers cases until the role is filled, preserving continuity during administrative disruptions. 24/7 crisis coverage with defined response and escalation: families receive written guidance at intake, a published on‑call number, a 15‑minute response window, and escalation to a designated administrator/clinical supervisor, minimizing service gaps during adverse events. CFT‑driven criteria for graduation (with preference to family voice/choice): transition occurs when needs are sufficiently met and the team—centering family voice—agrees to end services, rather than ending due to administrative timelines.

Culturally responsive celebrations are a required practice: the Victor Wrap Manual directs that graduations are tailored to each family’s culture, dynamics, and preferences; families choose how they prefer to celebrate accomplishments. Involving partners and community: the Manual encourages engaging referral sources and community members (e.g., teachers, coaches, neighbors) in celebrations—explicitly promoting community partnership in transition events. Administrative support via flexible funds: the SOP establishes Flex Funds with criteria and tracking, designed to meet urgent, individualized needs when not readily met by other resources—this policy framework enables reasonable, culturally relevant celebration supports (e.g., supplies, space, transportation) when aligned to the team mission and ICFP. Time and structure for community resourcing: the SOP’s Resource Development/Intensive Case Management requires staff to build bridges to community organizations (faith groups, schools, businesses, neighborhood orgs), which directly supports arranging culturally meaningful celebration venues/partners. Staff availability to attend and support: the Manual frames celebrations and recognitions as part of the program’s core transition practice (not an add‑on), signaling that staff participation is expected and program‑supported as families graduate.

Wraparound Approach to Services SOP, pages 9-12, 15
Victor Wraparound Manual, pages 29-32

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The Victor Wraparound program uses multiple formal tools and processes throughout services to record and evaluate family and youth, including tribal, satisfaction throughout their Wrap experience. The tools are outlined in the Victor Wrap Manual and Services SOP.

Victor conducts satisfaction surveys of families, youth, and community stakeholders (including tribes) to evaluate quality of services, meeting frequency, and whether needs are being met. (SOP 2026 pp. 12–13)

2. Net Promoter Score (NPS) Survey (Manual 2026 p. 35)
Families rate likelihood to recommend Victor’s services and provide open‑ended feedback.

3. Youth & Family Satisfaction Outcome Measure (Manual 2026 pp. 33–34)
Evaluates whether families feel supported and whether services helped them meet their goals.

4. Wraparound Fidelity Index (WFI & WFI‑EZ) (SOP 2026 p. 16)
Collects satisfaction-related feedback from caregivers, youth, facilitators, and team members.

5. Team Observation Measure (TOM) (SOP 2026 pp. 16–17)
Supervisor observations demonstrate quality of teaming and family experience.

6. Focus Groups (Manual 2026 p. 35)
Conducted twice a year to gather family voice and deeper satisfaction feedback.

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. School Functioning as an Outcome (Manual 2026 pp. 33–34):
The Wraparound program tracks school attendance, grades, and behavioral performance as part of its formal outcome measures. Families’ progress in these areas is evaluated quarterly.

2. IP-CANS Educational Domain (SOP 2026 pp. 6–7):
The IP-CANS tool is used to identify educational needs and evaluate progress in school functioning during reassessments every 6 months.

3. ICFP and Goal Monitoring (Manual 2026 pp. 19–22):
School-related goals are included in the Individualized Child and Family Plan (ICFP). Progress is reviewed in each CFT meeting.

4. CFT Meetings Oversight (Manual 2026 pp. 23–28):
CFT meetings monitor attendance, grade reports, teacher feedback, and completion of school-related goals.

5. CQI and Reporting (SOP 2026 pp. 15–16):
School functioning data is incorporated into Continuous Quality Improvement and quarterly reporting to county partners.

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Community-Based Services as a Core Principle (Manual 2026 pp. 7–9):
Engagement in community activities is embedded in the Wraparound Principles, requiring staff to help families connect with social, recreational, educational, and cultural activities.

2. Resource Development and Community Linkage (SOP 2026 pp. 10–12):
Family Support Counselors document community linkages, including participation in clubs, sports, after-school programs, churches, community centers, and other local resources.

3. Connection Map to Track Community Engagement (Manual 2026 pp. 18–19):
Connection Maps are updated regularly to capture families’ natural and community supports, documenting growth in community participation.

4. CFT Meetings to Monitor Progress (Manual 2026 pp. 23–28):
CFT Meetings include structured reviews of recreational activities, participation in community programs, and progress toward community integration goals.

5. IP-CANS Assessment of Community Functioning (SOP 2026 pp. 6–7):
The IP-CANS evaluates recreational, social, and community functioning needs, with reassessments every six months to monitor improvements.

6. Outcome Measure: Improved Community Functioning (Manual 2026 pp. 33–34):
Community engagement is tracked as a formal outcome, evaluating participation, connectedness, and reduced isolation.

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Interpersonal Functioning as an Outcome (Manual 2026 pp. 33–34):
The Wraparound program evaluates improved interpersonal functioning as a core outcome, including family relationships, peer interactions, and communication patterns.

2. IP-CANS Assessment of Social/Emotional Domains (SOP 2026 pp. 6–7):
The IP-CANS tool records social/emotional needs, family functioning, and relationship challenges. It is updated every 6 months to evaluate changes over time.

3. Strength Assessment of Family Interpersonal Assets (Manual 2026 pp. 17–18):
The Strengths Assessment identifies interpersonal strengths and relational capacities within the family, supporting improved functioning.

4. Connection Map to Record Family & Support Network Dynamics (Manual 2026 pp. 18–19):
Connection Maps record family relationships, natural supports, and areas needing reconnection or relationship repair.

5. CFT Meetings Evaluate Interpersonal Dynamics (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings include structured review of communication, conflict resolution, teamwork, and relational progress.

6. Crisis & Safety Planning Reflects Relational Risks (Manual 2026 pp. 15–17):
Crisis and Safety Plans identify interpersonal triggers and family communication patterns that may affect safety or stability.

7. WFI-EZ and TOM Tools Evaluate Interpersonal Quality (SOP 2026 pp. 16–17):
The WFI-EZ and TOM gather feedback and observe team interactions, measuring relationship quality, communication, and fidelity to Wraparound principles.

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Caregiver Confidence as an Outcome (Manual 2026 pp. 33–34):
The Wraparound program formally measures increased caregiver confidence as a key program outcome, assessing whether caregivers feel more capable in managing their child’s needs and navigating systems.

2. IP-CANS Assessment of Caregiver Functioning (SOP 2026 pp. 6–7):
The IP-CANS tool records caregiver functioning, unmet needs, and support adequacy. Reassessments every six months track improvement in caregiver capacity.

3. Connection Map to Evaluate Community Connectedness (Manual 2026 pp. 18–19):
The Connection Map documents caregivers’ natural supports and community ties, highlighting areas where reconnection or new supports are needed.

4. Strength Assessment to Build Caregiver Confidence (Manual 2026 pp. 17–18):
Strengths Assessments help caregivers identify personal and relational strengths, increasing their confidence through acknowledgment and support.

5. CFT Meetings Monitor Confidence and Resource Use (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings continuously review caregiver progress, independence, and engagement with community resources.

6. Caregiver Support Groups Enhance Confidence (SOP 2026 pp. 11–12):
Support groups led by Caregiver Peer Partners promote confidence-building, resource sharing, and mutual support among caregivers.

7. Resource Development and Community Linkage (SOP 2026 pp. 12–13):
Family Support Counselors help caregivers access community services, reducing reliance on formal supports and building long-term independence.

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Assessment of Placement History and Risk (SOP 2026 pp. 6–7):
The Wraparound assessment process documents placement history, presenting problems, placement risks, and unmet needs tied to stability. This establishes a baseline for tracking future placement changes.

2. Eligibility Criteria Related to Placement Instability (SOP 2026 p. 6):
Wraparound serves youth currently in out-of-home care or at risk of placement loss or disruption. Staff monitor and document any movement toward or away from risk of placement change.

3. CFT Meetings Track Placement Stability (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings provide documented updates on home stability, living situation changes, safety concerns, and factors that may influence placement outcomes.

4. Crisis and Safety Planning (Manual 2026 pp. 15–20):
Crisis and Safety Plans outline high-risk behaviors or events that could trigger placement changes. Activation of these plans is documented and reviewed to evaluate patterns leading to instability.

5. Monitoring and Evaluation Procedures (SOP 2026 pp. 15–17):
Victor’s monitoring processes track outcomes such as stable and least restrictive living environment, crisis events, and positive exits. These indicators help evaluate frequency and types of placement changes.

6. Placement Post-Program Outcome (Manual 2026 pp. 33–34):
Placement stability is measured as an outcome at program completion, including whether placement changes decreased and whether youth transitioned to the least restrictive and most stable placement.

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Hospitalizations as a Formal Outcome (Manual 2026 pp. 33–34):
The Wraparound program tracks the reduction in hospitalizations and crisis visits as a core outcome measure. This includes documenting frequency of psychiatric hospital stays and emergency-based crisis episodes.

2. Baseline Documentation During Assessment (SOP 2026 pp. 6–7):
The assessment process records the youth’s mental and physical health needs, history of hospitalizations, and presenting problems that may contribute to crisis events requiring hospitalization.

3. Crisis Response and On-Call Documentation (SOP 2026 p. 9):
The 24/7 crisis response system requires that crisis calls and emergency responses be documented, including any incidents that result in hospital visits.

4. Crisis and Safety Planning (Manual 2026 pp. 15–20):
Crisis and Safety Plans identify high-risk behaviors and strategies to prevent hospitalization. Updates to these plans reflect any hospital visits and the conditions leading up to them.

5. CFT Meetings Review Hospitalization Events (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings monitor recent hospital visits, identify patterns, and adjust interventions or safety planning accordingly. Documentation is kept in CFT minutes.

6. Monitoring and Evaluation (SOP 2026 pp. 15–17):
The program’s CQI process tracks hospitalization frequency, reviews crisis service utilization data, and evaluates trends to support service improvements.

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. 24/7 Crisis Response Documentation (SOP 2026 p. 9):
All crisis events are logged through the 24/7 on-call crisis response system. Documentation includes response time, nature of the crisis, and which professionals (on-call staff, clinical supervisors, administrators) were involved.

2. Crisis and Safety Planning Procedures (Manual 2026 pp. 15–17):
Crisis and Safety Plans identify likely crisis situations, define response protocols, and document each crisis requiring plan activation. These plans track both frequency and required professional involvement.

3. CFT Review and Documentation of Crises (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings formally review all crises since the last meeting. Discussions include frequency, triggers, interventions used, and level of professional support involved. This information is recorded in CFT minutes.

4. Assessment of Crisis History and Risk (SOP 2026 pp. 6–7):
Initial assessments document crisis-related behaviors, historical crisis incidents, and risk factors. This creates a baseline to evaluate changes in crisis frequency and support needs over time.

5. Monitoring and CQI Evaluation (SOP 2026 pp. 15–17):
The Continuous Quality Improvement process tracks crisis trends, evaluates service use, and monitors whether professional interventions effectively reduce crisis frequency. Reports include data on hospitalizations, crisis visits, and emergent interventions.

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

1. Transition Phase Documentation (Manual 2026 pp. 30–31):
The Transition Phase documents readiness for exit, including progress on goals, remaining needs, and the family’s ability to function independently without formal supports.

2. CFT Meeting Documentation (Manual 2026 pp. 23–28):
Child and Family Team (CFT) meetings document all exit-related decisions, including progress, safety considerations, and team consensus on graduation readiness.

3. Six-Month Review Process (Manual 2026 pp. 29–30):
The six-month review formally determines whether a family exits immediately, transitions toward graduation, or continues services for an additional six months. This process documents when a family exits and why.

4. Graduation Phase Records Exit Reasons (Manual 2026 pp. 31–32):
Graduation reflects that the family has met goals, ensured safety, strengthened natural supports, and no longer requires Wraparound services. Documentation includes reasons for exit and accomplishments.

5. Aftercare and Exit Documentation (Manual 2026 p. 15):
Aftercare procedures include documenting services delivered, aftercare referrals, and the official date and reason for exiting HFW. A 30-day follow-up option supports continuity.

6. Positive Exit Outcome Tracking (SOP 2026 pp. 15–17; Manual 2026 pp. 33–34):
Program outcomes formally track positive exits, including whether the youth achieved stability, met goals, and exited to a least restrictive, sustainable environment.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Families receive a clear explanation of the Ten Best Practice Principles and the four phases/milestones of the Wraparound process, including Engagement, Plan Development, Implementation, and Transition. (Manual 2026 pp. 5–9, 13–20

Staff explain mandatory reporting obligations, family rights, confidentiality standards, and ICWA legal requirements when serving an Indian child. (SOP 2026 pp. 6–7, 11–12)

Families receive an overview of each participating role in the Child and Family Team (CFT), including the Facilitator, Parent Partner, Youth Partner, Clinician, HFW Supervisor, natural supports, and—when applicable—Tribal representatives. (Manual 2026 pp. 11–12; SOP 2026 pp. 6–7, 11–12)

Families are informed about the importance of natural supports, how they participate in the Wraparound process, and how their involvement strengthens long-term support networks. (Manual 2026 pp. 18–19)

When serving an Indian child, the HFW team must explain Tribal sovereignty, the Tribe’s role as an equal CFT partner, cultural considerations, and legal protections under the Indian Child Welfare Act. (SOP 2026 pp. 6–7)

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

During the Engagement phase, the team discusses any initial crisis or safety concerns with the family. If pressing concerns arise, an immediate crisis response plan is created, provided to the family, and documented in the chart. (Manual 2026 pp. 15–17))

The immediate crisis response plan developed during the Engagement phase is used to inform—but not replace—the formal Safety Plan developed later during the Plan Development phase. The Safety Plan becomes the primary tool used to identify risks and outline responses. (Manual 2026 pp. 15–17)

All families receive written instructions at intake on how to access the 24/7 crisis response system, including the on-call number, expected response time, and the escalation path for additional support when needed. (SOP 2026 p. 9)

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

A Family Vision is developed collaboratively with every family during the Engagement phase and is documented in the youth’s chart. This vision reflects the family’s priorities, hopes, and long-term goals. (Manual pp. 15-16)

A Strengths, Needs, and Culture Discovery document is initiated for every youth and family. This document is included in the youth’s chart and updated at least every 90 days. The team continuously adds new strengths, needs, and cultural preferences as they are discovered. (Manual pp. 16-18; 21-22)

The updated Strengths, Needs, and Culture Discovery document is provided to all newly identified team members to ensure alignment with the family’s evolving needs, strengths, and cultural identity. (Manual pp. 21-22)

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

A natural supports inventory is completed with every youth and family and documented in the case file. This ensures identification of informal supports available to the family. (Manual pp. 18–19)

Children’s System of Care partners who should be included on the HFW team are identified and engaged early in the process to ensure cross-system collaboration. (Manual pp. 7–9, 11–13; SOP pp. 15–16)

The HFW team collaborates with the youth and family to identify potential formal and natural team members. When serving an Indian child, Tribal representatives are identified and their role on the team is discussed. (Manual pp. 8, 11–12; SOP pp. 6–7, 11–12)

All engagement and team-building activities are documented in the youth’s file, including CFT Meeting minutes and case notes. (SOP pp. 7–8; Manual pp. 15–18, 21–22)

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Staff adjust working hours and meeting times/locations to accommodate the needs of families and the Wraparound Team, ensuring accessibility and full participation. (SOP p. 9 and Manual pp. 7–9, 21–23)

Staff are trained to collaborate with families and all HFW team members to schedule meetings that align with family preferences and maximize involvement. This includes accommodating cultural, logistical, and individual needs to support effective participation. (SOP pp. 16-18 and Manual pp. 21–23)

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Before the HFW Plan of Care is developed, the facilitator leads the team in establishing formal team agreements, identifying and documenting team strengths, and creating a mission statement aligned with the Family Vision. These documents are completed with every family and stored in the youth’s file. (Manual 2026 pp. 23–28; pp. 15–17)

Strengths gathered during the Engagement phase are reviewed and updated throughout teaming and planning. Newly discovered strengths are added to the Strengths, Needs, and Culture Discovery documentation and entered into the youth’s file. Updates occur at least every 90 days, consistent with CFT and ICFP review cycles. (Manual 2026 pp. 17–19; SOP 2026 pp. 6–7)

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

Before the HFW Plan of Care is developed, underlying needs for each youth and family are identified through assessment and early teaming. These needs are prioritized, incorporated into the Individualized Child and Family Plan (ICFP), and documented in the youth’s file. (SOP 2026 pp. 7–8; pp. 6–7)

Goals and outcomes are created directly from prioritized needs. The Victor Wraparound Approach to Services SOP requires that goals are specific, measurable, and connected to needs rather than deficit- or behavior-based framing. (SOP 2026 pp. 7–8; pp. 15–17)

The ICFP is developed collaboratively during Child and Family Team (CFT) meetings. Youth, caregivers, natural supports, service providers, and system partners all contribute to goal-setting to ensure accuracy and shared ownership. (SOP 2026 pp. 7–8)

CFT meetings document strategies and action steps, including strengths acknowledgements, action items, responsible parties, timelines, and progress checks. Strategies may appear in the Plan of Care, meeting minutes, forms, or progress notes. (SOP 2026 pp. 7–8)

Facilitators receive structured training including Wraparound 101, Wraparound 102, in-vivo coaching (minimum 12 hours), annual continuing education (16 hours/year), and ongoing observation/coaching to support their ability to guide teams in identifying needs, generating strategies, and creating action plans. (SOP 2026 pp. 16–18)

All steps above combine to ensure the HFW Plan of Care is developed in a collaborative, team-driven environment, reviewed every 30–45 days, and updated every 90 days based on team input and youth/family progress. (SOP 2026 pp. 7–8)

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Facilitators receive ongoing training through Wraparound 101, Wraparound 102, in-vivo coaching, supervision, and annual continuing education. These trainings prepare facilitators to lead inclusive planning processes that reflect HFW principles and build trust and shared vision. (SOP 2026 pp. 15–17)

The Plan of Care (ICFP) incorporates goals and objectives identified by Children’s System of Care partners, including behavioral health, child welfare, probation, schools, and Tribal representatives when applicable. (SOP 2026 pp. 15–17)

The Plan of Care is documented in the youth’s file, distributed to all team members, reviewed every 30–45 days, and updated every 90 days to ensure alignment with identified needs, measurable goals, strategies, and HFW practice standards. (SOP 2026 pp. 7–8, 15–17)

Victor’s CQI process includes regular review of Plans of Care, fidelity tools (WFI, WFI-EZ, TOM), and outcome data to provide feedback to staff and supervisors for training, coaching, and improved plan quality. (SOP 2026 pp. 15–17)

Victor Wrap 101 and 102 Training Curriculum

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

An individualized Crisis & Safety Plan is documented in the youth’s file. It identifies potential safety/high‑risk/crisis situations and lists proactive and reactive strategies chosen with the family. The plan also includes who to call for support, with 24/7 contact details. (SOP 2026 pp. 8–9)

All families receive written guidance at intake on how to access the 24/7 crisis response system, including the on‑call number, expected response time, and escalation to a supervisor/administrator. (SOP 2026 p. 9)

Crisis/Safety planning occurs in Child & Family Team (CFT) meetings with the youth, caregivers, natural supports, providers, and (when applicable) Tribal representatives. Initial urgent response plans from engagement inform—but do not replace—the formal Safety Plan created in Plan Development. (Manual 2026 pp. 15–17; SOP 2026 pp. 8–9)

Facilitators receive ongoing training and coaching (Wraparound 101, 12 hours in‑vivo coaching, annual Wraparound 102, and 16 hours/year of ongoing training with observation/coaching and supervision) to lead collaborative, culturally responsive crisis/safety planning. (SOP 2026 pp. 16–18)

Plans are reviewed through Continuous Quality Improvement to ensure individualized strategies, an appropriate progression of proactive→reactive responses, cultural relevance (including Tribal participation for Indian children), and effective use of natural supports. Findings feedback to staff/supervisors for training and coaching. (SOP 2026 pp. 15–17)

WFI/WFI‑EZ interviews and TOM observations provide fidelity feedback on whether crisis/safety planning reflects Wraparound principles (e.g., individualized practice, natural supports, culturally responsive strategies), informing coaching and improvements. (SOP 2026 pp. 16–17)

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

1. Facilitator Review of Strategies and Action Items (SOP 2026 pp. 7–8):
Facilitators lead the HFW team in reviewing strategies and action items during CFT meetings. Meeting documentation must include strengths acknowledgements, action items, responsible parties, due dates, progress/completion checks, and plan adjustments. This ensures assignments are tracked, timelines monitored, and strategies updated as needed.

2. Tracking Assignments and Progress (SOP 2026 pp. 7–8):
CFT meeting minutes are required to document responsible individuals, due dates, and task completion status. These procedures ensure accountability and support timely progress on all elements of the Plan of Care.

3. Strategy Adjustments Through Regular Review (SOP 2026 pp. 7–8):
The ICFP/Plan of Care is reviewed every 30–45 days and updated at least every 90 days, supporting the ongoing adjustment of strategies and action items as family needs evolve.

4. Training and Coaching on HFW-Aligned Implementation (SOP 2026 pp. 16–18):
Staff receive structured training, including Wraparound 101, Wraparound 102, a minimum of 12 hours of in-vivo coaching, 16 hours of annual continuing training, and ongoing supervision/coaching. These trainings support implementation aligned with HFW principles such as team-based decision making, collaboration, strengths-based practice, and shared vision.

5. Celebrating Successes as Part of Implementation (SOP 2026 pp. 5–6, 7–8):
The Victor Wraparound Approach to Services SOP reinforces celebrating strengths and successes through the HFW principles and requires strengths acknowledgements at every CFT meeting. This embeds recognition of progress directly into team processes.

6. CQI-Based Coaching and Implementation Support (SOP 2026 pp. 15–17):
The Continuous Quality Improvement (CQI) process analyzes implementation outcomes, provides feedback to staff and supervisors, identifies training needs, and enhances the quality of plan implementation. Fidelity tools such as WFI/WFI-EZ and TOM further reinforce team performance and coaching needs.

Victor Wraparound 101 and 102 Training Curriculum

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

1. Reviews of Strategies, Progress, and Action Items Occur in HFW Team Meetings (SOP 2026 pp. 7–8):
CFT meeting minutes must document strengths acknowledgements, strategy/action items, responsible parties, due dates, progress checks, and plan adjustments, ensuring structured team-based review.

2. Facilitator Adjusts Plan as Successes Occur or New Needs Emerge (SOP 2026 pp. 7–8):
The facilitator leads the team in modifying strategies and updating the ICFP/Plan of Care during CFT reviews. Updates are documented in the youth’s file and reflect new needs, progress, or selected strategies.

3. Documentation and Communication of Tasks, Assignments, Supports, and Flex Funds (SOP 2026 pp. 7–8; pp. 10–11):
Facilitators document task assignments, completion status, team attendance, formal and natural supports used, and flex fund decisions. These updates are shared with all team members through CFT meeting minutes.

4. Forms Updated and Individualized to Meet Changing Needs (SOP 2026 pp. 7–9):
The ICFP and Safety Plans are updated regularly (every 30–45 days, with full updates every 90 days or as needed), ensuring all documents remain individualized and reflective of evolving youth and family needs

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

Facilitator guides the CFT to establish formal team agreements (engagement norms, decision-making, communication) and documents them so they can be used in meetings and remain present in the youth’s file. (Manual 2026 pp. 15–17, 21–22)

CFT minutes must capture attendance, strengths acknowledgements, strategy/action items, responsible parties & due dates, progress/completion checks, and plan adjustments; ICFP is reviewed every 30–45 days and updated at least every 90 days. (SOP 2026 pp. 7–8)

Wraparound 101 (3-day), minimum 12 hours of in‑vivo coaching/mentoring, annual Wraparound 102, 16 hours/year of continuing training, plus observation/coaching and supervision—skills aimed at building/engaging/maintaining effective teams. (SOP 2026 pp. 16–18)

The Facilitator’s leadership guides trust-building, shared vision, and clear teaming rules in alignment with principles. (Manual 2026 pp. 21–23)

CFT minutes completed by the Facilitator, track responsible parties, due dates, progress; CQI requires using data to improve practice, provide timely feedback to staff, and identify training needs. (SOP 2026 pp. 7–8; 15–17)

The Connection Map tool used to identify, expand, and track natural supports at intake and reviews, informing supervision/coaching discussions. (Manual 2026 pp. 18–19, 29–31)

ICFP is filed and distributed to team members; reviewed every 30–45 days; updated at least every 90 days. ICWA requires inclusion/orientation of Tribal representatives as equal CFT members when serving an Indian child. (SOP 2026 pp. 7–8; 6–7; 11–12)

Staff explain HFW principles & phases, clarify roles, review current plans/strategies, and use team-building—steps leveraged when onboarding new formal or natural supports. (Manual 2026 pp. 5–9; 13–17; 21–23)

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

The CFT—led by the facilitator—reassesses needs/strengths at the 6‑month review and selects one of three paths (graduate now, short transition then graduate, or continue services), embedding benchmark‑based decision-making for transition readiness. (Manual 2026 pp. 29–30)

Transition work includes titrating services, shifting tasks to natural supports, and the family facilitating its own CFTs—practical indicators of readiness that the team has monitored throughout services. (Manual 2026 pp. 30–31)

Transition planning is critical and occurs as the plan is implemented and goals are achieved; service intensity decreases as readiness is demonstrated. (SOP 2026 p. 9)

The team produces a thorough, individualized transition plan detailing needs, referrals, community resources, contact information, and helpful documents for use after services end. (Manual 2026 p. 32)

The ICFP/Plan of Care (the team’s plan) is filed in the client record and distributed to team members; it is reviewed every 30–45 days and updated at least every 90 days, including at transition. (SOP 2026 pp. 7–8)

The Safety Plan is updated upon transition to reflect current functioning and potential crises beyond graduation. (SOP 2026 p. 8)

The facilitator leads a collaborative Child & Family Team process to align the plan with the family vision/mission and prioritized needs; this teaming approach carries through to transition plan development. (Manual 2026 p. 22)

Facilitators receive Wraparound 101 (3 days), a minimum of 12 hours of in‑vivo coaching, annual Wraparound 102, at least 16 hours/year of related continuing training, and ongoing observation/coaching and supervision—preparing them to guide collaborative transition planning. (SOP 2026 pp. 16–18)

Transition focuses on decreasing formal supports, increasing natural/community supports, and families facilitating their own CFTs—ensuring supports will persist past HFW and the family can access them. (Manual 2026 pp. 30–31)

The transition plan packages referrals, resources, and contact details the family will rely on after formal services end. (Manual 2026 p. 32)

In the final 90 days, staff identify aftercare resources and complete linkages at graduation (e.g., medication support, outpatient MH, vocational/educational supports, support groups), and offer 30-day post‑graduation contact—ensuring persistence and access beyond HFW. (SOP 2026 pp. 14–15)

SOP recognizes Adoption Assistance Program (AAP) eligibility within Wraparound, and post‑adoption needs are addressed through the aftercare linkage procedures when applicable. (SOP 2026 p. 6)

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Safety Plan identifies potential safety/high‑risk situations and documents proactive/reactive strategies; it must be updated upon transition to reflect current functioning and anticipate crises beyond graduation; families also receive written guidance for 24/7 crisis access. (SOP 2026 pp. 8–9)

Crisis & Safety Plan is guided by the Family Mission Statement; the CFT anticipates crises and builds strategies that elevate natural supports so families can manage crises independently over time. (Manual 2026 pp. 16–17)

Facilitator guides a collaborative Child & Family Team process aligned with the family vision/mission—this teaming approach carries through transition planning. (Manual 2026 pp. 21–22)

Wraparound 101 (3 days), ≥12 hours in‑vivo coaching, annual Wraparound 102, ≥16 hours/year continuing training, plus observation/coaching and supervision prepare facilitators to lead collaborative crisis/safety planning. (SOP 2026 pp. 16–18)

Program uses data to improve practice, provide timely feedback to staff, and identify training needs—applies to the quality of crisis/safety planning and implementation. (SOP 2026 pp. 15–17)

TOM observations and WFI/WFI‑EZ interviews assess whether planning is individualized, shows appropriate proactive→reactive strategy progression, is culturally relevant (including ICWA/Tribal participation as applicable), and maximizes natural supports—feeding supervision/coaching. (SOP 2026 pp. 16–17)

Connection Map and milestone reviews track growth and reliance on natural supports and inform ongoing coaching/supervision. (Manual 2026 pp. 18–19, 29–31)

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

Celebrations are a core, expected practice during Transition/Graduation; they are tailored to each family’s culture, values, dynamics, and preferences, and families are asked how they prefer to celebrate. (Manual 2026 pp. 31–32)

Flex funds may be used—when aligned with team goals and approved by the CFT—to meet individualized needs when other resources are unavailable; expenditures must be cost‑effective/sustainable and documented. (SOP 2026 pp. 10–11)

Family Support Counselors build linkages with community organizations (e.g., churches, gyms, rec centers, after‑school programs) and develop resources that can host or contribute to family‑defined celebrations. (SOP 2026 pp. 10–13)

Program planning ensures adequate staffing, flexible scheduling, and participation in family‑driven activities/CFTs during implementation and transition. (SOP 2026 p. 9)

CQI provides feedback and identifies training needs—reinforcing strength‑based practice that includes recognition and celebration of progress. (SOP 2026 pp. 15–17)

Staff help plan and attend celebrations that honor milestones and the family’s chosen style. (Manual 2026 pp. 31–32)

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

Families serve as full and active partners at every level of the Wraparound process, participating in decisions that guide service delivery and local implementation. (Manual 2026 pp. 7–9)

The Child & Family Team (CFT) develops, implements, and evaluates individualized plans, giving families direct influence on implementation decisions. (Manual 2026 pp. 7–9)

Wraparound emphasizes family-driven planning, ensuring families provide direction on goals, strategies, and program engagement. (Manual 2026 pp. 5–9)

Wraparound programs conduct Focus Groups at least twice a year with 50% or more family participants to shape program design, policies, and procedures. (Manual 2026 p. 35)

Plans of Care are reviewed every 30–45 days in CFT meetings, ensuring families continuously influence local implementation procedures. (SOP 2026 pp. 7–8)

Family feedback—including satisfaction surveys, outcomes data, and fidelity tools—is incorporated into CQI to improve practice, identify training needs, and update policies and procedures. (SOP 2026 pp. 15–17)

Family satisfaction and experience with services are formally tracked as program outcomes and inform changes in service planning and implementation. (Manual 2026 pp. 33–34)

Fidelity Tools – WFI, WFI-EZ, TOM): These tools collect caregiver and youth feedback that is used for staff coaching, workforce development, and improving service delivery quality. (SOP 2026 pp. 16–17)

Feedback from Focus Groups directly informs program design, staff development, and operational improvement. (Manual 2026 p. 35)

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

The Community Leadership Team (CLT) is a system-level structure responsible for addressing program concerns, resolving system barriers, strengthening interagency partnerships, and supporting Continuous Quality Improvement (CQI). The Wrap Program Director or representative participates bringing agency issues, improvement ideas, and collaboration needs to the CLT. (SOP 2026 pp. 15–17). There is a high focus on the importance of collaboration with system partners—including Child Welfare, Probation, Behavioral Health, and community partners—requiring agency-level engagement consistent with CLT expectations. Supervisors and leadership contribute to cross-system communication and fidelity oversight, aligning directly with CLT responsibilities. (Manual 2026 pp. 11–13)

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

Eligibility criteria include youth who are dependents/wards, at risk of out-of-home placement, currently placed, or receiving AAP benefits. Youth with significant behavioral, emotional, or safety-related needs are explicitly identified as target populations—not exclusion criteria. (SOP 2026 p. 6). The Victor Manual emphasizes that Wraparound serves families with multiple, long-standing unmet needs that extend beyond therapy, including serious behavior, trauma, and school or relational difficulties—confirming that high-need youth are not excluded. (Manual 2026 pp. 5–7, 33–34)

Victor programs maintain adequate staffing to ensure the frequency and intensity of services required by high-need families. Caseload planning ensures staff availability for 24/7 crisis response, including after-hours on-call systems and supervisor/administrator escalation. (SOP 2026 pp. 9–10, 15–17). The Victor Manual identifies that early-phase services are intensive and hands-on, requiring staff roles to be distributed across the team (Facilitator, FSC, Parent Partner, Youth Partner) to meet complex needs. Effective implementation requires manageable caseloads and consistent availability for engagement, CFT meetings, and crisis support. (Manual 2026 pp. 19–21, 23–28)

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Wraparound services must include intensive, individualized, family-centered supports delivered across home, school, and community settings. Contracts reflect resources for 24/7 crisis response, flexible intervention capacity, and individualized supports. (SOP 2026 pp. 7–11)

The Victor Wrap Manual notes that Wraparound serves youth with multiple, complex unmet needs requiring immediate, hands-on, individualized support—especially during the first 30–45 days. This necessitates contract structures that fund high-fidelity interventions. (Manual 2026 pp. 15–21, 23–28)

Workforce development requirements include Wraparound 101 training (3 days), a minimum of 12 hours of in-vivo coaching, annual Wraparound 102, at least 16 hours of continuing training annually, and ongoing supervision/coaching. Contracts must fund required staffing to meet these expectations. (SOP 2026 pp. 16–18)

The Victor Wrap Manual outlines required functions for key roles—Facilitator, Parent Partner/Peer Specialist, Youth Partner, Family Support Counselor, Clinician, and HFW Supervisor—that correspond to statewide Workforce Standard 9.3. Contracts account for the inclusion of these roles. (Manual 2026 pp. 11–13)

Victor Wrap Programs maintain data systems that capture outcomes, demographics, service utilization, staffing patterns, fidelity scores (WFI, WFI-EZ, TOM), crisis data, flex fund tracking, transition outcomes, and CQI inputs. (SOP 2026 pp. 7–9, 15–17)

Wrap program required tools—including IP-CANS, Strengths Assessments, Connection Maps, Crisis & Safety Plans, ICFPs, and outcome tracking (school functioning, community functioning, interpersonal functioning, caregiver confidence, hospitalizations, placement stability, satisfaction)— use reliable data systems. (Manual 2026 pp. 15–23, 33–35)

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) The process for identification and reinvestment of HFW savings is documented, followed, and transparently communicated to the community and stakeholders.

Description of Practice, Name of Supporting Documentation and Page #:

Some Victor Wrap programs within specific counties have a Wraparound Steering Committee comprised of system leaders (Child Welfare, Probation, Office of Education, Behavioral Health, and Victor) who meet 2–3 times per year to review Wraparound programming, outcomes, and funds, cost-savings, and reinvestment opportunities. All reinvestment proposals are approved by the Committee, who keeps stewardship of the funds, approving all reinvestment programming with authority over use/allocation of funds. (SOP 2026 p. 13) For the other Victor Wrap programs, this is N/A.

The Victor Wrap process requires quarterly CQI reviews using program data (e.g., outcomes, fidelity, service utilization) to improve practice and address system barriers, creating a structured forum for transparent review of program performance that can include fiscal stewardship discussions. (SOP 2026 pp. 15–17)

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

Flex Funds are identified as a required component of Wraparound services to meet individualized and urgent needs when other resources are unavailable. They are part of the program’s funding structure and support high-fidelity, needs-driven service delivery. (SOP 2026 p. 10)

Flex Funds are intended to address immediate needs, and the Wrap SOP specifies that timely access must be ensured for families, guided by Child and Family Team (CFT) recommendations. (SOP 2026 p. 10)

The Wrap SOP outlines clear criteria for evaluating Flex Fund requests, including alignment with team mission, cultural relevance, sustainability, strength-based strategies, and ensuring the request represents a good investment. Decisions are informed by CFT review and team mission. (SOP 2026 p. 10)

The Wrap SOP specifies a documented appeal process, including communicating reasons for denial to youth, families, and the CFT, and providing a pathway for re-evaluation by program leadership. (SOP 2026 p. 10)

The Wrap SOP outlines required tracking of all Flex Fund requests—approved or denied—including amount, purpose, and team recommendation, and mandates aggregated reporting for system transparency and CQI. (SOP 2026 p. 10)

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

The Wrap SOP requires that all flex fund requests—approved or denied—be documented, including the amount, purpose, and Child and Family Team (CFT) recommendation. This information must be tracked and reported in aggregate to ensure transparency for funders and program partners. (SOP 2026 p. 10)

The Wrap SOP mandates that program partners maintain oversight of flex-fund usage and trends. This ensures transparency in allocation, decision-making, and fiscal stewardship between providers and funders. (SOP 2026 p. 10)

As providers Victor is expected and does pool flexible funds so that availability is not restricted by a single funding source. This ensures flex funds are accessible to all families served, supporting equitable and needs-driven service delivery. (SOP 2026 p. 10)

The SOP explicitly states that funding requirements from any one source should not limit the availability of flex funds for families. This ensures flex funds are managed as a shared program resource. (SOP 2026 p. 10)

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

Victor as a provider is expected to pool flexible funds across funding streams so that availability is not restricted by a single source—an operational approach consistent with funding braiding across the System of Care. (SOP 2026 p. 10)

When one funding source has limitations, program procedures direct staff to rely on other pooled funding sources so access to flex funds is maintained and gaps are filled. (SOP 2026 p. 10)

The SOP explicitly states that requirements tied to any single funding source should not limit families’ access to flexible funds; flex funds are managed as a shared resource across the program. (SOP 2026 p. 10)

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

Victor Wrap Programs collects, analyzes, and reports program data including the demographics of children served as part of quarterly CQI reviews. (SOP 2026 pp. 15–16)

Victor recruitment and hiring are designed to attract and maintain bilingual staff (Spanish/English/County Threshold languages); translation services are provided as needed; focus groups and surveys inform modifications to meet unique cultural needs. (SOP 2026 p. 11)

“Culturally Respectful and Relevant” and “Natural Supports” principles require engaging family-identified/community supports on the CFT to provide cultural representation when direct staffing cannot fully match family needs. (Manual 2026 pp. 7–9)

The facilitator leads a collaborative CFT process aligned to the family vision/mission, drawing on natural/community supports to reflect culture and preferences. (Manual 2026 p. 22)

Victor agencies provide translation services as needed to ensure full access across the county population. (SOP 2026 p. 11)

Natural supports on the CFT may assist with language/cultural resonance where appropriate, with consents and boundaries. (Manual 2026 pp. 7–9)

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

Staff are trained to understand Tribal sovereignty, traditions, values, and ICWA requirements; expectations include respectful communication, collaboration, and advocacy with Tribes when serving Indian children. (SOP 2026 pp. 6–7, 11–12)

Wraparound 101/102, in‑vivo coaching (≥12 hours), and ongoing supervision/coaching reinforce culturally respectful practice and collaboration with Tribal partners. (SOP 2026 pp. 16–18)

“Culturally Respectful and Relevant” principle requires teams to respect the family’s beliefs and traditions; when Native ancestry is present, the CFT should include Tribal representatives. (Manual 2026 pp. 7–9)

When serving an Indian child, the HFW team partners with Tribal representatives, coordinates services with the Tribe, and integrates Tribal customs and resources into planning, CFT Meetings, and services. (SOP 2026 pp. 6–7, 11–12)

Facilitators support inclusion of Tribal representatives on the CFT; teams encourage participation in culturally meaningful practices and recognize the value of Tribal services/supports. (Manual 2026 pp. 7–9)

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

Victor leadership operates a CQI process with quarterly reviews of outcomes, caseloads, supervision/training indicators, fidelity, and demographics; findings are used to improve practice, provide timely staff feedback, identify training needs, and elevate system barriers via County Leadership Team (CLT). QA conducts random file audits; new-hire orientation, team meetings, and monthly All-Staff meetings engage all staff. (SOP 2026 pp. 15–17)

Team Meetings, weekly individual and group supervision and ongoing observation/coaching build cohesion and shared practice; Wrap 101, ≥12 hours in-vivo coaching, annual Wrap 102, and ≥16 hours/year continuing training create a competency-building culture. (SOP 2026 pp. 11–12, 16–18); Manual 2026 (Principles & Milestones) set expectations for respectful, strength-focused teaming. (Manual 2026 pp. 7–9, 21–23)

CFT minutes document attendance, strengths acknowledgements, action items, responsible parties/due dates, progress checks, and plan adjustments, standardizing transparent communication; leadership designates CLT/ILT representatives for cross-agency decision-making and barrier resolution; team meetings, supervisions, all-staff meetings and policy updates communicate changes. (SOP 2026 pp. 7–8, 15–16)

Leadership embeds the Ten Wraparound Principles and four phases/milestones into operations; SOP requires ICFP completion within 30 days, review every 30–45 days, and updates at least every 90 days—operationalizing fidelity. (Manual 2026 pp. 6–9, 14–23; SOP 2026 pp. 7–8)

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Victor ensures the required roles/functions (e.g., HFW Supervisor, Fidelity Coach, Wraparound Clinical Supervisor, Clinician, Facilitator, Family Support Counselor/Community Developer, Caregiver Parent Partner/Peer Specialist, Youth Partner, Psychiatrist) are fulfilled; roles may be dedicated positions or combined if functions are clearly assigned and performed. (SOP 2026 pp. 2–4)

The Wrap Manual outlines and provides narrative purpose and core functions for Facilitator, Parent/Caregiver Partner/Peer Specialist, Youth Partner, Family Support Counselor/Community Developer, Clinician, Licensed Clinician, and HFW Supervisor. (Manual 2026 pp. 11–13)

Job role qualifications/experience/licensure and verification steps for Fidelity Coach, HFW Supervisor, Wraparound Clinical Supervisor, Clinician, Facilitator, FSC/Community Developer, Caregiver Peer Partner, and Youth Partner are detailed and outlined in the Wrap SOP. (SOP 2026 pp. 2–4)

HFW principles (team-based, family voice/choice, cultural relevance, natural supports, outcomes focus) and milestone guidance shape role expectations and duties. (Manual 2026 pp. 7–9, 21–23)

Minimum qualifications are linked to high-risk youth populations and licensure/experience confirm HFW-specific knowledge and skills within job descriptions. (SOP 2026 pp. 2–4)

Hiring processes include education/licensure verification, DOJ/FBI Live Scan clearances, and professional reference checks; upon hire, Wrap 101 and ≥12 hours of in-vivo coaching provide early skills demonstration and coaching. (SOP 2026 pp. 16–19)

Weekly individual supervision with HFW/Clinical Supervisors; CQI uses WFI/WFI-EZ and TOM to provide timely feedback and identify training needs for continuous improvement. (SOP 2026 pp. 11–12, 15–17)

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

Leadership considers increases to the pay scale when comparative market data indicate below-industry wages; acceptable sources include CA EDD LMI and BLS—standard proxies for local cost-of-labor/cost-of-living alignment. (SOP 2026 p. 19)

Each team coordinates services for an average of 8–12 youth with clearly assigned roles; leadership ensures adequate on-call staffing for 24/7 crisis response to match CFT safety needs. (SOP 2026 p. 9)

Program employs Caregiver Peer Partners/Certified Peer Specialists and Youth Partners; training pathway includes Wraparound 101, ≥12 hours of in-vivo coaching, annual Wraparound 102, and ≥16 hours/year of ongoing training—creating development routes that support advancement. (SOP 2026 pp. 4–5, 17–18)

Pay scale adjustments can be made based on market data without a position change (Compensation Practices); supervision, observation, and coaching responsibilities (HFW/Clinical Supervisors, Fidelity Coach) provide leadership growth opportunities within existing roles. (SOP 2026 pp. 12, 16–19)

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: (3) HFW staff are trained internally by utilizing internal curriculum. Counties and providers who choose to utilize their own curriculum are required to submit their internal curriculum that aligns with the Statewide standardized Foundational HFW curriculum.

Description of Practice, Name of Supporting Documentation and Page #:

All Wraparound staff complete Victor’s Wraparound 101 training (3-day initial training) as part of structured onboarding to High Fidelity Wraparound. (SOP 2026 pp. 16–18)

The Family Vision Manual outlines the Wraparound principles and phases (Engagement, Plan Development, Implementation, Transition) that anchor initial training content and practice expectations. (Manual 2026 pp. 6–9, 14–23)

Staff receive ≥16 hours/year of continuing training, ≥12 hours of in-vivo coaching/mentoring, observation/coaching, and weekly individual supervision—covering general Wraparound and role-specific competencies (e.g., Facilitator, Parent Partner, Youth Partner, FSC, Clinician). (SOP 2026 pp. 11–12, 16–18)

Teaming/milestone guidance (CFT facilitation, strengths discovery, Connection Map, Safety Plan & ICFP development) provides the practice blueprint reinforced through ongoing training and peer shadowing. (Manual 2026 pp. 15–23)

Annual Wraparound 102 serves as a booster training in general Wraparound, complemented by targeted role coaching/refreshers. (SOP 2026 pp. 16–18)

Leaders participate in the same Wrap 101/102, CE, and in-vivo structures and have added responsibilities for supervision, observation/coaching, and fidelity oversight (WFI/WFI-EZ, TOM)—constituting initial, ongoing, and booster trainings tailored to supervisory roles. (SOP 2026 pp. 11–12, 16–18)

All staff receive training on ICWA and Tribal sovereignty and expectations for respectful, culturally aligned collaboration with Tribes; CQI and Operational Performance processes use demographics/outcomes/stakeholder feedback to identify unique population needs and inform targeted training. (SOP 2026 pp. 6–7, 11–12, 15–17)

Principles require culturally respectful and relevant practice and inclusion of Tribal representatives when Native ancestry is present, guiding population-specific training content. (Manual 2026 pp. 7–9)

Victor Wrap 101 and 102 Training Curriculum

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

Parent/Caregiver Partners with lived experience help families understand Wraparound principles, expectations, CFT process, timelines, and collaboration—functions that are incorporated into required trainings and shadowing. (Manual 2026 pp. 11–12)

Youth Partners ensure youth voice and choice and serve as experiential coaches during teaming and practice modeling. (Manual 2026 p. 12)

Peer Partner and Youth Partner roles are required program functions, embedding lived experience into practice development and training activities. (SOP 2026 pp. 2–4)

Community Leadership Team (CLT) and Interagency Leadership Team (ILT) include county partners (Child Welfare, Probation, Behavioral Health, Education) and are venues for shared learning, training, and system alignment. (SOP 2026 pp. 15–16)

Victor Wraparound programs rely on community-based services and natural supports; partners participating on CFTs require orientation/training to function effectively on HFW teams. (Manual 2026 pp. 7–9)

Ongoing training/feedback structures are used with system partners to strengthen participation and support of HFW within the System of Care. (SOP 2026 pp. 15–17)

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

All staff and leadership receive Wraparound 101 (3-day initial training) + a minimum of 12 hours of in-vivo coaching/mentoring, with ongoing observation/coaching and weekly supervision, form the core apprenticeship at hire. (SOP 2026 pp. 11–12, 16–18)

All staff receive training, overview and practice of implementing the ten Wraparound Principles and four phases/milestones (Engagement, Plan Development, Implementation, Transition) with required activities (Strengths Assessment, Connection Map, Crisis & Safety Plan, ICFP/CFT facilitation) to define the values/skills/knowledge for apprenticeship. (Manual 2026 pp. 6–9, 14–23)

Apprenticeship includes learning effective, criteria-based use of flex funds—timely access for urgent needs; alignment to team mission/ICFP; cultural relevance; sustainability; good investment; pooled funding; tracking/aggregate reporting; and appeal process. (SOP 2026 p. 10)

A 24/7 crisis response system provides after-hours access with escalation to a clinical supervisor and/or designated administrator—ensuring staff consultation and coaching at all times. (SOP 2026 p. 9)

Weekly individual supervision and routine observation/coaching reinforce ongoing skill development outside of emergencies. (SOP 2026 pp. 11–12, 16–18)

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

Victor Leadership conducts quarterly CQI reviews of program activity and outcomes (e.g., caseloads, supervision/training indicators, fidelity, demographics) and uses results to improve practice, provide timely feedback to staff, and identify training needs. (SOP 2026 pp. 15–17)

WFI/WFI-EZ and TOM observations supply role-relevant feedback that informs targeted coaching and training plans. (SOP 2026 pp. 16–17)

HFW principles and milestone activities (CFT facilitation, Strengths Assessment, Connection Map, Crisis & Safety Plan, ICFP) define the specific practice behaviors to reinforce through feedback and coaching. (Manual 2026 pp. 6–9, 14–23)

Victor CQI requires aggregate analysis of service utilization, demographics, supervision/training, fidelity, and outcomes; leadership modifies program operations based on findings to better serve families. (SOP 2026 pp. 15–17)

Outcomes tracked include school functioning, community functioning, interpersonal functioning, caregiver confidence, hospitalizations/crisis visits, placement stability, and satisfaction—clear targets for CQI-driven improvement. (Manual 2026 pp. 33–35)

System barriers identified through CQI and fidelity monitoring are elevated to the Community Leadership Team (CLT) / Interagency Leadership Team (ILT) for cross-agency problem solving and alignment. (SOP 2026 pp. 15–16)

CLT/ILT forums are used to share data, review trends, and plan corrective actions affecting cross-system HFW participation. (SOP 2026 pp. 15–16)

Date Started: November 3, 2025

Date Submitted: February 24, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures High-Fidelity Wraparound (HFW) staff engage families early, consistently, and in alignment with required timelines through clearly defined policies, structured phase-based service delivery, supervision oversight, and continuous quality improvement mechanisms. Engagement begins immediately upon referral and reflects a family-driven, culturally responsive approach, including collaboration with Tribes when serving an Indian child.

Timely Engagement (Within 10 Calendar Days of Referral):
Upon receipt of a referral including AAP eligible self-referrals, the assigned Facilitator initiates contact as soon as possible, but no later than 10 calendar days. Engagement efforts are documented and may include in-person outreach, phone contact, electronic communication (with consent), and coordinated care with referring systems. When serving an Indian child, culturally responsive practices include collaboration with Tribal representatives consistent with agency policy.

Plan of Care Completion (Within 30 Calendar Days):
Through Phase One (Engagement and Family Preparation) and Phase Two (Plan Development), the Child and Family Team (CFT) develops a strengths-based, needs-driven Wraparound Plan of Care within 30 calendar days from the start of services. The Plan reflects family voice and choice, measurable outcomes, crisis/safety planning, and coordinated service strategies.

Ongoing Plan Review (Every 30–45 Days):
The Plan of Care is reviewed within the context of a formal Child and Family Team meeting at least every 30 calendar days. During these reviews, the team evaluates progress, addresses barriers, and refines strategies using structured outcome tools such as CANS, TOM, and LOCUS when applicable.

Formal Plan Updates (At Least Every 90 Days):
The Plan of Care is updated at minimum every 90 calendar days, or more frequently as clinically indicated. Updated plans are distributed to all team members and documented in the youth’s clinical record to ensure coordinated implementation and accountability.

Supervision & CQI Oversight:
Supervisors and QA/QI leadership monitor compliance with engagement and documentation timelines through structured supervision, internal HFW case reviews, performance improvement processes, and outcome monitoring systems. Staff receive feedback regarding timeliness and adherence to HFW standards, and trends are incorporated into agency-wide continuous quality improvement efforts.

Training & Engagement Strategies:
All staff receive HFW aligned training on timely engagement strategies, culturally responsive practice, and alternative outreach approaches when families are difficult to reach. This includes flexible scheduling, field-based engagement, collateral collaboration, and coordinated system outreach to prevent delays in service initiation and plan development.

Collectively, these procedures ensure compliance with HFW standards while reinforcing Penny Lane’s commitment to family-centered, culturally responsive, and outcome-driven service delivery.

Policy & Appendix References:

Engagement & Intake
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
210 Language Access & Cultural and Linguistic Responsiveness

Plan Development & Review
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Plan Updates & Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & CQI
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#34 Supervisor Review Tool (SPRT)
#43 CANS
#36 TOM
#44 Penny Lane Internal Referral Request HFW

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers operationalizes Principle 1: Family Voice and Choice as a foundational expectation of High-Fidelity Wraparound (HFW) practice. The youth and family are recognized as the primary drivers of the Wraparound process, and their perspectives, culture, strengths, and lived expertise shape all planning, decision-making, and problem-solving. In the case of an Indian child, Tribal representatives are engaged as equal and essential members of the Child and Family Team (CFT), ensuring culturally grounded and legally compliant partnership.

From initial engagement through transition, staff intentionally elicit and elevate the youth and family’s values, vision, preferences, and goals. The Family Vision Statement and Team Mission Statement are developed collaboratively during Phase One and Phase Two and formally documented within the Plan of Care. These statements guide the development of strategies and supports and serve as the anchor for all team decisions.

Strengths including cultural identity, community connections, capabilities, interests, traditions, and natural supports, are comprehensively assessed and clearly documented in the clinical record. This strengths-based foundation informs the selection of interventions, service mix, crisis planning, and natural support integration.

For Indian children, Penny Lane ensures Tribal voice is prioritized and treated as equal within the team structure. Tribal participation is incorporated into coordinated care and CFT processes, and cultural identity and Tribal values are integrated into planning and service delivery consistent with agency policy and HFW standards.

Supervisory oversight reinforces fidelity to Family Voice and Choice. Supervisors and Wraparound Coaches routinely review documentation, observe team meetings when appropriate, and utilize structured fidelity tools to ensure youth and family voice is authentically represented. Feedback is provided through supervision, internal case reviews, and performance improvement processes to strengthen staff competency and confidence.

Additionally, Penny Lane systematically gathers direct feedback from families regarding their Wraparound experience. Tools such as the Wraparound Fidelity Index (WFI), Team Observation Measure (TOM 2.0), satisfaction surveys, and quality assurance follow-up calls are utilized to capture the family’s perception of voice, partnership, and empowerment within the process. This feedback is reviewed as part of the agency’s Continuous Quality Improvement (CQI) structure and informs practice enhancement efforts.

Through structured engagement, documented vision and strengths integration, supervisory oversight, fidelity monitoring, and routine family feedback, Penny Lane ensures Family Voice and Choice is not aspirational but embedded in daily HFW practice.

Policy & Appendix References:

Engagement & Family Voice
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness

Plan Development & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
413 High-Fidelity Wraparound Service Delivery
502 Progress Notes and Service Documentation

Supervision & Fidelity Oversight
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that functional strengths of the youth, family, team members, and the broader community are intentionally identified, documented, reviewed, and operationalized throughout the High-Fidelity Wraparound (HFW) process. Strengths are not abstract qualities; they are defined in functional, actionable terms and directly inform decision-making, strategy development, and service planning.

From the onset of engagement, Facilitators conduct structured strengths discovery conversations that culminate in a documented Strengths Inventory. This inventory includes youth competencies, caregiver capabilities, cultural assets, natural supports, team member contributions, and community-based resources. Strengths are reviewed at each Child and Family Team (CFT) meeting and are visibly integrated into the Plan of Care to drive interventions and solutions.

The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is a required and foundational tool in the strengths identification process. Strength domains identified through IP-CANS are incorporated into the Strengths Inventory and embedded into the Plan of Care as leverage points for goal attainment. Identified strengths extend beyond the IP-CANS to include individualized cultural, relational, experiential, and environmental assets.

HFW teams maintain a solution-focused orientation, emphasizing resilience, capacity building, and progress. Team discussions are structured to redirect focus toward actionable strategies and measurable growth rather than dwelling on past negative events. Supervisors and Wraparound Coaches reinforce strengths-based practice through observation of team meetings, review of Plans of Care, and structured case reviews.

Staff receive ongoing coaching and formal training in strengths-based and solution-focused service delivery, including integration of IP-CANS findings into planning. Fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), along with satisfaction surveys and QA follow-up calls, are utilized to routinely elicit family feedback regarding their experience of strengths-based services. Feedback data informs staff coaching, performance improvement planning, and agency-wide continuous quality improvement initiatives.

Through these integrated procedures, Penny Lane ensures that strengths-based practice is consistently embedded in documentation, service delivery, supervision, and fidelity monitoring, reinforcing a culture of empowerment and solution-focused care.

Policy References:
Strengths Identification & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Planning
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
718 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)
#43 CANS

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are anchored in the identification and prioritization of the youth and family’s high-priority underlying needs. The HFW process emphasizes needs-driven planning rather than behavior-focused or service-driven interventions. Needs statements are developed to reflect the underlying reasons why problematic situations or behaviors are occurring, avoiding language framed solely as deficits, diagnoses, or compliance issues.

During Phase One (Engagement and Family Preparation) and Phase Two (Plan Development), Facilitators guide the Child and Family Team (CFT) through structured conversations to identify and prioritize needs before establishing goals or selecting strategies. These needs statements are documented clearly in the Plan of Care and serve as the foundation for measurable goals and coordinated interventions.

The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is required and central to the identification process. IP-CANS domains are used to inform individualized needs statements and to ensure clinical accuracy and consistency in prioritization. However, needs identification extends beyond IP-CANS scoring and includes culturally contextualized, relational, environmental, and systemic factors identified through family engagement and team collaboration.

Staff receive ongoing training and supervisory coaching to strengthen their ability to formulate clear, functional needs statements and to shift planning conversations from symptom management to underlying need resolution. Supervisors and Wraparound Coaches review Plans of Care through structured tools and internal case reviews to ensure needs are appropriately articulated prior to goal and strategy development.

The HFW process continues until the team, youth, and family collectively determine that prioritized needs are sufficiently met. Transition planning is based on measurable progress toward needs resolution rather than time-limited service delivery. Formal transition and graduation occur only when the team agrees that sustainable supports and capacity have been established to maintain progress.

Through structured planning, required IP-CANS integration, supervisory oversight, and fidelity monitoring, Penny Lane operationalizes needs-driven practice as a core standard of HFW service delivery.

Policy References:
Needs Identification & Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery

Documentation & Transition
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment
419 Graduation and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#22 Safety and Crisis Plan
#26 Wraparound Fidelity Index
#34 Supervisor Review Tool (SPRT)
#43 CANS

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are highly individualized, flexible, and creatively tailored to the unique needs, strengths, values, culture, and preferences of each youth and family. The HFW Plan of Care is not formulaic; it is intentionally customized to reflect the family’s lived experience, community context, and natural supports. Strategies are designed to reduce harm over time, build sustainable capacity, and leverage the assets within the youth’s family, informal networks, and community. In the case of an Indian child, individualized planning explicitly includes Tribal collaboration and recognition of the Tribe as a culturally essential and equal partner in planning and implementation.

Agency documentation templates, including the Plan of Care and CFT meeting forms are structured to allow narrative flexibility and individualized strategy development rather than checkbox-driven planning. Strengths, needs, and outcome statements are written uniquely for each family and are directly linked to customized strategies that reflect cultural identity, community assets, and family preference.

Staff receive ongoing training and coaching in flexible and creative service delivery. Facilitators receive specialized coaching in leading Child and Family Teams (CFTs) to think beyond traditional service menus and develop tailored strategies that reflect informal supports, faith-based connections, educational partnerships, cultural practices, and other community-based resources. Supervisors and Wraparound Coaches routinely review Plans of Care and observe team meetings to ensure individualized strengths, needs, outcomes, and strategies are evident and not standardized across cases.

Family experience is continuously evaluated through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM), and quality assurance follow-up calls. Feedback is incorporated into performance improvement processes and workforce coaching to strengthen individualized practice across teams.

Through flexible documentation, structured coaching, fidelity monitoring, and feedback loops, Penny Lane operationalizes individualized planning as a measurable HFW standard rather than a philosophical ideal.

Policy & Appendix References:

Individualized Planning & Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
312 Flex Funds

Documentation & Plan Review
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that natural supports and community-based resources are integral components of the High-Fidelity Wraparound (HFW) process. HFW teams are intentionally structured to include individuals identified by the youth and family as meaningful, supportive, and sustainable connections. These may include extended family members, faith leaders, mentors, educators, neighbors, coaches, Tribal representatives (when applicable), and other informal supports.

From the onset of engagement, Facilitators develop a Natural and Community Supports Inventory that identifies existing relational assets and potential informal resources within the family’s network and local community. This inventory is updated throughout service delivery and actively referenced during Child and Family Team (CFT) meetings to ensure strategies leverage natural supports rather than defaulting to formal service systems.

The HFW Plan of Care prioritizes strategies that occur within the family’s community context and are supported by informal networks whenever clinically appropriate. This approach reduces reliance on formal supports over time and strengthens long-term sustainability. Community-based interventions may include school partnerships, faith-based supports, peer networks, recreational programs, cultural organizations, and Tribal engagement in the case of an Indian child.

Staff receive ongoing training and supervisory coaching in identifying, engaging, and integrating natural supports into the HFW process. Facilitators are coached to shift team discussions from service-based solutions to relationship-based and community-based solutions. Supervisors and Wraparound Coaches routinely review Plans of Care and observe CFT meetings to assess whether natural supports are meaningfully included in team composition, strategy assignment, and action steps.

Family feedback regarding the integration and effectiveness of natural supports is routinely elicited through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), and quality assurance follow-up calls. Feedback trends are incorporated into Continuous Quality Improvement (CQI) initiatives and inform targeted staff coaching and training to strengthen community-based practice.

Through structured documentation, workforce development, fidelity monitoring, and feedback systems, Penny Lane operationalizes Natural Support and Community-Based principles as measurable and sustained components of HFW service delivery.

Policy & Appendix References

Natural Support Identification & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness

Community-Based Strategy Implementation
405 Phase Three – Implementation
312 Flex Funds
421 Home Visits
425 Youth Education Services (HFW Alignment)

Documentation & Plan Review
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams recognize and elevate a family’s traditions, values, cultural identity, and heritage as essential sources of strength throughout the Wraparound process. Cultural discovery is not treated as a secondary consideration but as a foundational component of engagement, needs identification, strategy development, and transition planning.

Prior to the development of the HFW Plan of Care, Facilitators complete a comprehensive strengths, needs, and culture discovery process. This includes exploration of cultural identity, spiritual beliefs, family traditions, language preferences, community affiliations, lived experiences, and historical factors that influence family functioning. Cultural information is clearly documented in the youth’s case file and directly integrated into the Family Vision, needs statements, strengths inventory, and intervention strategies.

HFW teams design strategies that are relevant to and respectful of the youth and family’s cultural context. This may include engagement with culturally aligned mentors, faith-based organizations, community groups, bilingual supports, culturally informed therapeutic approaches, and, when serving an Indian child, formal collaboration with Tribal representatives as equal and essential partners in planning. Cultural responsiveness extends into transition planning, where teams intentionally connect families to culturally relevant community supports to sustain progress beyond formal HFW services.

Staff receive ongoing training and supervisory coaching in eliciting cultural information respectfully and integrating it meaningfully into service planning. Cultural humility, bias awareness, and culturally responsive engagement are reinforced through workforce development, supervision, and fidelity monitoring. Supervisors and Wraparound Coaches review documentation and observe team meetings to ensure cultural factors are actively influencing decision-making rather than being documented without application.

Family feedback regarding culturally respectful and relevant services is routinely collected through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and quality assurance outreach calls. Feedback data is analyzed through Continuous Quality Improvement (CQI) processes and used to inform targeted coaching, training enhancements, and practice refinement.

Through structured cultural discovery, documentation standards, workforce development, and feedback integration, Penny Lane operationalizes culturally respectful and relevant practice as a measurable and sustained HFW standard.

Policy & Appendix References:

Cultural Discovery & Engagement
210 Language Access & Cultural and Linguistic Responsiveness
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
415 Parent Support & Advocacy (HFW-Aligned)

Plan Development & Transition
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery
503 Aftercare, Graduation, and Disenrollment

Documentation & Review
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams are intentionally structured to include both formal service providers and natural supports across the Children’s System of Care. Teams function as shared decision-making bodies responsible for developing, implementing, and monitoring an individualized Plan of Care that reflects the youth and family’s prioritized needs. Collaboration is not symbolic; it is operationalized through shared task ownership, clearly assigned action steps, and structured follow-through mechanisms.

Each HFW team establishes documented Team Agreements that outline shared expectations, communication norms, confidentiality standards, attendance commitments, and accountability structures. These agreements reinforce mutual respect, collective responsibility, and solution-focused engagement. The Child and Family Team (CFT) meeting structure promotes inclusive dialogue, ensuring all voices, including youth, caregivers, natural supports, system partners, and, when applicable, Tribal representatives, contribute meaningfully to planning and problem-solving.

Plans of Care and CFT meeting minutes clearly assign strategies and action items to specific team members, reinforcing shared ownership and follow-through. Facilitators monitor completion of tasks and revisit progress at subsequent meetings to ensure accountability and sustained collaboration. Supervisors and Wraparound Coaches routinely review documentation and observe meetings to assess evidence of shared responsibility, cross-system coordination, and authentic collaboration.

Family and team member feedback regarding their experience of team engagement, collaboration, optimism, and commitment is routinely elicited through satisfaction surveys, fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), and quality assurance follow-up calls. Observational data from internal case reviews further assesses team dynamics and shared ownership of strategies. Feedback findings are incorporated into Continuous Quality Improvement (CQI) processes and used to inform targeted coaching, performance development, and workforce training initiatives.

Through structured team agreements, accountability systems, fidelity monitoring, and integrated feedback loops, Penny Lane operationalizes Team-Based and Collaborative principles as measurable standards that foster shared ownership, collective optimism, and sustained commitment to youth and family success.

Policy & Appendix References

Team Formation & Collaboration
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews

Documentation & Accountability
404 Phase Two – Plan Development
405 Phase Three – Implementation
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are outcomes-driven, measurable, and continuously monitored to inform real-time decision-making. The HFW Plan of Care is structured to link clearly defined needs statements to measurable outcomes, individualized strategies, and assigned action steps with specified timeframes. Progress is not assumed; it is objectively tracked and reviewed within the context of Child and Family Team (CFT) meetings and supervisory oversight.

Each Plan of Care includes specific, measurable strategies and action items aligned to prioritized underlying needs. Timeframes, responsible team members, and expected indicators of progress are documented. Facilitators track completion of action items between meetings and provide structured updates during CFT meetings to ensure accountability and transparency. When progress is not occurring as anticipated, strategies are adjusted collaboratively, and changes are documented and redistributed to all team members to maintain coordinated implementation.

The Integrated Practice Child and Adolescent Needs and Strengths (IP-CANS) assessment is a required and central component of needs identification and outcome tracking. The assigned Wraparound Facilitator, in collaboration with the clinical supervisor and therapist, is responsible for completing the IP-CANS within required timelines and updating it according to established reassessment schedules. IP-CANS results are shared with the Child and Family Team in a developmentally appropriate and strengths-based manner to support collaborative decision-making.

Data derived from the IP-CANS informs prioritization of needs and helps monitor functional improvement over time. However, IP-CANS data does not replace active tracking of needs resolution, measurable goal attainment, or action item completion. Transition planning is based on objective evidence that prioritized needs have been sufficiently met, demonstrated through measurable progress, consistent strategy implementation, and sustainable support structures, not solely through standardized instrument scores.

Supervisors and QA/QI leadership monitor outcome alignment through internal HFW case reviews, Supervisor Review Tool (SPRT) audits, fidelity measures (TOM, WFI), and structured documentation review. Continuous Quality Improvement (CQI) processes analyze outcome trends to strengthen staff practice, reinforce measurable planning standards, and ensure fidelity to outcomes-based principles.

Through structured documentation, defined assessment responsibilities, measurable planning frameworks, and integrated data review processes, Penny Lane operationalizes outcomes-based practice as a core and measurable standard of High-Fidelity Wraparound.

Policy & Appendix References:

Outcomes-Based Planning & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Plan Adjustment
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Assessment & Standardized Tools
714 CANS
716 LOCUS
715 TOM

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams approach setbacks, crises, and limited progress as indicators that the Plan of Care requires revision, not as evidence of youth or caregiver failure. The HFW process is designed to remain engaged with families through challenges, maintaining a solution-focused and strengths-based stance while adapting strategies as needed. Persistence is operationalized through structured supervision, access to additional supports, and flexible service delivery mechanisms that reinforce the team’s commitment to sustainable outcomes.

HFW teams continue working with youth and families until prioritized needs are sufficiently met and the team, giving preference to family voice and choice, collectively agrees that services should transition. Setbacks prompt structured review of needs statements, strategy effectiveness, and task completion within Child and Family Team (CFT) meetings. Plans are revised collaboratively, and alternative strategies are implemented to address emerging barriers.

Clear processes are in place to support teams facing challenges. Facilitators may access additional supervision, consultation with Wraparound Coaches, and internal High-Fidelity Wraparound case reviews to problem-solve complex situations. Teams may request flexible funding to remove barriers and implement creative solutions aligned with the family’s needs. Crisis response protocols provide structured guidance for stabilization, post-crisis review, and safety planning, ensuring continuity of engagement rather than service discontinuation.

Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, de-escalation strategies, and advanced facilitation skills to lead effective brainstorming sessions during times of difficulty. Supervisors reinforce persistence by reviewing documentation, observing CFT meetings, and ensuring that plan revisions reflect HFW principles, including family voice, strengths-based practice, and needs-driven planning.

Continuous Quality Improvement (CQI) processes monitor patterns related to setbacks, crisis recurrence, and plan adjustments to strengthen agency-wide practice standards. Through structured escalation pathways, flexible resource access, and reinforced coaching infrastructure, Penny Lane operationalizes Persistence as an embedded and measurable HFW practice standard.

Policy & Appendix References

Crisis Response & Plan Revision
405 Phase Three – Implementation
406 Phase Four – Transition
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Flexible Supports & Resource Access
312 Flex Funds
411 Coordinated Care

Supervision & Additional Support
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#29 Flex Fund Request Form
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that transitions from High-Fidelity Wraparound (HFW) services are intentional, needs-based, and collaboratively planned in advance. Transition occurs only when prioritized underlying needs have been sufficiently met, sustainable supports are established, and the youth and family, through shared decision-making, agree that formal HFW services are no longer required. Transitions are not driven by administrative timelines, funding constraints, or adverse events, but by measurable progress and readiness determined by the Child and Family Team (CFT).

Transition planning begins early in the Wraparound process and is integrated into ongoing Plan of Care reviews. As needs are progressively met, teams focus on strengthening natural supports, building community connections, and reducing reliance on formal services to promote sustainability. When an adverse event occurs, the HFW team responds with plan revision and support stabilization rather than service termination.

To ensure continuity and prevent sudden loss of services, clear internal procedures govern discharge, graduation, and aftercare planning. Transition plans include documentation of resolved needs, remaining supports, crisis response strategies, and linkages to community-based resources. When appropriate, referrals to step-down services or alternative supports are coordinated in advance to ensure seamless continuity.

Transitions are celebrated in alignment with the youth and family’s culture, values, and preferences. Celebrations may include formal graduation ceremonies, culturally meaningful acknowledgments, community gatherings, or individualized recognition activities. Administrative structures support this process by allowing access to flexible funds when appropriate, accommodating staff time for community linkage and celebration planning, and encouraging team participation in transition events.

Supervisors review transition plans to ensure they reflect needs resolution rather than administrative closure. Quality Assurance and Continuous Quality Improvement (CQI) processes monitor discharge trends to ensure fidelity to needs-based transition standards.

Through structured planning, supervisory oversight, flexible administrative support, and culturally responsive celebration practices, Penny Lane operationalizes transition as a strength-based milestone that honors family voice and ensures sustainable outcomes beyond formal HFW services.

Policy & Appendix References:

Transition & Disenrollment
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment

Plan Review & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
502 Progress Notes and Service Documentation
409 Child and Family Team (CFT) Meetings

Crisis Safeguards
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage

Flexible & Community-Based Supports
312 Flex Funds
411 Coordinated Care
425 Youth Education Services (HFW Alignment)

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#29 Flex Fund Request Form

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers maintains formal policies and procedures to systematically record, evaluate, and respond to youth and family satisfaction with their High-Fidelity Wraparound (HFW) experience. Satisfaction is viewed as a critical outcome indicator and an essential component of fidelity to HFW principles. The agency utilizes structured feedback mechanisms to assess families’ perceptions of engagement quality, cultural responsiveness, collaboration, progress toward needs resolution, and overall service experience.

Youth and family satisfaction data is collected through multiple channels, including standardized fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM 2.0), satisfaction surveys, and Quality Assurance (QA) follow-up calls. Feedback is reviewed by supervisors and QA/QI leadership to identify strengths, areas for improvement, and practice trends. Findings are incorporated into Continuous Quality Improvement (CQI) processes and inform targeted coaching, training enhancements, and performance development plans.

In cases involving an Indian child, Tribal representatives are recognized as equal partners in the HFW process. The agency ensures that Tribal perspectives are invited and documented during planning, review, and transition phases. Feedback regarding the Tribe’s experience with collaboration, cultural respect, and shared decision-making is incorporated into quality review processes to ensure Tribal satisfaction is assessed and addressed.

Satisfaction data is not collected for compliance purposes alone; it is actively analyzed and used to refine service delivery, strengthen cultural responsiveness, reinforce Family Voice and Choice, and enhance team collaboration. Supervisors provide direct feedback to staff regarding satisfaction outcomes, and aggregate data trends are reviewed at the program leadership level to inform system-wide improvements.

Through structured documentation, standardized fidelity measures, and integrated CQI review processes, Penny Lane demonstrates clear policies and procedures to record and evaluate youth, family, and Tribal satisfaction with the HFW experience.

Policy & Appendix References:

Satisfaction Monitoring & Evaluation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews

Service Delivery & Collaboration
402 High-Fidelity Wraparound Family Assessment & Engagement Process
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness

Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Outcome & Fidelity Tools
715 TOM
714 CANS
716 LOCUS

Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#4 CFT Meeting Minutes
#17 Plan of Care Template

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services actively support and monitor improvements in youth educational and vocational functioning. Educational stability, school engagement, and vocational development are treated as core outcome domains within the individualized Plan of Care. HFW teams collaborate with families, schools, and community partners to promote consistent attendance, academic progress aligned with grade-level expectations or Individualized Education Plans (IEPs), and development of age-appropriate vocational skills and experiences.

Educational functioning is assessed during the engagement and needs discovery process and incorporated into prioritized needs statements when relevant. The Plan of Care includes measurable strategies to address attendance barriers, behavioral challenges in school settings, academic support needs, and vocational readiness goals. Interventions may include coordination with school personnel, participation in IEP meetings, linkage to tutoring or mentoring programs, advocacy support, and connection to community-based vocational resources.

Attendance patterns, academic performance indicators, and vocational engagement are documented in progress notes and reviewed during Child and Family Team (CFT) meetings. Youth Education Services and coordinated care processes ensure cross-system collaboration. When applicable, IP-CANS education domain ratings inform planning and progress tracking; however, educational data is also directly monitored through school reports, attendance records, and team review discussions.

Supervisors and QA/QI leadership review documentation to ensure that educational goals are measurable and actively monitored. Outcome trends related to attendance and performance are incorporated into Continuous Quality Improvement (CQI) processes to strengthen practice consistency and cross-system collaboration.

Through structured documentation, cross-system coordination, and measurable educational goal tracking, Penny Lane maintains clear policies and procedures to record and evaluate school attendance, performance, and vocational development outcomes.

Policy & Appendix References:

Educational & Vocational Service Integration
425 Youth Education Services (High-Fidelity Wraparound Alignment)
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process

Plan Development & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings

Documentation & Outcomes Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#43 CANS

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services promote measurable improvements in youth community functioning, including reduced justice involvement and increased engagement in pro-social community activities. Community integration, lawful behavior, and positive participation in structured activities are treated as key indicators of stability and long-term sustainability within the individualized Plan of Care.

During the engagement and needs discovery phases, teams assess current justice involvement, probation status (if applicable), peer associations, recreational engagement, and community participation. When justice involvement or limited pro-social engagement is identified as a prioritized need, measurable strategies are incorporated into the Plan of Care. These strategies may include coordinated care with probation or legal partners, mentorship connections, restorative justice participation, structured extracurricular activities, employment readiness programs, and linkage to culturally relevant community organizations.

Justice involvement levels, compliance requirements, and community participation are documented in progress notes and reviewed at Child and Family Team (CFT) meetings. Data sources may include probation updates, school reports, caregiver reports, and youth self-report. IP-CANS domains related to behavioral health, risk behaviors, and functioning inform needs identification and progress tracking; however, direct monitoring of community engagement and justice involvement remains a central planning component.

Supervisors and QA/QI leadership review documentation to ensure measurable goals related to community functioning are established and monitored. Trends in justice involvement and community participation are incorporated into Continuous Quality Improvement (CQI) processes to strengthen system coordination and strategy effectiveness.

Through structured documentation practices, cross-system collaboration, standardized assessment integration, and measurable outcome tracking, Penny Lane maintains clear policies and procedures to record and evaluate justice involvement and engagement in community activities.

Policy & Appendix References:

Community-Based & Justice Coordination
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
425 Youth Education Services (HFW Alignment)
402 High-Fidelity Wraparound Family Assessment & Engagement Process

Plan Development & Monitoring
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings

Documentation & Outcomes Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Crisis & Risk Monitoring
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#43 CANS

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services promote measurable improvements in youth and family interpersonal functioning. Strengthening relationships, reducing stress and strain within the home, and improving communication and relational stability are core outcome domains embedded in the HFW process. Interpersonal functioning is assessed during engagement, prioritized when identified as a need, and systematically monitored throughout service delivery.

During Phase One (Engagement and Family Preparation), Facilitators conduct strengths and needs discovery conversations that explore family dynamics, relational stressors, communication patterns, peer relationships, and caregiver-child interactions. When interpersonal strain is identified as an underlying need, it is translated into a clearly articulated needs statement and linked to measurable goals within the Plan of Care.

The Plan of Care includes specific strategies designed to improve communication, conflict resolution, emotional regulation, parenting capacity, peer relationships, and relational trust. These strategies may include structured family meetings, skill-building interventions, Parent Partner coaching, therapeutic collaboration, and connection to culturally relevant relational supports. Action items are assigned, tracked, and reviewed during Child and Family Team (CFT) meetings to monitor progress and adjust strategies as needed.

Interpersonal functioning is documented through progress notes, CFT meeting minutes, and standardized tools such as the IP-CANS, which includes domains addressing family functioning, social relationships, and behavioral/emotional regulation. However, IP-CANS data complements, not replaces ongoing monitoring of relational improvements, stress reduction, and observable behavioral changes within the home.

Supervisors and QA/QI leadership review documentation to ensure that interpersonal goals are measurable, linked to underlying needs, and regularly evaluated. Feedback from families regarding relationship improvements and stress reduction is routinely elicited through satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and QA follow-up calls. This data informs Continuous Quality Improvement (CQI) processes and staff coaching initiatives.

Through structured needs identification, measurable planning, standardized assessment integration, and continuous feedback review, Penny Lane maintains clear policies and procedures to record and evaluate improvements in youth and family interpersonal functioning.

Policy & Appendix References:

Interpersonal Needs Identification & Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Family Support & Skill Development
414 Parent Education and Training
415 Parent Support & Advocacy (HFW-Aligned)

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that families have access to effective, needed services and supports while simultaneously building caregiver capacity, confidence, and long-term self-sufficiency. High-Fidelity Wraparound (HFW) services are designed not only to address immediate needs but to strengthen caregiver skills, increase knowledge of available resources, and foster sustained connectedness to community supports beyond formal service involvement.

During engagement and needs discovery, the HFW team assesses caregiver strengths, stressors, resource awareness, and crisis management capacity. When caregiver confidence or system navigation challenges are identified as underlying needs, they are translated into measurable needs statements within the Plan of Care. Strategies are then developed to build caregiver competence in advocacy, problem-solving, crisis response planning, and community linkage.

Parent Education and Training, Parent Support & Advocacy, and coordinated care efforts are integrated into service delivery to enhance caregiver skill-building and empowerment. Caregivers are supported in leading team discussions, participating in decision-making, and navigating educational, behavioral health, and community systems. Crisis and Safety Plans are developed collaboratively to ensure caregivers understand prevention strategies, warning signs, and response steps.

Progress toward increased caregiver confidence and resource connectedness is documented in progress notes, reviewed in Child and Family Team (CFT) meetings, and measured through feedback mechanisms such as satisfaction surveys, Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), and QA follow-up calls. IP-CANS domains related to caregiver resources, supervision, and family functioning inform planning and reassessment; however, qualitative and observable indicators of confidence and independence are also actively tracked.

Supervisors and QA/QI leadership monitor documentation to ensure caregiver empowerment goals are measurable and linked to needs resolution. Continuous Quality Improvement (CQI) processes review trends in caregiver confidence outcomes and inform staff coaching and workforce development efforts.

Through structured planning, measurable documentation standards, parent capacity-building services, and integrated feedback systems, Penny Lane maintains clear policies and procedures to record and evaluate caregiver confidence and connectedness to community resources.

Policy & Appendix References:

Caregiver Capacity & Resource Access
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
411 Coordinated Care
414 Parent Education and Training
415 Parent Support & Advocacy (HFW-Aligned)

Crisis & Sustainability Planning
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
406 Phase Four – Transition

Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are intentionally designed to promote youth permanency and stability within community-based living environments. Preventing placement disruptions, institutional admissions, and residential transitions is a core outcome objective of the HFW model. Teams prioritize stabilization strategies that address underlying needs, strengthen caregiver capacity, enhance safety planning, and leverage natural supports to prevent escalation to higher levels of care.

At intake and throughout service delivery, the HFW team assesses current placement stability, prior placement history, and risk factors for disruption. When placement instability is identified as a concern, measurable needs statements are developed and incorporated into the Plan of Care. Strategies may include intensive safety planning, crisis prevention interventions, caregiver coaching, flexible funding supports, coordination with child welfare or probation, school stabilization efforts, and mobilization of natural supports to reduce stressors within the home.

Placement status and any changes in living arrangements are documented in progress notes and reviewed at Child and Family Team (CFT) meetings. When a placement change occurs, teams conduct structured review discussions to analyze contributing factors and revise the Plan accordingly. Special Incident Reports (SIRs), crisis documentation, and coordinated care updates are utilized when applicable to ensure accurate tracking and systemic response.

Supervisors and QA/QI leadership monitor the frequency and type of placement changes through documentation review, internal HFW case reviews, and outcome monitoring processes. Data regarding institutional admissions (e.g., detention, psychiatric hospitalization, STRTP placement) and residential transitions are analyzed as part of Continuous Quality Improvement (CQI) efforts to strengthen prevention strategies and early intervention practices.

Transition from HFW services is not initiated due to placement disruption alone; rather, the team remains engaged in revising strategies and strengthening supports to re-establish stability whenever possible. Through structured monitoring, crisis response integration, cross-system collaboration, and measurable outcome tracking, Penny Lane maintains clear policies and procedures to record and evaluate placement changes and promote permanency within community-based settings.

Policy & Appendix References:

Placement Stability & Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care

Crisis & Incident Monitoring
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
205 Special Incident Reports

Documentation & Outcome Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Flexible Supports
312 Flex Funds

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 CANS

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services are structured to promote behavioral health stability and reduce the frequency of psychiatric hospitalizations and emergency room visits. Stabilization is achieved through proactive needs-driven planning, integrated crisis prevention strategies, coordinated care, and ongoing monitoring of behavioral health indicators. Preventing avoidable hospital admissions is a key outcome objective embedded within the individualized Plan of Care.

During engagement and ongoing service delivery, the HFW team assesses the youth’s behavioral health history, prior hospitalizations, crisis triggers, and risk factors. When hospitalization risk is identified as a prioritized need, the Plan of Care includes measurable strategies such as enhanced safety planning, therapeutic coordination, skill-building interventions, caregiver coaching, natural support mobilization, and crisis prevention protocols.

Hospital visits and crisis events are documented in progress notes, Special Incident Reports (SIRs) when applicable, and reviewed during Child and Family Team (CFT) meetings. Post-crisis reviews are conducted to analyze contributing factors and revise strategies to prevent recurrence. The Immediate Safety and Stabilization Plan and Safety and Crisis Plan are updated as needed to reflect new information and reinforce preventive supports.

Standardized tools such as the IP-CANS inform behavioral health needs identification and reassessment; however, hospital utilization tracking includes direct documentation of emergency department visits, psychiatric admissions, and crisis interventions. Supervisors and QA/QI leadership monitor hospitalization frequency through internal HFW case reviews and outcome monitoring processes to identify patterns and strengthen early intervention practices.

Continuous Quality Improvement (CQI) efforts incorporate data related to crisis response and hospital utilization trends to inform staff coaching, service intensity adjustments, and system collaboration improvements. Through structured documentation practices, crisis response protocols, measurable planning standards, and supervisory oversight, Penny Lane maintains clear policies and procedures to record and evaluate the frequency of hospital visits and promote sustained behavioral health stability.

Policy & Appendix References:

Behavioral Health & Crisis Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
205 Special Incident Reports
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#43 CANS

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) services build the capacity of youth and their natural supports to prevent, de-escalate, and manage crises with reduced reliance on professional intervention over time. The HFW process is structured to move from professionally driven stabilization toward family-led crisis prevention and response, strengthening long-term sustainability within the home and community.

During engagement and throughout service delivery, the HFW team identifies crisis triggers, early warning signs, protective factors, and existing informal supports. A comprehensive Safety and Crisis Plan is developed collaboratively with youth, caregivers, and team members. The plan clearly outlines prevention strategies, coping skills, de-escalation steps, designated natural support roles, and defined thresholds for professional involvement.

As needs are addressed and caregiver capacity increases, teams prioritize strengthening natural supports’ ability to manage emerging stressors independently. Facilitators track crisis frequency, severity, and level of professional involvement (e.g., team intervention, mobile crisis response, emergency services, hospitalization). Crisis events are documented in progress notes, reviewed in Child and Family Team (CFT) meetings, and formally recorded through Special Incident Reports (SIRs) when applicable.

Crisis reviews focus on identifying contributing factors, reinforcing prevention strategies, and revising the Plan of Care as needed. Supervisors and QA/QI leadership monitor crisis data trends, including the level of professional involvement required, through internal HFW case reviews and outcome monitoring systems. This data informs Continuous Quality Improvement (CQI) initiatives aimed at strengthening prevention planning and enhancing natural support engagement.

Training for Facilitators includes post-crisis debriefing, safety planning, conflict resolution, and facilitation of team-based problem-solving to ensure that crisis events become opportunities for skill-building rather than service dependency. Through structured crisis documentation, measurable tracking, supervisory oversight, and proactive safety planning, Penny Lane maintains clear policies and procedures to record crisis frequency and professional involvement levels.

Policy & Appendix References:

Crisis Prevention & Response
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
205 Special Incident Reports
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes
#43 CANS

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that youth and families exit High-Fidelity Wraparound (HFW) services based on demonstrated stabilization and sufficient progress toward prioritized underlying needs, not due to adverse events, administrative timelines, funding constraints, or system pressures. Discharge decisions are collaborative, needs-based, and grounded in measurable outcomes and team consensus, with preference given to family voice and choice.

Throughout service delivery, the Child and Family Team (CFT) monitors progress toward needs resolution, strategy effectiveness, caregiver capacity, natural support engagement, and crisis frequency. Transition planning begins well in advance of formal discharge and includes strengthening community connections, reinforcing crisis prevention skills, and ensuring sustainability without intensive professional support.

When considering exit from HFW, the team reviews objective indicators including:
Measurable goal completion
Reduction in crisis frequency and severity
Stabilization of living placement
Improved interpersonal and community functioning
Increased caregiver confidence and resource navigation capacity

Adverse events (e.g., hospitalization, placement change, justice involvement) trigger Plan review and revision, not discharge. Teams remain engaged during crises and implement revised strategies consistent with the Principle of Persistence.

All exits from HFW are formally documented, including the reason for discharge, level of stabilization achieved, and aftercare planning. Disenrollment summaries and transition plans are completed and retained in the clinical record. Supervisors review all discharge documentation to ensure exits are aligned with needs-based criteria. QA/QI leadership monitors discharge patterns and reasons for exit through outcome tracking systems to ensure fidelity to stabilization-driven transition standards.

Through structured documentation, supervisory oversight, measurable outcome review, and CQI monitoring, Penny Lane maintains clear policies and procedures to record and evaluate when and why families exit HFW, ensuring discharges are clinically appropriate and aligned with HFW principles.

Policy & Appendix References:

Transition & Discharge Standards
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment

Plan Monitoring & Documentation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
502 Progress Notes and Service Documentation

Crisis Safeguards & Persistence
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
205 Special Incident Reports

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#23 Special Incident Report (SIR)

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that every youth and family receives a comprehensive and developmentally appropriate orientation to the High-Fidelity Wraparound (HFW) process at the onset of services. Orientation is embedded within Phase One (Engagement and Family Preparation) and is designed to promote transparency, informed participation, and shared understanding of the Wraparound framework. Families are positioned as equal partners from the beginning, with clarity regarding their role, rights, and responsibilities.

During initial engagement, the assigned Facilitator reviews the HFW model in full, including the guiding principles (Family Voice and Choice, Strength-Based, Individualized, Natural Supports, Community-Based, Culturally Respectful, Team-Based, Collaborative, Outcomes-Based, and Persistence) and the four phases of the Wraparound process (Engagement, Plan Development, Implementation, and Transition). This overview ensures families understand that services are needs-driven, team-based, and time-limited based on stabilization rather than administrative timelines.

Legal and ethical considerations are reviewed as part of the informed consent process. This includes confidentiality and its limits, mandated reporting requirements, documentation standards, information sharing protocols (Release of Information), client rights, grievance procedures, and crisis response expectations. When serving an Indian child, orientation includes recognition of Tribal involvement, collaboration expectations, and the Tribe’s role as an equal voice on the team consistent with culturally responsive and legally informed practice.

The Facilitator clearly explains the role of each team member, including:
The youth as an active participant
The caregiver as decision-maker and expert on their family
Natural supports as integral contributors
Formal system partners (e.g., therapist, probation, school)
The Facilitator as team coordinator
The Parent Partner as peer support advocate
Supervisory and QA oversight structures

Families are provided written materials that reinforce this orientation and are encouraged to ask questions to ensure full understanding. Orientation discussions are documented in the clinical record.

Supervisors review documentation to confirm that orientation occurred and that the family has been adequately informed. Ongoing feedback from families through fidelity tools (WFI, TOM), satisfaction surveys, and QA calls helps evaluate the effectiveness of orientation practices and informs Continuous Quality Improvement (CQI) efforts.

Through structured engagement procedures, documented informed consent processes, written educational materials, and supervisory oversight, Penny Lane ensures that all families are fully oriented to the HFW process, principles, phases, and team roles.

Policy & Appendix References:

Engagement & Orientation
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness

Legal & Ethical Standards
417 Electronic Communications with Clients and Caregivers
205 Special Incident Reports
502 Progress Notes and Service Documentation

Service Delivery Structure
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#20 Release of Information – Foster Youth
#21 Release of Information – Non-Foster Youth
#33 Definition of Confidentiality Form
#4 CFT Meeting Minutes
#42 Penny Lane Wraparound 101 Workbook

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that pressing safety concerns and urgent needs are addressed immediately so that families can fully engage in the High-Fidelity Wraparound (HFW) process. Stabilization is treated as a prerequisite to effective team-based planning. During Phase One (Engagement and Family Preparation), Facilitators assess immediate safety risks, crisis history, and urgent stressors to determine whether an immediate intervention plan is required.

If pressing concerns are identified, the HFW team develops a written Immediate Safety and Stabilization Plan in collaboration with the youth and caregiver. This plan outlines crisis triggers, warning signs, prevention strategies, designated support persons, and clear steps for response. The plan is provided to the family and documented in the clinical record. When necessary, the team mobilizes coordinated care partners or crisis response resources to ensure stabilization.

The Immediate Crisis Response Plan informs, but does not replace, the comprehensive HFW Safety and Crisis Plan developed during Phase Two (Plan Development). Once stabilization is achieved, the Child and Family Team (CFT) integrates crisis prevention strategies into the broader Plan of Care to address underlying needs and reduce recurrence risk. Safety planning remains dynamic and is reviewed and updated during CFT meetings, especially following any crisis event.

All families are provided with clear instructions on how to access 24/7 crisis response services. Penny Lane maintains defined business hours crisis response coverage and structured after-hours protocols to ensure continuous support availability. Families receive written and verbal information regarding emergency contacts, mobile crisis resources, and when to access emergency services.

Supervisors review crisis documentation to ensure immediate safety planning is completed when indicated and that crisis response procedures align with HFW principles. Special Incident Reports (SIRs), crisis documentation, and internal case reviews are utilized to monitor crisis frequency and response effectiveness. Continuous Quality Improvement (CQI) processes evaluate crisis trends and inform workforce training and system coordination improvements.

Through structured engagement screening, documented stabilization planning, 24/7 crisis access protocols, and supervisory oversight, Penny Lane ensures that immediate concerns are addressed promptly while preserving fidelity to the broader HFW process.

Policy & Appendix References:

Crisis Assessment & Immediate Stabilization
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
413 High-Fidelity Wraparound Service Delivery

Safety Planning & Plan Integration
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings

Documentation
205 Special Incident Reports
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Appendix Forms
#10 Immediate Safety and Stabilization Plan
#22 Safety and Crisis Plan
#23 Special Incident Report (SIR)
#4 CFT Meeting Minutes
#17 Plan of Care Template

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) Facilitators intentionally guide youth and families through structured conversations to identify individual and family strengths, prioritized underlying needs, cultural identity, and a shared vision for a better future. This discovery process occurs during Phase One (Engagement and Family Preparation) and establishes the foundation for needs-driven, strengths-based, and culturally responsive planning.

During engagement, the Facilitator collaborates with the youth and caregiver to develop a clearly articulated Family Vision statement. The Vision reflects the family’s hopes, long-term goals, and definition of success. This Vision is documented in the youth’s chart and serves as the guiding framework for all subsequent planning and strategy development.

In addition to the Vision statement, a comprehensive Strengths, Needs, and Culture Discovery document is initiated for every youth and family. This document captures functional strengths, cultural traditions, family values, lived experiences, community connections, and identified needs. It is maintained in the clinical record, updated at least every ninety (90) days, and revised whenever new strengths, needs, or cultural considerations are identified during service delivery.

The written summary document serves multiple purposes:
Guides initial Plan of Care development
Ensures all team members understand the youth and family’s strengths and cultural context
Orients new team members as they join the Child and Family Team (CFT)
Reinforces Family Voice and Choice throughout implementation

The document is reviewed and referenced during CFT meetings to maintain alignment between the Family Vision, identified needs, and selected strategies. Supervisors review documentation through internal case reviews and Supervisor Review Tool (SPRT) processes to ensure Vision statements and discovery summaries are present, individualized, and actively integrated into planning.

Through structured documentation, scheduled updates, team dissemination practices, and supervisory oversight, Penny Lane ensures that strengths, needs, culture, and Vision are clearly communicated, regularly refreshed, and foundational to all HFW planning and service delivery.

Policy & Appendix References:

Engagement & Discovery
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness

Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)
#43 CANS

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) teams intentionally engage formal service providers, natural supports, and cross-system partners across the Children’s System of Care to support the youth and family. Team composition is driven by Family Voice and Choice and includes individuals who care about the youth and can meaningfully contribute to needs resolution. When serving an Indian child, Tribal representatives are engaged as equal partners and recognized as essential contributors to culturally responsive planning.

During Phase One (Engagement and Family Preparation), Facilitators complete a Natural Supports Inventory with the youth and family. This inventory identifies extended family members, mentors, educators, faith leaders, coaches, community members, and other informal supports. The inventory is documented in the clinical record and updated as new supports are identified.

Facilitators also identify and engage relevant formal Children’s System of Care partners, which may include mental health providers, child welfare staff, probation officers, school personnel, regional center representatives, medical providers, and community-based organizations. Participation is based on the youth’s needs and family preference. Team member roles and responsibilities are clearly defined during orientation and revisited as needed to ensure accountability and collaboration.

The Facilitator leads structured engagement and team-building activities to foster a positive, respectful, and solution-focused team culture. Activities may include establishing Team Agreements, clarifying communication expectations, reviewing the Family Vision, and facilitating collaborative brainstorming. Engagement efforts and team-building processes are documented in meeting minutes and progress notes to reflect active participation and shared ownership.

Supervisors and Wraparound Coaches review documentation and observe Child and Family Team (CFT) meetings to ensure inclusive engagement, role clarity, and cross-system collaboration are evident. Fidelity tools such as the Wraparound Fidelity Index (WFI) and Team Observation Measure (TOM) further assess team engagement quality. Continuous Quality Improvement (CQI) processes incorporate team participation data to strengthen system coordination and collaborative practice standards.

Through structured team identification processes, documented engagement practices, role clarification procedures, and supervisory oversight, Penny Lane operationalizes comprehensive team engagement as a measurable HFW practice standard.

Policy & Appendix References:

Team Engagement & Formation
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
210 Language Access & Cultural and Linguistic Responsiveness

Documentation
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#26 Wraparound Fidelity Index
#36 TOM
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) meetings are scheduled and conducted in ways that prioritize family voice, accessibility, and equitable participation. Meeting logistics are intentionally designed to remove barriers and reflect family schedules, cultural considerations, transportation access, work obligations, trauma history, and communication preferences. The Child and Family Team (CFT) process is structured to adapt to the family, not the reverse.

Facilitators collaborate with youth and caregivers to determine meeting times, locations, and formats that maximize participation and comfort. Meetings may occur in the family’s home, community settings, agency offices, schools, or via telehealth platforms depending on family preference and accessibility needs. When appropriate, teams utilize flexible scheduling, including evenings or alternative hours, to ensure caregiver and natural support participation.

The HFW team proactively arranges meeting logistics, which may include:
Transportation coordination or mileage support
Interpretation or bilingual services
Telehealth access and technical support
Trauma-informed meeting structure and pacing
Accessibility accommodations

Staff are trained to work collaboratively with families and cross-system partners to schedule meetings in alignment with family needs while maximizing team participation. Scheduling decisions are documented in case notes and meeting minutes to reflect family-centered planning practices.

Supervisors and Wraparound Coaches monitor meeting accessibility practices through documentation review and observation of CFT meetings. Feedback from families regarding meeting accessibility and inclusivity is gathered through fidelity tools (WFI, TOM), satisfaction surveys, and QA follow-up calls. Continuous Quality Improvement (CQI) processes analyze feedback trends to strengthen equitable access practices and workforce responsiveness.

Through flexible scheduling policies, trauma-informed planning, logistical coordination, and supervisory oversight, Penny Lane operationalizes accessible and family-centered meeting practices as a core HFW standard.

Policy & Appendix References:

Meeting Logistics & Accessibility
301 Hours of Operation
310 Client Transportation
409 Child and Family Team (CFT) Meetings
210 Language Access & Cultural and Linguistic Responsiveness
417 Electronic Communications with Clients and Caregivers
421 Home Visits

Service Delivery & Coordination
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
413 High-Fidelity Wraparound Service Delivery

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and CQI

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#4 CFT Meeting Minutes
#25 Transportation Agreement
#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that, following initial engagement activities, the High-Fidelity Wraparound (HFW) Facilitator intentionally leads the Child and Family Team (CFT) in establishing a strong collaborative foundation prior to development of the Wraparound Plan of Care. This structured groundwork reinforces team cohesion, shared purpose, and alignment with the Family Vision.

Before the Plan of Care is developed during Phase Two (Plan Development), the Facilitator guides the team through three essential activities:

Formal Team Agreements
The team develops documented agreements outlining how members will engage in meetings, communicate respectfully, resolve disagreements, maintain confidentiality, and make decisions. These agreements reinforce shared expectations, psychological safety, and collective accountability.

Team Strengths Inventory
Building upon strengths identified during engagement, the Facilitator leads the team in identifying additional strengths of the youth, caregivers, natural supports, formal providers, and community resources. Strengths are framed functionally and documented in the youth’s case file. The inventory is dynamic and updated as new strengths are discovered.

Team Mission Statement
In alignment with the Family Vision, the team collaboratively creates a written Mission Statement that defines the overall purpose and direction of the HFW team. The Mission operationalizes the Vision by clarifying the team’s shared commitment and approach to supporting the youth and family.

The youth’s and family members’ strengths initially identified during engagement are revisited and expanded as trust deepens and additional assets emerge. These updated strengths are documented and integrated into planning discussions. The Team Agreements, Strengths Inventory, and Mission Statement are retained in the clinical record and referenced during meetings to reinforce alignment and accountability.

Supervisors and Wraparound Coaches review documentation prior to approval of the Plan of Care to ensure that these foundational elements are completed and meaningfully integrated into the planning process. Internal HFW case reviews and Supervisor Review Tool (SPRT) audits further assess compliance and quality. Continuous Quality Improvement (CQI) processes monitor documentation consistency and reinforce practice standards through targeted coaching and workforce development.

Through structured facilitation, required documentation, supervisory oversight, and fidelity monitoring, Penny Lane ensures that Team Agreements, Strengths Inventory, and Mission development are completed prior to Plan of Care development and are foundational to the HFW process.

Policy & Appendix References:

Engagement & Team Formation
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#3 Strengths Assessment
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator intentionally guides the Child and Family Team (CFT) through a structured, needs-driven planning process prior to finalizing the HFW Plan of Care. This process builds upon the Strengths, Needs, and Culture Discovery completed during engagement and reinforces collaborative, measurable, and individualized planning.

Before the Plan of Care is developed, the Facilitator leads the team in reviewing all underlying needs identified during engagement and invites the youth, caregivers, and team members to identify any additional needs that may have emerged. These needs are written as functional underlying needs statements, reflecting the reasons behaviors or challenges are occurring rather than deficits or diagnoses, and are clearly documented in the youth’s file. The team then prioritizes needs based on urgency, impact, and family preference.

From the prioritized needs, the team collaboratively develops specific, measurable goals and outcomes. Goals are directly linked to the underlying needs and are framed in terms of desired functional improvement rather than symptom suppression or compliance. The youth and family actively participate in defining what success looks like and how progress will be measured.

The Facilitator then engages the team in structured brainstorming to generate multiple creative, individualized strategies before narrowing down selected interventions. Brainstorming emphasizes use of strengths, natural supports, cultural assets, and community resources. Multiple potential strategies are documented in meeting minutes, progress notes, or draft planning materials to preserve creative options and allow for flexibility if revisions are needed.

Selected strategies are then translated into clearly assigned action items with responsible team members and timeframes. These action items are incorporated into the individualized HFW Plan of Care. The planning process is conducted in a team-based, collaborative environment that reinforces shared ownership and accountability.

Facilitators receive ongoing training and supervisory coaching in:
Writing functional underlying needs statements
Developing measurable goals from needs
Leading collaborative prioritization discussions
Facilitating effective brainstorming sessions
Translating strategies into actionable steps

Supervisors review Plans of Care through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure needs prioritization, measurable goal alignment, documented brainstorming, and collaborative development are evident. Continuous Quality Improvement (CQI) processes monitor documentation quality and reinforce planning standards through targeted workforce coaching.

Through structured facilitation, documented needs prioritization, measurable goal development, collaborative brainstorming, and supervisory oversight, Penny Lane ensures that individualized HFW Plans of Care are developed in alignment with HFW principles and team-based practice standards.

Policy & Appendix References:

Needs Identification & Plan Development
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Monitoring
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#43 CANS

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) team develops a comprehensive initial Plan of Care through a structured, collaborative, and principle-driven team process. The Facilitator leads the Child and Family Team (CFT) in integrating prioritized needs, measurable goals, and individualized strategies into a coordinated, strengths-based Plan that reflects Family Voice and Choice. When serving an Indian child, Tribal representatives are engaged as equal partners in the planning process to ensure cultural alignment and shared decision-making.

The Plan of Care is explicitly aligned with the Family Vision and Team Mission Statement and is grounded in the documented strengths, prioritized underlying needs, and cultural context of the youth and family. The planning process elicits multiple perspectives from formal system partners, natural supports, caregivers, and youth, fostering trust, shared ownership, and a unified direction.

The Plan addresses needs across multiple life domains, including behavioral health, education, family functioning, community integration, safety, permanency, and vocational development—as identified and prioritized by the HFW team. Goals and objectives from Children’s System of Care partners (e.g., mental health, child welfare, probation, education, regional center) are integrated into a single coordinated Plan to reduce fragmentation and duplication.

Strategies and action items are clearly documented with:
Assigned responsible team members
Established due dates
Defined measurable outcomes
Shared understanding of roles

Strategies are culturally relevant and intentionally balanced across formal services, natural supports, community resources, and family-driven interventions. Over time, the Plan is designed to increase reliance on natural supports and reduce dependence on formal systems.

Services are delivered within the youth and family’s community and scheduled in alignment with family preferences, accessibility needs, trauma-informed considerations, and equitable participation standards. Natural supports and sustainable community resources are embedded in the Plan, or strategies are included to identify and develop these supports prior to transition.

Transition planning is embedded throughout implementation. The Plan sets benchmarks for moving toward less restrictive, less intrusive, and less formal supports, while honoring the family’s pace and readiness. Graduation occurs based on stabilization and needs resolution, not administrative requirements.

Facilitators receive ongoing training and supervisory coaching to lead high-quality planning processes that demonstrate HFW principles. Supervisors and Wraparound Coaches review Plans of Care through structured internal case reviews and Supervisor Review Tool (SPRT) audits to ensure all required components are present and of high quality. Plans are documented in the clinical record and distributed to all team members to ensure coordinated implementation.

Continuous Quality Improvement (CQI) processes analyze Plan quality, documentation trends, cross-system integration, and fidelity data (WFI, TOM, CANS, LOCUS) to inform workforce development and strengthen planning consistency across teams.

Through structured facilitation, cross-system coordination, documented accountability, supervisory oversight, and CQI review, Penny Lane operationalizes comprehensive Plan of Care development as a measurable and sustainable HFW practice standard.

Policy & Appendix References:

Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
406 Phase Four – Transition

Documentation & Distribution
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#17 Plan of Care Template
#4 CFT Meeting Minutes
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator leads the Child and Family Team (CFT) in developing a comprehensive, individualized Crisis and Safety Plan that prioritizes safety needs, anticipates high-risk situations, and outlines proactive and reactive strategies. Crisis planning is strengths-based, culturally responsive, and family-driven, ensuring that strategies are chosen by the youth and caregivers and reflect their preferences, lived experience, and cultural values.

During Phase Two (Plan Development), the team collaboratively identifies potential triggers, escalation patterns, environmental stressors, and safety vulnerabilities. The Crisis and Safety Plan clearly documents:

Potential safety risks and high-risk scenarios
Early warning signs
Proactive prevention strategies
Reactive intervention steps in progressive order
Designated natural supports and formal contacts
24/7 crisis response information

Strategies emphasize the use of natural supports wherever possible and prioritize family-led prevention and de-escalation before professional intervention is required. The plan includes clear instructions regarding who to contact for support at any time, ensuring families understand how to access crisis response resources when needed.

The development of the Crisis and Safety Plan occurs within a team-based, collaborative environment. Facilitators receive ongoing training and supervisory coaching in trauma-informed crisis planning, cultural humility, de-escalation techniques, and facilitation of structured safety discussions. Supervisors and Wraparound Coaches review Crisis and Safety Plans to ensure they reflect individualized, culturally relevant, and progressive strategies rather than generic templates.

Crisis and Safety Plans are reviewed during Child and Family Team meetings, especially following crisis events, and are revised as needed to strengthen prevention efforts. Internal case reviews and Continuous Quality Improvement (CQI) processes evaluate plans for evidence of individualized strategy progression, meaningful natural support integration, and cultural alignment. Feedback is incorporated into staff coaching and workforce development efforts to reinforce high-quality crisis planning practices.

Through structured team facilitation, documented individualized planning, supervisory oversight, and CQI review mechanisms, Penny Lane operationalizes crisis and safety planning as a measurable HFW standard that strengthens prevention, safety, and long-term stabilization.

Policy & Appendix References:

Crisis & Safety Planning
404 Phase Two – Plan Development
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation
502 Progress Notes and Service Documentation
205 Special Incident Reports

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#23 Special Incident Report (SIR)
#17 Plan of Care Template
#4 CFT Meeting Minutes

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) team actively implements the initial Plan of Care and systematically monitors progress toward meeting prioritized needs and achieving measurable outcomes. Implementation is conducted in alignment with HFW principles, emphasizing shared ownership, accountability, strengths-based practice, and Family Voice and Choice.

The Facilitator leads the Child and Family Team (CFT) in reviewing strategies and action items at each team meeting. Meeting agendas and minutes include structured sections for:

Review of previously assigned action items
Status updates and completion tracking
Identification of barriers to implementation
Adjustment of strategies as needed
Confirmation of next steps and responsible parties

Individual assignments are tracked, and timelines are reinforced to maintain forward momentum. When strategies are not producing expected outcomes, the team collaboratively revises the Plan in a solution-focused manner consistent with HFW principles. Adjustments are documented and redistributed to all team members to ensure coordinated implementation.

The team intentionally acknowledges and celebrates progress as successes occur, whether small milestones or significant breakthroughs. Celebrations are culturally responsive and aligned with family preferences, reinforcing strengths and sustaining motivation. Recognition may occur within CFT meetings, through written acknowledgments, community-based celebrations, or informal affirmations that honor the youth and family’s growth.

Staff receive ongoing training and supervisory coaching in implementing Plans of Care with fidelity to HFW principles. Training emphasizes strengths-based facilitation, collaborative monitoring, measurable tracking, persistence through setbacks, and the intentional celebration of progress. Supervisors review meeting minutes and Plans of Care through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure action tracking and success recognition are evident.

Continuous Quality Improvement (CQI) processes analyze documentation trends, fidelity tool results (WFI, TOM), and outcome data to reinforce implementation quality and strengthen practice consistency. Through structured monitoring, team accountability, workforce coaching, and intentional celebration of progress, Penny Lane operationalizes Plan implementation as an active, measurable, and principle-aligned HFW standard.

Policy & Appendix References:

Plan Implementation & Monitoring
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation & Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the High-Fidelity Wraparound (HFW) Facilitator leads a continuous, structured review process to assess progress, evaluate strategy effectiveness, and revise the Plan of Care as needed. The Plan is treated as a dynamic document that evolves in response to measurable outcomes, emerging needs, and team feedback, rather than a static service agreement.

Reviews of strategies, goals, and action items occur within formal Child and Family Team (CFT) meetings. During these meetings, the Facilitator guides the team in:

Reviewing progress toward prioritized needs
Assessing completion of assigned action items
Evaluating the effectiveness of selected strategies
Identifying new or emerging needs
Revising goals or selecting alternative strategies when necessary

When adjustments are required, whether due to success, limited progress, crisis events, or changing circumstances, the team collaboratively updates the Plan. Changes are documented in the youth’s clinical file and reflected in updated Plans of Care. The Plan is formally updated and redistributed to all team members at least every ninety (90) days, and more frequently when clinically indicated.

The Facilitator documents and communicates critical implementation elements through meeting minutes and case documentation, including:

Completion of tasks and assignment of new action items
Team attendance and participation
Use of formal and natural supports
Allocation and use of flexible funds
Updates to strategies, goals, and needs statements

Meeting minutes serve as the primary communication tool to ensure transparency and shared accountability. Updated Plans of Care are distributed to all team members to maintain coordinated implementation across Children’s System of Care partners.

Documentation forms, including the Plan of Care template and meeting minutes are designed to allow flexibility and individualization, enabling updates that reflect the youth and family’s evolving needs, cultural context, and progress trajectory.

Supervisors and Wraparound Coaches review documentation through internal HFW case reviews and Supervisor Review Tool (SPRT) audits to ensure plan updates are timely, individualized, and reflective of team-based decision-making. Continuous Quality Improvement (CQI) processes analyze plan update patterns and documentation quality to inform workforce coaching and practice refinement.

Through structured meeting reviews, dynamic plan adjustments, comprehensive documentation practices, and supervisory oversight, Penny Lane operationalizes ongoing Plan review and revision as a measurable and fidelity-aligned HFW standard.

Policy & Appendix References:

Plan Review & Revision
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery
406 Phase Four – Transition

Documentation & Communication
502 Progress Notes and Service Documentation
312 Flex Funds
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) Facilitators actively monitor and strengthen team cohesion, trust, and commitment throughout the Wraparound process. Effective collaboration is treated as an essential condition for successful Plan implementation. The Facilitator intentionally cultivates a respectful, solution-focused team culture where all members, including youth, caregivers, formal providers, natural supports, and when applicable, Tribal representatives experience shared ownership and accountability.

Team Agreements are established during initial team formation and are reviewed regularly at Child and Family Team (CFT) meetings to reinforce communication norms, shared expectations, and decision-making processes. Agreements remain present and visible during meetings to anchor collaboration and promote psychological safety.

Facilitators are trained and coached in advanced team facilitation skills, including conflict resolution, trust-building, collaborative problem-solving, and managing cross-system dynamics. Supervisors and Wraparound Coaches provide ongoing observation and feedback to strengthen facilitation effectiveness and team engagement practices.

The use and integration of natural supports are monitored over time. Facilitators intentionally assess whether natural supports are meaningfully engaged in strategies and action items, and whether reliance on formal supports is gradually decreasing as stability increases. Supervisors review Plans of Care and meeting documentation to ensure natural supports are actively utilized. Feedback regarding natural support engagement is incorporated into coaching and Continuous Quality Improvement (CQI) processes.

When new team members are added, whether formal partners or natural supports, the Facilitator conducts a structured orientation process. Orientation includes:

Explanation of the HFW principles and phases
Review of the Family Vision and Team Mission
Summary of prioritized needs and current strategies
Clarification of roles and responsibilities
Engagement in team-building discussions to integrate the new member into the team culture

This process ensures continuity, alignment, and sustained collaboration despite team composition changes.

Through structured Team Agreements, workforce training, supervisory oversight, monitored natural support integration, and formal orientation procedures, Penny Lane operationalizes team cohesion and collaborative functioning as measurable HFW practice standards.

Policy & Appendix References:

Team Development & Engagement
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery

Documentation
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#4 CFT Meeting Minutes
#17 Plan of Care Template
#3 Strengths Assessment
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that transition from High-Fidelity Wraparound (HFW) services is purposeful, collaborative, and based on measurable benchmarks indicating sufficient progress toward the Family Vision, Team Mission, and prioritized needs. Transition planning is not event-driven or administratively imposed; it is initiated when the youth, family, and team collectively determine readiness based on monitored outcomes and stabilization indicators.

Throughout implementation, the Child and Family Team (CFT) tracks measurable progress, natural support engagement, caregiver confidence, reduced crisis frequency, and improved functioning across life domains. When pre-determined benchmarks are achieved, the Facilitator leads the team in formally identifying readiness for transition. Family voice and choice guide this determination.

Once readiness is established, the Facilitator leads the development of an individualized Transition Plan within a team-based meeting. The Transition Plan:

Identifies remaining needs, if any
Specifies ongoing services and natural supports
Clarifies how formal HFW supports will be tapered or transferred
Establishes sustainability strategies
Includes crisis response continuity planning
Documents timelines and responsible parties

The individualized Transition Plan is documented in the youth’s clinical file and distributed to all team members to ensure coordinated follow-through. Transition planning includes verification that identified services and supports will persist beyond formal HFW involvement and that the family understands how to access them independently.

For adoptive families utilizing Adoption Assistance Program (AAP) funding, families are specifically educated regarding available post-adoptive services and community-based resources that can provide continued support. This education is documented and integrated into the transition planning process to ensure continuity and stability.

Facilitators receive ongoing training and supervisory coaching in leading effective transition discussions, identifying sustainability indicators, and supporting graduated movement toward less restrictive and less formal services. Supervisors review Transition Plans through internal case reviews and Supervisor Review Tool (SPRT) audits to ensure benchmarks, sustainability planning, and family readiness are clearly documented.

Continuous Quality Improvement (CQI) processes monitor transition trends and outcomes to reinforce needs-based discharge practices and long-term sustainability standards.

Through structured readiness assessment, individualized transition documentation, coordinated team collaboration, and supervisory oversight, Penny Lane operationalizes transition planning as a measurable and fidelity-aligned HFW standard.

Policy & Appendix References:

Transition Planning & Sustainability
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment
413 High-Fidelity Wraparound Service Delivery

Plan Monitoring & Benchmark Review
404 Phase Two – Plan Development
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Coordinated Care & Ongoing Supports
411 Coordinated Care
312 Flex Funds

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that, prior to the conclusion of formal High-Fidelity Wraparound (HFW) services, the Facilitator leads the Child and Family Team (CFT) in developing or revising a comprehensive Crisis and Safety Plan specifically tailored to the post-transition period. This transition-focused planning ensures that youth and families are equipped with individualized, culturally relevant, and sustainable strategies to manage potential future crises without reliance on formal HFW support.

As part of Phase Four (Transition), the team reviews the existing Crisis and Safety Plan and updates it—or develops a new transition-focused plan—to reflect the youth and family’s anticipated needs after HFW concludes. The updated plan:

Identifies potential crisis situations that may arise post-transition
Defines early warning signs
Outlines proactive prevention strategies
Specifies reactive, stepwise intervention strategies
Identifies natural and community supports who will remain engaged
Provides clear 24/7 contact guidance when professional services are necessary

The youth and caregivers play a central role in identifying preferred strategies, selecting trusted natural supports, and ensuring cultural relevance of prevention and response approaches. Emphasis is placed on maximizing natural and community supports, strengthening caregiver-led crisis management capacity, and reinforcing informal networks to promote long-term sustainability.

The development of the transition-focused Crisis and Safety Plan occurs in a team-based, collaborative meeting environment. Facilitators receive ongoing training and supervisory coaching in trauma-informed crisis planning, culturally responsive facilitation, and post-transition sustainability strategies. Supervisors and Wraparound Coaches review documentation to ensure plans reflect individualized strategy progression and meaningful natural support integration.

Structured review processes, including internal HFW case reviews and Continuous Quality Improvement (CQI) audits, assess crisis and safety plans for:

Individualization and specificity
Clear proactive-to-reactive strategy progression
Cultural relevance
Natural support integration
Alignment with transition benchmarks

Feedback from these reviews informs workforce training and coaching efforts to strengthen transition readiness and crisis prevention practices agency-wide.

Through structured transition planning, documented individualized crisis strategies, collaborative team processes, and supervisory oversight, Penny Lane operationalizes post-transition safety planning as a measurable and fidelity-aligned HFW standard.

Policy & Appendix References:

Crisis & Transition Planning
406 Phase Four – Transition
405 Phase Three – Implementation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Documentation
502 Progress Notes and Service Documentation
503 Aftercare, Graduation, and Disenrollment

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Training & Workforce Development
703 Workforce Training & Competency Development
718 Wraparound 101 – HFW Foundational Training

Appendix Forms
#22 Safety and Crisis Plan
#10 Immediate Safety and Stabilization Plan
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#4 CFT Meeting Minutes
#17 Plan of Care Template

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the conclusion of formal High-Fidelity Wraparound (HFW) services is intentionally celebrated as a positive milestone reflecting growth, resilience, and progress. Transition is framed as an achievement aligned with the Family Vision and Team Mission, not simply the end of services. Celebrations are designed to be meaningful, culturally relevant, and reflective of the youth and family’s preferences, values, and traditions.

During Phase Four (Transition), the Facilitator collaborates with the youth and family to determine how they would like to mark the conclusion of HFW involvement. Celebrations may include formal graduation meetings, culturally significant ceremonies, community-based gatherings, recognition during a final Child and Family Team (CFT) meeting, written affirmations of progress, or other family-preferred acknowledgments. The format, tone, and level of visibility are determined by the youth and family.

Administrative structures support celebratory transitions by allowing:
Access to flexible funds when appropriate
Allocation of staff time for celebration planning and participation
Engagement of community partners and natural supports
Development of commemorative materials or recognition documents

These structures reinforce that celebration is an integral component of strengths-based practice and persistence, not an optional activity.

Supervisors review transition documentation to ensure that discharge reflects stabilization and includes recognition of progress. Transition summaries document celebration activities and family participation. Continuous Quality Improvement (CQI) processes monitor discharge practices to ensure transitions are needs-based and positively framed.

Through structured transition planning, culturally responsive celebration practices, administrative support mechanisms, and supervisory oversight, Penny Lane operationalizes celebration of transition as a fidelity-aligned and strengths-driven HFW standard.

Policy & Appendix References:

Transition & Discharge
406 Phase Four – Transition
419 Graduation and Disenrollment
503 Aftercare, Graduation, and Disenrollment

Plan Monitoring & Closure
405 Phase Three – Implementation
409 Child and Family Team (CFT) Meetings
502 Progress Notes and Service Documentation

Flexible & Community-Based Supports
312 Flex Funds
411 Coordinated Care

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Appendix Forms
#8 Disenrollment Summary/Aftercare Plan
#24 Transfer Review and Transition Plan
#17 Plan of Care Template
#4 CFT Meeting Minutes
#29 Flex Fund Request Form

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that youth and family voice extends beyond individual case planning and meaningfully informs all levels of High-Fidelity Wraparound (HFW) implementation. Youth and caregiver feedback is systematically incorporated into service planning, policy refinement, workforce development, and Continuous Quality Improvement (CQI) processes. Family Voice and Choice is operationalized not only at the team level but also at the organizational level.

At the service delivery level, youth and caregivers are primary decision-makers within the Child and Family Team (CFT). Their preferences, priorities, and satisfaction directly influence strategy selection, Plan revisions, and transition planning. At the program level, structured feedback mechanisms, including Wraparound Fidelity Index (WFI), Team Observation Measure (TOM), satisfaction surveys, and Quality Assurance (QA) follow-up calls, collect data on the family experience across multiple domains.

Mechanisms are in place for families to participate in local HFW implementation decisions. This may include participation in advisory discussions, structured feedback forums, satisfaction surveys, or quality improvement initiatives designed to capture lived experience input. Feedback themes are aggregated and reviewed by leadership and QA/QI teams to inform:

Policy and procedure revisions
Workforce training priorities
Cultural responsiveness improvements
System coordination practices

Family feedback trends are analyzed as part of CQI review cycles. Supervisors and leadership integrate findings into coaching strategies, performance improvement planning, and workforce development initiatives. When feedback identifies gaps in accessibility, engagement, cultural relevance, or collaboration, targeted corrective actions are implemented and monitored.

Documentation processes ensure that feedback is not only collected but evaluated and acted upon. QA/QI leadership tracks feedback patterns and presents findings within program oversight structures to ensure continuous learning and improvement.

Through structured feedback systems, family participation mechanisms, leadership review processes, and integrated CQI practices, Penny Lane operationalizes youth and family partnership as a core governance and implementation standard within the HFW program.

Policy & Appendix References:

Family Voice & Service Planning
402 High-Fidelity Wraparound Family Assessment & Engagement Process
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Quality Improvement & Feedback Integration
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews

Policy & Workforce Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#4 CFT Meeting Minutes
#17 Plan of Care Template

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers actively participates in the County-established Community Leadership Team (CLT) to support shared decision-making and systems-level alignment with California Wraparound Standards and High-Fidelity Wraparound (HFW) principles. The agency designates an identified leadership representative, typically at Deputy Director level, who consistently participates in Community Leadership Team meetings and collaborates with Interagency Leadership Teams (ILTs) and other cross-system partners.

Through this representation, Penny Lane contributes to system-level oversight and continuous improvement efforts that include:

Promoting inclusion of Tribes within the region as equal partners in community-level planning
Ensuring child-serving entities across systems (mental health, child welfare, probation, education, regional centers, community-based organizations) have opportunities to participate in CLT discussions
Identifying and addressing interagency barriers that impede coordinated service delivery
Supporting cross-agency training initiatives to strengthen family-centered, culturally relevant practice
Reviewing Wraparound implementation trends and fidelity data
Monitoring flex fund access, utilization patterns, and procedural equity
Participating in community-level review of family plans to ensure alignment with HFW values and principles

Penny Lane’s representative brings agency-level data, quality improvement findings, and practice insights to CLT discussions to inform system refinement. Conversely, CLT guidance and cross-agency initiatives are communicated internally to program leadership and integrated into workforce training, supervision practices, and policy refinement efforts.

At the organizational level, internal processes mirror community-level oversight by reviewing:

Flex fund utilization patterns
Fidelity monitoring data (WFI, TOM)
IP-CANS and outcome trends
Discharge and transition patterns
Cross-system collaboration challenges

These reviews inform Continuous Quality Improvement (CQI) planning and workforce development strategies consistent with county and state HFW standards.

Through active leadership participation, structured communication pathways, cross-system collaboration, and integrated CQI processes, Penny Lane fulfills its responsibility to engage in Community Leadership Team activities and contribute to systems-level fidelity and interagency coordination.

Policy & Appendix ReferencesL:

Interagency Collaboration & Coordinated Care
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery
412 Internal High-Fidelity Wraparound Case Reviews

Flex Fund Oversight
312 Flex Funds

Performance & Data Review
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Workforce & Cross-System Training
703 Workforce Training & Competency Development
719 Wraparound 101 – HFW Foundational Training

Outcome & Fidelity Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) eligibility and referral processes promote adequate, appropriate, and equitable access to services. Youth who meet established eligibility criteria are not excluded based on the severity, complexity, or nature of their needs. The program is structured to serve youth with significant behavioral health challenges, system involvement, placement instability risk, or multi-domain needs requiring intensive, coordinated intervention.

Referral pathways are clearly defined and accessible through interagency partnerships, internal referral mechanisms, and community outreach. Intake procedures ensure timely review of eligibility criteria without imposing additional barriers that would limit access for high-acuity youth. HFW services are publicly communicated through outreach materials, cross-system coordination, and partnership engagement to ensure youth and families who would benefit are informed of availability.

Once enrolled, families receive services designed to address complex and multi-system needs. The HFW model integrates cross-system coordination, crisis response planning, flexible funding support, and 24/7 crisis access to ensure continuity and responsiveness. The program maintains defined business hours crisis coverage and structured after-hours protocols to ensure families have access to support when urgent needs arise.

Staffing structures are intentionally planned to maintain appropriate caseload sizes aligned with HFW intensity standards. Caseload assignments are monitored to ensure staff can provide the frequency of contact, team facilitation, community-based service delivery, and crisis responsiveness required for high-acuity cases. Supervisors monitor workload distribution and adjust assignments as needed to preserve service quality and timely engagement.

Administrative and clinical leadership evaluate staffing ratios, productivity benchmarks, and service utilization patterns to ensure adequate workforce capacity. Continuous Quality Improvement (CQI) processes review referral trends, access data, and service intensity indicators to confirm that eligibility criteria are applied equitably and that program capacity aligns with community needs.

Through equitable referral practices, non-restrictive eligibility criteria, workforce capacity planning, 24/7 crisis access protocols, and structured supervisory oversight, Penny Lane ensures that HFW services remain accessible, intensive, and responsive to youth and families with complex needs.

Policy & Appendix References:

Referral & Eligibility
401 Referral and Intake Process
402 High-Fidelity Wraparound Family Assessment & Engagement Process
44 Penny Lane Internal Referral Request HFW

Service Delivery & Intensity
413 High-Fidelity Wraparound Service Delivery
301 Hours of Operation
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage
421 Home Visits

Staffing & Workforce Capacity
713 High-Fidelity Wraparound (HFW) Team Staffing
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding

Performance & Capacity Monitoring
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Flexible Supports
312 Flex Funds

Appendix Forms
#14 LA County Referral Form
#44 Penny Lane Internal Referral Request HFW
#27 Wrap Line Flyer
#17 Plan of Care Template

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that fiscal practices, internal budget planning, and contract implementation are fully aligned with the values and principles of High-Fidelity Wraparound (HFW) and the California Wraparound Standards. Within the structure of county and system-level contracts, the agency strategically allocates resources to sustain fidelity, workforce stability, data integrity, and individualized service delivery.

Fiscal oversight is integrated into program leadership, quality improvement infrastructure, and workforce planning to ensure funding supports both direct services and the operational components required for high-quality HFW implementation.

Alignment of Contracts and Budgeting with HFW Standards-
Penny Lane ensures that contract implementation and internal budget management reflect the full scope of HFW requirements, including:

High-Fidelity Direct Services and Supports-
Agency budgets prioritize the delivery of intensive, individualized, community-based services that meet the immediate and complex needs of youth and families. Fiscal planning supports:

Adequate staffing ratios to maintain manageable caseloads
Community-based engagement and home visits
Child and Family Team (CFT) facilitation
Crisis response infrastructure (business hours and after-hours coverage)
Flexible funding allocations
Coordination across Children’s System of Care partners
Rates are operationalized to ensure service intensity consistent with HFW fidelity expectations rather than minimal compliance.

Required Workforce Development and Staffing-
Budget allocations support required HFW roles and functions, including:

HFW Facilitators
Parent Partners
Youth Partners (as applicable)
Family Specialists
Clinical Supervisors (licensed)
HFW Supervisors/Managers
Fidelity oversight and QA functions
Fiscal planning includes funding for:
Initial apprenticeship training
Ongoing supervision and coaching
Annual booster trainings
ICWA and Tribal sovereignty training
Role-specific workforce development
Leadership development and mentoring programs

Compensation strategies, including bilingual differentials, retention incentives, education reimbursement, and supervision structures, are designed to maintain workforce stability and support fidelity implementation.

Data Collection and Data Management Systems-
Penny Lane allocates funding to ensure robust data collection, documentation, and quality improvement systems consistent with HFW standards. Budgeted infrastructure supports:

Electronic Health Record (EHR) systems
IP-CANS administration and tracking
TOM and WFI fidelity monitoring
LOCUS implementation
QA review processes
Internal case review systems
Data reporting and performance dashboards

Data systems are integrated into supervisory and leadership review processes to support continuous quality improvement and contract compliance.

Fiscal Oversight and Continuous Quality Improvement-
Leadership regularly reviews fiscal performance alongside fidelity and outcome data to ensure alignment between resource allocation and HFW implementation standards. Budget monitoring includes:

Staffing capacity analysis
Caseload distribution review
Flexible fund utilization trends
Training investment tracking
Crisis utilization patterns
Discharge and transition stability indicators

When service needs exceed current allocations, leadership collaborates with funders and system partners to identify funding adjustments or resource reallocation strategies that preserve fidelity and service continuity.

Commitment to HFW Values in Fiscal Practice-
Penny Lane’s fiscal model reflects core HFW values:

Family-driven allocation of flexible resources
Investment in workforce stability and cultural responsiveness
Support for cross-system coordination
Data-informed decision-making
Sustainability of services beyond formal involvement

Budgets are structured not only to fund direct service hours but also to sustain the infrastructure necessary for high-quality Wraparound practice.

Policy & Appendix References:

Fiscal Governance & Flexible Funds
312 Flex Funds

Workforce & Staffing
713 High-Fidelity Wraparound (HFW) Team Staffing
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding

Data & Quality Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Service Delivery & Crisis Infrastructure
413 High-Fidelity Wraparound Service Delivery
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage

Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS

Appendix:
#46 Organizational Chart
#29 Flex Fund Request Form
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS
#34 Supervisor Review Tool
#17 Plan of Care Template

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers maintains a structured process to ensure families have timely access to flexible funds to address urgent, individualized needs that cannot be met through traditional funding streams or community resources. Flexible funds are embedded within the High-Fidelity Wraparound (HFW) service model as a strategic tool to remove barriers, stabilize placements, strengthen natural supports, and advance the Team Mission and individualized Plan of Care.

Flexible funds are included as part of the HFW funding structure and are accessible to teams when needs align with HFW principles. Requests originate through the Child and Family Team (CFT) process and must demonstrate alignment with the individualized Plan of Care. When serving an Indian child, flexible funds may be utilized to support Tribal services or activities that directly address identified youth and family needs, consistent with culturally respectful practice and collaborative partnership.

The defined approval process ensures that each request is evaluated against established criteria, including whether the proposed expenditure:

Adds value to the Team Mission and supports the individualized Plan of Care
Builds upon documented family strengths
Directly addresses prioritized youth and family needs
Is culturally relevant and responsive
Strengthens natural supports and/or community capacity
Represents a fiscally responsible investment
Includes a sustainability plan when applicable

Requests are submitted through a standardized Flexible Fund Request Form and reviewed by designated program leadership (e.g., Program Manager, Regional Director, or Senior Director) in accordance with county and agency policy. Approval processes are designed to be timely to address urgent needs and prevent service disruption.

If a request is denied, there is a structured communication process to inform the team, youth, and family of the rationale. Teams may revise and resubmit requests with additional justification or explore alternative funding or community-based resources. This process reinforces transparency and shared problem-solving.

Supervisors and QA/QI leadership monitor flexible fund utilization patterns, approval timelines, and alignment with HFW principles through internal case reviews and Continuous Quality Improvement (CQI) processes. Regular review ensures funds are equitably distributed, strategically utilized, and aligned with individualized planning standards.

Through structured funding allocation, defined approval criteria, transparent communication practices, and CQI oversight, Penny Lane operationalizes flexible funds as a responsive, equitable, and fidelity-aligned component of the HFW program.

Policy & Appendix References:

Flexible Funds Governance
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care

Documentation & Approval
502 Progress Notes and Service Documentation

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing

Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers maintains structured collaboration and shared oversight with funders and system partners regarding the availability, allocation, and monitoring of flexible funds within the High-Fidelity Wraparound (HFW) Program. Flexible funds are managed transparently to ensure equitable access, fiscal accountability, and alignment with HFW principles across all families served.

Flexible funds are pooled and held at the program level to ensure that resources are available to meet the individualized needs of all enrolled families rather than being restricted to individual teams or cases. This pooled structure promotes equity, sustainability, and strategic allocation based on prioritized needs.

Each flexible fund request is formally documented through standardized procedures that capture:

Requested amount
Purpose of the request
Linkage to prioritized needs and Plan of Care
HFW team recommendation
Approval or denial decision
Final allocation amount

Documentation ensures that both approved and denied requests are tracked. Denials are recorded along with rationale to promote transparency and learning. This tracking allows program leadership and funders to analyze utilization patterns, identify trends, and assess alignment with funding criteria.

Flexible fund utilization data—including total funds available, amounts allocated, categories of use, and approval rates is reviewed regularly by program leadership and shared with funders as required. This ensures collaborative fiscal oversight and alignment with contractual and county requirements.

Continuous Quality Improvement (CQI) processes review flexible fund patterns to evaluate whether allocations:

Reflect individualized, needs-driven planning
Support natural supports and community-based strategies
Promote sustainability
Demonstrate equitable distribution across families

Supervisors and leadership use utilization data to provide coaching and ensure consistent application of approval criteria across teams.

Through pooled fund management, structured documentation practices, transparent reporting, and collaborative oversight with funders and providers, Penny Lane ensures responsible stewardship and equitable access to flexible funds consistent with HFW standards.

Policy & Appendix References:

Flexible Fund Governance & Oversight
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care

Documentation & Tracking
502 Progress Notes and Service Documentation
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement

Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing

Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that the requirements or limitations of any single funding source do not restrict the availability of flexible funds or limit the resources necessary to meet the individualized needs of youth, families, Tribes, and communities served through High-Fidelity Wraparound (HFW). The program operates within a braided funding framework that strategically integrates multiple System of Care funding streams to preserve flexibility, equity, and responsiveness.

Flexible funds and HFW program resources are supported through coordinated use of available funding sources (e.g., BHSA, Title IV-E, CalWORKs, Medi-Cal, county allocations, and other System of Care funding streams). This braided funding structure allows Penny Lane to sustain access to individualized supports without overreliance on a single revenue source.

When limitations exist within a particular funding stream, leadership explores alternate funding mechanisms or increases reliance on other available sources to fill gaps. The approval process ensures that funding source requirements are considered for compliance purposes but do not create barriers to families receiving needed support. In situations where one funding stream cannot cover a request, alternate funding options are reviewed collaboratively to prevent service disruption.

Flexible fund access decisions are based on alignment with the individualized Plan of Care, HFW principles, and identified needs, not solely on funding category restrictions. This ensures that youth and families are not excluded from receiving flexible supports due to administrative constraints tied to a single funding source.

Leadership monitors funding allocations and access patterns through internal fiscal review and Continuous Quality Improvement (CQI) processes. Cross-system collaboration with funders supports shared oversight and strategic resource alignment to maintain equitable access across families served.

Through braided funding strategies, fiscal oversight processes, and commitment to HFW principles, Penny Lane ensures that funding requirements do not limit flexible fund availability or undermine individualized, needs-driven service delivery.

Policy & Appendix References:

Flexible Fund Governance
312 Flex Funds
413 High-Fidelity Wraparound Service Delivery
411 Coordinated Care

Fiscal Oversight & Resource Planning
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Staffing & Administrative Oversight
713 High-Fidelity Wraparound (HFW) Team Staffing

Documentation & Tracking
502 Progress Notes and Service Documentation

Appendix Forms
#29 Flex Fund Request Form
#17 Plan of Care Template
#4 CFT Meeting Minutes
#34 Supervisor Review Tool (SPRT)

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that High-Fidelity Wraparound (HFW) staffing reflects the cultural, racial, and linguistic diversity of the youth, families, and communities served. Workforce planning is intentionally aligned with demographic trends to promote culturally responsive engagement, equitable access, and meaningful representation within service delivery.

The agency monitors the demographic composition of the population served and incorporates this data into recruitment and hiring strategies. Hiring practices prioritize bilingual and bicultural candidates, community-connected staff, and professionals with lived experience reflective of the families served. Recruitment efforts include outreach to diverse professional networks, community-based organizations, and culturally specific institutions to strengthen workforce representation.

When recruitment challenges limit the ability to directly match staff to the cultural, racial, or linguistic needs of a specific family, alternative strategies are implemented. These may include:

Engaging culturally aligned natural supports or community leaders as team members
Partnering with culturally specific organizations
Involving Tribal representatives when serving an Indian child
Leveraging Parent Partners who share lived or cultural experience

When a staff member fluent in the family’s preferred language is unavailable, professional interpretation services are utilized to ensure equitable communication. In certain circumstances, a trusted natural support may assist with language interpretation when appropriate and compliant with confidentiality standards. Language Access policies guide interpretation practices to preserve confidentiality and service quality.

Supervisors and leadership monitor workforce diversity metrics and service access trends through Continuous Quality Improvement (CQI) processes. Workforce development initiatives incorporate cultural humility training, bias awareness education, and culturally responsive facilitation practices to ensure staff are equipped to serve diverse populations effectively.

Through intentional recruitment strategies, demographic monitoring, alternative engagement mechanisms, language access protocols, and ongoing workforce development, Penny Lane operationalizes culturally, racially, and linguistically responsive staffing as a measurable HFW implementation standard.

Policy & Appendix References:

Workforce Recruitment & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing

Cultural & Linguistic Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness
413 High-Fidelity Wraparound Service Delivery
402 High-Fidelity Wraparound Family Assessment & Engagement Process

Supervision & Continuous Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Appendix Forms

#1 Welcome to Penny Lane’s HFW
#2 Wraparound Family Guide
#3 Strengths Assessment
#41 Agency Overview HR
#45 PL MH Flyer
#46 Wraparound Organizational Chart

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that, in cases involving Indian children, the High-Fidelity Wraparound (HFW) Program prioritizes respect for Tribal sovereignty, traditions, cultural values, and self-determination. The HFW team recognizes the Tribe as an equal and essential partner in planning and service delivery and actively promotes culturally rooted support systems that reflect the youth and family’s Tribal identity.

Staff receive structured training on Tribal sovereignty, traditions, values, and culturally responsive engagement practices. This includes formal annual training under the Indian Child Welfare Act (ICWA) to ensure compliance with federal and state mandates, understanding of Tribal rights, and respectful collaboration standards. ICWA Annual Training reinforces:

Legal foundations of Tribal sovereignty
Requirements for Tribal notification and participation
Culturally respectful communication practices
The importance of Tribal voice as equal decision-makers
Advocacy responsibilities when serving Indian children

When serving an Indian child, the HFW team actively builds partnerships with Tribal representatives and ensures they are invited and supported as equal voices on the Child and Family Team (CFT). The team works collaboratively to:

Align the Plan of Care with Tribal values and traditions
Encourage participation in Tribal ceremonies, practices, and community life
Identify culturally rooted services and supports available through the Tribe
Integrate Tribal resources into crisis planning, transition planning, and long-term sustainability strategies
Advocate for culturally aligned interventions and system coordination

Plans of Care reflect culturally relevant strategies that prioritize Tribal and natural supports wherever possible. Supervisors and QA/QI leadership monitor documentation to ensure Tribal partnership is meaningful, ongoing, and clearly reflected in case records.

Continuous Quality Improvement (CQI) processes incorporate review of Tribal engagement practices and ICWA compliance indicators. Feedback from Tribal representatives and families is integrated into workforce development and policy refinement efforts to strengthen cultural responsiveness and intergovernmental collaboration.

Through annual ICWA training, structured partnership practices, documented collaboration, and CQI oversight, Penny Lane operationalizes respect for Tribal sovereignty and culturally rooted service delivery as a measurable and fidelity-aligned HFW standard.

Policy & Appendix References:

Cultural & Tribal Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness
402 High-Fidelity Wraparound Family Assessment & Engagement Process
403 Phase One – Engagement and Family Preparation
409 Child and Family Team (CFT) Meetings
413 High-Fidelity Wraparound Service Delivery

Plan Development & Implementation
404 Phase Two – Plan Development
405 Phase Three – Implementation
406 Phase Four – Transition

Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Supervision & Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Appendix Forms
#3 Strengths Assessment
#17 Plan of Care Template
#4 CFT Meeting Minutes
#26 Wraparound Fidelity Index
#36 TOM

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures a high degree of collective responsibility for High-Fidelity Wraparound (HFW) program quality, cohesion, communication, and fidelity to mission. Leadership intentionally creates organizational structures that promote staff engagement, creativity, flexibility, and shared ownership of outcomes. Program quality is not viewed as the responsibility of a single department; rather, it is embedded across all roles, facilitators, supervisors, quality assurance staff, program managers, and executive leadership.

Leadership establishes structured processes to engage staff in program quality and improvement efforts. These include regular supervision sessions, internal HFW case reviews, CQI meetings, performance dashboards, fidelity tool reviews (CANS, TOM, WFI, LOCUS), and structured feedback loops. Staff are encouraged to identify service delivery challenges and propose innovative solutions aligned with HFW principles.

Cohesion is intentionally cultivated through team-based staffing models, structured supervision, cross-role collaboration, and leadership accessibility. Supervisors foster psychologically safe environments that support reflective practice, collaborative problem-solving, and strengths-based recognition of staff contributions. Leadership models HFW values internally by reinforcing respect, shared decision-making, and solution-focused dialogue.

Open communication is promoted through regular staff meetings, cross-level leadership forums, structured email and documentation protocols, and transparent reporting of program data and improvement initiatives. Staff are informed of policy updates, system changes, performance trends, and strategic priorities. Feedback from staff is actively solicited and integrated into program development and policy refinement.

A clear sense of mission and compliance with HFW philosophy is reinforced through ongoing training, onboarding processes, coaching, and fidelity monitoring. Leadership ensures staff understand and operationalize the HFW principles, phases, and activities in daily practice. Internal review tools and fidelity audits reinforce alignment between documented practice and HFW standards. Creative and flexible problem-solving is encouraged when barriers arise, provided solutions remain consistent with HFW values.

Through structured leadership engagement, transparent communication systems, CQI infrastructure, workforce development strategies, and fidelity monitoring processes, Penny Lane operationalizes collective responsibility for quality, cohesion, and mission alignment as a foundational HFW program standard.

Policy & Appendix References:

Performance & Quality Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
412 Internal High-Fidelity Wraparound Case Reviews

Workforce Development & Mission Alignment
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
718 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Service Delivery & Fidelity
413 High-Fidelity Wraparound Service Delivery
714 CANS
715 TOM
716 LOCUS

Organizational Structure
103 Penny Lane Wraparound Organizational Chart
713 High-Fidelity Wraparound (HFW) Team Staffing

Appendix Forms
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers maintains rigorous hiring practices and structured performance assessment processes to ensure staff possess the competencies necessary to implement High-Fidelity Wraparound (HFW) with fidelity and integrity. Recruitment, onboarding, supervision, and evaluation processes are intentionally aligned with Wraparound values, principles, phases, and activities.

Rigorous Hiring Practices-
All HFW positions are supported by formal job descriptions that reflect best practices in Wraparound facilitation, family engagement, cultural responsiveness, crisis management, and coordinated care. Recruitment processes include:

Review of relevant education, licensure, and certifications (as applicable)
Behavioral interview questions aligned with HFW competencies
Evaluation of experience in family-centered, strengths-based practice
Assessment of cultural humility and community engagement experience
Background and credential verification in compliance with agency policy

Hiring decisions prioritize alignment with HFW philosophy, demonstrated collaboration skills, crisis responsiveness, and commitment to family voice and choice.

Defined HFW Team Roles-
Job descriptions clearly articulate expectations, required competencies, and performance standards for the following HFW team roles (functions may be fulfilled by designated positions within the program structure):

Youth Partner – Engages youth voice, supports self-advocacy, and promotes youth-driven participation.
Parent Partner – Provides lived-experience advocacy, caregiver support, and reinforces family voice and choice.
HFW Facilitator – Leads the Child and Family Team (CFT), oversees Plan of Care development and implementation, and ensures fidelity to HFW principles.
Family Specialist – Provides skill-building, support, and resource linkage aligned with prioritized needs.
Fidelity Coach – Monitors adherence to HFW standards, provides coaching feedback, and supports fidelity improvement.
Clinical Supervisor (Licensed) – Provides clinical oversight, crisis consultation, documentation review, and compliance monitoring.
HFW Supervisor/Manager (License not required) – Oversees program operations, staffing, quality improvement, and fidelity implementation.

Each role includes clearly defined responsibilities related to engagement, documentation, crisis planning, coordinated care, natural support integration, and data-informed practice.

Performance Assessment & Ongoing Evaluation-
Meaningful performance assessments are conducted through:
Structured supervision and documentation review
Internal HFW case reviews
Fidelity monitoring (CANS, TOM, WFI, LOCUS as applicable)
Evaluation of timeliness and Plan of Care quality
Crisis response documentation review
Feedback from families and team members

Performance evaluations assess both quantitative indicators (timeliness, documentation quality, action tracking) and qualitative competencies (engagement skill, team facilitation, cultural responsiveness, collaboration).

Supervisors provide structured feedback, coaching plans, and professional development recommendations aligned with workforce training standards. Identified performance gaps inform individualized development plans and targeted booster trainings.

Continuous Quality Improvement Integration-
Hiring practices and performance assessment data are reviewed at the leadership level to ensure workforce capacity aligns with program needs and fidelity expectations. Trends inform recruitment priorities, job description refinement, and training enhancements.

Through structured recruitment standards, clearly defined role expectations, rigorous supervision practices, fidelity monitoring tools, and data-informed performance management, Penny Lane operationalizes workforce accountability and excellence as foundational to HFW program quality.

Policy & Appendix References:

Hiring & Credentialing
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing
103 Penny Lane Wraparound Organizational Chart

Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Supervision & Performance Oversight
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)
412 Internal High-Fidelity Wraparound Case Reviews

Fidelity & Outcome Monitoring
714 CANS
715 TOM
716 LOCUS

Appendix
#45 PL MH Flyer
#41 Agency Overview HR
JD- Facilitator
JD- Child and Family Specialist
JD- Intensive Service Clinical Manager
JD- Intensive Service Program Manager
JD- Parent Partner
JD- Parent Partner Coordinator/ Family Specialist
JD- IS QA Manager/ Fidelity Wraparound Coach

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers implements comprehensive Human Resources and leadership strategies designed to maintain a stable, engaged workforce and reduce turnover across High-Fidelity Wraparound (HFW) programs. Workforce stability is treated as a strategic priority directly connected to service quality, fidelity, and continuity of care for youth and families.

Human Resources, in partnership with executive and program leadership, utilizes structured recruitment, competitive compensation, workload monitoring, advancement pathways, and employee engagement initiatives to sustain a high-performing and diverse workforce.

Matching Wages to Cost of Living-
Penny Lane offers competitive salaries and comprehensive benefits aligned with the cost of living in Los Angeles County and surrounding service areas. Compensation strategies include:

Market-informed salary benchmarking
Competitive starting wages
Bilingual differential compensation ($5,000 annually)
Retention bonus programs
4-tier service time (billing) incentive program
Education reimbursement (up to $2,000 annually)
Workforce grant stipends (tuition and loan repayment opportunities)
401K with employer match and profit-sharing

These compensation strategies reflect the agency’s commitment to equitable wages and long-term staff retention.

Maintaining Manageable Workloads-
Workforce planning aligns with HFW intensity standards to ensure manageable caseloads and appropriate service frequency. Leadership monitors:
Caseload size relative to acuity
Crisis coverage structures
Service intensity benchmarks
Documentation support systems
Hybrid and flexible work scheduling

Supervisors regularly review workload distribution to ensure staff can meet engagement timelines, conduct community-based services, and maintain high-quality documentation without burnout.

24/7 supervisory access and crisis consultation further support staff in high-acuity situations.

Clear and Accessible Promotion/Advancement Structures-
Penny Lane maintains clearly defined job descriptions for all roles, including Youth Partner, Parent Partner, Facilitator, Family Specialist, Clinical Supervisor, Fidelity Coach, and HFW Supervisor/Manager.

Advancement structures are transparent and accessible, including:
Internal postings for five (5) business days prior to external recruitment
Career ladder pathways across program levels
Master’s practicum placement opportunities
Mentoring Program for new and emerging staff
Leadership development opportunities

Promotion pathways are inclusive and do not exclude individuals with lived experience. Parent Partners and Youth Partners are valued as essential team roles and are provided opportunities for growth and leadership engagement within the organization.

Wage Increases and Leadership Opportunities Without Position Change-
The agency provides mechanisms for financial and professional growth that do not require a formal position change, including:

Retention bonuses
Service time incentive program
Education reimbursement and CEU support
Bilingual pay differential
Specialized group supervision
Participation in committees (e.g., Racial Justice Committee)
Conference presentation and training facilitation opportunities
Peer recognition and incentive programs

These structures allow staff to expand leadership influence, increase earnings, and build expertise without leaving their current role.

Performance Management & Stability Monitoring-
Employee Development Performance (EDP) evaluations occur five months after hire or transfer and annually thereafter. Performance management aligns expectations with job descriptions and supports professional growth planning.

Primary source credential verification, licensure monitoring, and scope-of-practice oversight ensure workforce integrity and regulatory compliance.

Human Resources supports Talent Management, Health & Wellness initiatives, mentoring, and supervision structures that foster belonging, engagement, and retention within a heart-centered culture.

Organizational Culture & Retention-
Penny Lane promotes workforce cohesion and belonging through:

Heart-centered leadership philosophy
Core Gift Process training
Diversity Beyond the Basics training
Joint Commission Certification
Hybrid work models
Flexible scheduling
Recognition programs and incentives
Technology resources (laptop and phone provision)

These initiatives strengthen engagement, reduce burnout, and sustain workforce stability.

Through competitive compensation, structured advancement pathways, manageable workload oversight, professional development incentives, inclusive hiring practices, and leadership accessibility, Penny Lane operationalizes workforce stability as a foundational strategy to ensure sustained HFW fidelity and high-quality service delivery.

Policy & Appendix References:

Human Resources & Hiring
701 Education, Licensure, Registration, and Certification Verification
702 Verification of Staff Credentials
713 High-Fidelity Wraparound (HFW) Team Staffing
103 Penny Lane Wraparound Organizational Chart

Workforce Development & Retention
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Performance Management
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)

Service Delivery & Workload Oversight
413 High-Fidelity Wraparound Service Delivery
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage

Appendix:
#45 PL MH Flyer
#41 Agency Overview HR

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: (2) HFW staff are trained internally by utilizing the Statewide Standardized Foundational HFW curriculum. Prior to counties and providers utilizing the curriculum internally, they should (1) attend the Wraparound 101: Foundations for Fidelity training, available through the UC Davis RCFFP, (2) attend the Wraparound 101: Foundations for Fidelity Training for Trainers, available through UC Davis RCFFP, and (3) download the Wraparound 101: Foundations for Fidelity Training curriculum, or

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers maintains a structured, multi-tiered High-Fidelity Wraparound (HFW) Training Plan designed to ensure staff competency, leadership alignment, and fidelity to California Wraparound Standards. The training framework incorporates initial onboarding, ongoing professional development, annual booster trainings, and role-specific learning pathways for all staff, including Clinical Supervisors and Wraparound Supervisors/Managers.

Initial HFW Training:
All newly hired HFW staff complete formal foundational training prior to assuming independent case responsibility. Penny Lane utilizes structured internal Wraparound 101 training aligned with HFW principles, phases, activities, and fidelity standards. Foundational training includes:

Overview of HFW philosophy, values, and principles
Detailed instruction on the four phases of Wraparound
Child and Family Team facilitation
Strengths-based and needs-driven planning
Crisis and safety planning
Documentation standards
Cultural responsiveness and family voice

New staff also receive shadowing opportunities, supervised field exposure, and coaching prior to carrying a full caseload.

Ongoing General and Role-Specific Training:
All staff participate in ongoing training in both general Wraparound practice and role-specific competencies. Learning modalities include:

Formal in-service trainings
Supervisory coaching
Internal case reviews
Peer shadowing
Team-based learning meetings
Fidelity tool review (CANS, TOM, LOCUS, WFI)

Role-specific development ensures Facilitators, Parent Partners, Clinicians, Supervisors, and QA staff receive targeted skill enhancement aligned with their responsibilities.

Annual Booster Trainings:
At minimum annually, staff receive booster training in general Wraparound principles and in their designated role. Booster trainings reinforce fidelity expectations, address emerging practice trends, integrate policy updates, and respond to identified CQI data trends.

Supervisor & Leadership Development:
Clinical Supervisors and HFW Supervisors/Managers attend general Wraparound foundational training and receive additional leadership-focused training that includes:

Fidelity monitoring and coaching strategies
Reflective supervision practices
Data-driven performance oversight
Crisis management leadership
Workforce development and staff engagement
Quality improvement processes

Leadership development ensures supervisors can model, coach, and reinforce HFW principles consistently across teams.

ICWA, Tribal Sovereignty & Specialized Population Training:
All staff receive training on the Indian Child Welfare Act (ICWA) and Tribal sovereignty, including annual ICWA refresher training. Training reinforces legal compliance, respectful Tribal collaboration, and culturally rooted service delivery.

Mechanisms are in place to identify and provide specialized training responsive to populations with unique needs, including but not limited to:

LGBTQ+ youth
Commercially sexually exploited youth
Justice-involved youth
Youth with complex trauma
Developmental disabilities
Cultural and linguistic minority communities

Training priorities are informed by demographic data, service trends, and CQI findings.

Continuous Evaluation of Training Effectiveness:
Training participation and effectiveness are monitored through supervision feedback, fidelity review outcomes, performance evaluations, and CQI analysis. Identified skill gaps inform future training development and booster priorities.

Through structured onboarding, ongoing skill development, annual reinforcement, leadership training, ICWA compliance education, and responsive population-specific training, Penny Lane operationalizes a high-fidelity workforce development model aligned with HFW standards.

Policy & Appendix References:

Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Supervision & Performance Oversight
602 Supervisor-Led Continuous Quality & Performance Improvement
601 Performance Improvement (HFW)
412 Internal High-Fidelity Wraparound Case Reviews

Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS
26 Wraparound Fidelity Index

Cultural & Linguistic Responsiveness
210 Language Access & Cultural and Linguistic Responsiveness

Appendix Forms
#42 Penny Lane Wraparound 101 Workbook
#40 Wraparound Training Materials
#26 Wraparound Fidelity Index
#36 TOM
#43 CANS

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers administers its High-Fidelity Wraparound (HFW) Training Plan in active collaboration with youth, families, peer partners, and community stakeholders to ensure that training reflects lived experience, strengthens system alignment, and promotes authentic Family Voice and Choice. Training delivery is not limited to internal instruction; it is structured as a shared learning environment that integrates multiple perspectives within the Children’s System of Care.

Youth, caregivers, and Parent Partners with current or prior Wraparound experience are meaningfully incorporated into required Wraparound trainings. Their participation may include:

Co-facilitating portions of foundational and booster trainings
Sharing lived experience narratives
Participating in panel discussions
Contributing to scenario-based learning activities
Providing feedback on practice relevance and cultural responsiveness

Their inclusion reinforces the principle that families are equal partners in HFW implementation and strengthens staff understanding of family-centered engagement practices.

Community partners—including representatives from child welfare, probation, education, regional centers, behavioral health, community-based organizations, and when applicable, Tribal representatives are invited to attend Wraparound trainings or are offered targeted training opportunities. These trainings ensure cross-system partners:

Understand HFW principles, phases, and team roles
Clarify expectations for Child and Family Team participation
Strengthen coordinated care practices
Align service planning across systems
Enhance cultural responsiveness within collaborative environments

Outreach efforts are made to promote training opportunities across system partners to support cohesive and comprehensive service delivery. Training invitations are structured to encourage shared learning and reinforce a common understanding of HFW standards.

Supervisors and leadership evaluate training participation, collect feedback from family and community contributors, and integrate insights into Continuous Quality Improvement (CQI) processes. This collaborative training approach strengthens interagency alignment, reinforces family-driven practice, and enhances fidelity across the system of care.

Through meaningful incorporation of youth and families into training delivery, proactive engagement of community partners, and structured cross-system learning opportunities, Penny Lane operationalizes inclusive workforce development as a measurable HFW implementation standard.

Policy & Appendix References:

Workforce Training & Development
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training
718 Indian Child Welfare Act (ICWA) Annual Training

Parent & Family Engagement
414 Parent Education and Training
415 Parent Support & Advocacy (High-Fidelity Wraparound Aligned)

Interagency Collaboration
411 Coordinated Care
413 High-Fidelity Wraparound Service Delivery

Quality Improvement & Feedback
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement

Cultural & Community Engagement
210 Language Access & Cultural and Linguistic Responsiveness

Appendix Forms
#40 Wraparound Training Materials
#42 Penny Lane Wraparound 101 Workbook
#26 Wraparound Fidelity Index
#36 TOM

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers utilizes an apprenticeship-based workforce development model to ensure High-Fidelity Wraparound (HFW) staff develop competency in Wraparound values, principles, phases, and activities prior to assuming independent case responsibility. The apprenticeship process emphasizes practical skill development, reflective learning, and application of HFW philosophy within real-world team environments.

Initial Apprenticeship Model-
All newly hired HFW staff participate in a structured onboarding and apprenticeship period that includes:
Foundational Wraparound 101 training
Shadowing experienced facilitators and team members
Participation in Child and Family Team (CFT) meetings
Supervised development of Strengths, Needs, Culture Discovery documents
Guided development of Plans of Care and Crisis & Safety Plans
Training on flex fund utilization aligned with individualized planning standards

The apprenticeship covers core competencies, including family-driven facilitation, strengths-based planning, needs prioritization, crisis planning, coordinated care, and culturally responsive practice. Specific instruction is provided on the appropriate and effective use of flexible funds to meet individualized needs, including approval criteria, sustainability considerations, and documentation requirements.

New staff demonstrate competency through supervised practice, documentation review, and structured supervisory feedback before transitioning to full caseload responsibilities.

Ongoing Coaching and Reflective Supervision-
Ongoing coaching reinforces fidelity to HFW principles and continuous skill development. Supervisors provide:
Regular individual supervision sessions
Case consultation and reflective practice discussions
Real-time crisis consultation
Documentation review and feedback
Fidelity monitoring using tools such as CANS, TOM, and internal review instruments

Coaching emphasizes persistence, collaboration, strengths-based facilitation, and flexible problem-solving consistent with HFW values.

24/7 Supervisory Access-
Recognizing the intensity and crisis-responsive nature of HFW, leadership ensures that staff have access to supervisory support on a 24/7 basis when necessary. This includes:

Defined after-hours escalation protocols-
On-call supervisory structures
Crisis consultation availability
Leadership accessibility for urgent decision-making

This infrastructure reflects the flexible scheduling and crisis response needs of families and supports staff in making timely, aligned, and informed decisions during high-acuity situations.

Continuous Quality Improvement-
Supervisory structures are monitored through Continuous Quality Improvement (CQI) processes to ensure coaching effectiveness, responsiveness, and alignment with HFW standards. Workforce development data informs refinement of apprenticeship components and leadership coaching strategies.

Through structured apprenticeship pathways, ongoing reflective supervision, flex fund competency development, and 24/7 leadership accessibility, Penny Lane operationalizes workforce coaching and support as a foundational HFW implementation standard.

Policy & Appendix References:

Workforce Development & Apprenticeship
703 Workforce Training & Competency Development
704 New Hire Training & Onboarding
719 Wraparound 101 – HFW Foundational Training

Flexible Funds Training
312 Flex Funds

Supervision & Coaching
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews
713 High-Fidelity Wraparound (HFW) Team Staffing

Crisis Response & 24/7 Access
407 Crisis Response and Reporting
408 Crisis Response & After-Hours Coverage

Fidelity & Outcome Tools
714 CANS
715 TOM
716 LOCUS

Appendix Forms
#42 Penny Lane Wraparound 101 Workbook
#29 Flex Fund Request Form
#34 Supervisor Review Tool (SPRT)
#26 Wraparound Fidelity Index

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

Penny Lane Centers ensures that collected data is systematically analyzed and utilized to strengthen practice at the youth and family level, enhance overall program effectiveness, and inform system-level improvements that impact High-Fidelity Wraparound (HFW) implementation. Data is embedded within supervision, leadership oversight, and Continuous Quality Improvement (CQI) processes to promote accountability and ongoing refinement of service delivery.

At the practice level, data from IP-CANS, TOM, WFI, LOCUS, service activity tracking, crisis frequency, placement stability, educational outcomes, and flexible fund utilization is reviewed to assess progress and service alignment. Supervisors provide timely feedback to staff based on case-level data and performance reports. Data trends inform individualized coaching conversations, documentation review, fidelity monitoring, and targeted workforce development planning. Training needs are identified based on performance patterns, outcome gaps, and fidelity findings.

At the program level, aggregate data is analyzed to evaluate service intensity, timeliness of engagement, Plan of Care quality, discharge patterns, crisis utilization, hospitalization frequency, placement stability, and family satisfaction trends. Leadership uses these findings to adjust staffing structures, refine policies, enhance cross-system coordination, and improve access to resources. CQI meetings incorporate quantitative and qualitative data to drive measurable program improvements.

At the system level, data is utilized to identify structural or interagency barriers affecting families. Patterns such as service delays, resource shortages, funding constraints, or cross-system communication challenges are elevated to the Community Leadership Team (CLT) and relevant interagency partners. This ensures that data informs broader system advocacy, cross-agency collaboration, and policy refinement efforts.

Formal processes are in place to review data regularly, communicate findings across leadership and supervisory structures, and integrate feedback into operational planning. Data-informed decision-making reinforces fidelity to HFW principles, strengthens workforce competence, and supports sustainable system improvement.

Through structured data monitoring, supervisory feedback loops, CQI analysis, and system-level communication channels, Penny Lane operationalizes data utilization as a core governance and implementation standard within the HFW program.

Policy & Appendix References:

Outcomes & Data Monitoring
604 Outcomes Measurement, Monitoring, and Continuous Quality Improvement
714 CANS
715 TOM
716 LOCUS

Performance & Program Improvement
601 Performance Improvement (HFW)
602 Supervisor-Led Continuous Quality & Performance Improvement
412 Internal High-Fidelity Wraparound Case Reviews

Service Delivery & Documentation
502 Progress Notes and Service Documentation
413 High-Fidelity Wraparound Service Delivery

Interagency Collaboration
411 Coordinated Care

Appendix Forms
#26 Wraparound Fidelity Index
#36 TOM
#39/43 CANS
#34 Supervisor Review Tool (SPRT)

Date Started: January 6, 2026

Date Submitted: February 24, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

At Casa Esperanza, we prioritize effective engagement by adhering to California’s High-Fidelity Wraparound (HFW) fidelity indicators, which guide our interactions with families and enhance the internal coherence of our organization. This commitment is reflected in a series of structured processes and documentation:
a. The HFW Manager Supervisor meticulously monitors the initial contact made following a referral, as outlined in the Treatment Tracker on page 1. This ensures that families receive timely support from the outset.
b. The completion of the Plan of Care is another critical milestone tracked by the HFW Manager Supervisor; this documentation, referenced in the Treatment Tracker, page 1, confirms that families have a clear, actionable plan.
c. Regular reviews of the Plan of Care during team meetings are recorded by the HFW Manager Supervisor, ensuring that all team members remain aligned and engaged in the youth’s care process (see Treatment Tracker, page 1).
d. Updates to the Plan of Care are systematically monitored by the HFW Manager Supervisor, reinforcing our commitment to adapting to the evolving needs of each family (see Treatment Tracker, page 1).
e. To foster transparency and collaboration, the HFW Manager Supervisor discusses the Treatment Tracker with staff and supervisors every week during staff meetings; these discussions occur in reference to Treatment Tracker, page 1.
f. Our dedicated staff members receive specialized training from the Fidelity Coach, focusing on impactful engagement and team-building exercises designed to enrich interpersonal connections; details can be found in Engagement and Team Building Activities, pages 1-2.

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

We believe that effective implementation of the HFW model hinges on integrating family perspectives that honor their values, cultural backgrounds, and unique expertise. This input is actively sought during meetings and visits, with comprehensive documentation maintained in the youth’s case file, as evidenced by the following processes:
a. The HFW Facilitator actively elicits valuable insights from youth and families, gathering their perspectives through the Strengths-Needs-Culture-Discovery Form, pages 1-2, to ensure their voices are at the forefront of care.
b. The HFW Facilitator diligently works to ascertain the family’s core values and perspectives, creating a holistic understanding of their needs as seen in the Strengths-Needs-Culture-Discovery Form, pages 2-3.
c. Observations made by the HFW Fidelity Coach during meetings are documented to provide constructive feedback to staff, ensuring continual growth and adherence to best practices (see Coaching Observation Form, page 1).
d. Feedback from youth and families is collected through satisfaction surveys, overseen by the HFW Manager Supervisor, allowing us to assess the effectiveness of our approaches and make necessary adjustments (see Youth and Family Satisfaction Surveys, page 1).

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Our approach is grounded in the belief that each individual has strengths. The Manager takes the lead in developing a strengths inventory form that reflects the unique strengths identified through the IP-CANS assessment.
a. The HFW Facilitator conducts an insightful strengths inventory for each team member, as documented in the Team Strengths Inventory, page 1, fostering a culture of recognition and empowerment.
b. The HFW Family Specialist applies insights gained from the IP-CANS assessment to underline the family’s strengths, as detailed on page 1 of the IP-CANS.
c. Staff members partake in specialized training that emphasizes solution-focused, strength-based methodologies; this can be found in our Training Curriculum, page 1.
d. The HFW Manager Supervisor continually collects feedback from the youth and family through satisfaction surveys, ensuring that our services resonate well with those we support (see Youth and Family Satisfaction Surveys, page 1).

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Using insights from both the Strengths Inventory and the IP-CANS, we work collaboratively with families to identify and document their perceived needs.
a. The HFW Facilitator utilizes identified needs to set and prioritize goals, as outlined in the Strengths-Needs-Culture-Discovery Form, page 3, ensuring a focused approach to support.
b. The HFW Fidelity Coach conducts training centered on needs-focused planning, enriching the skillset of our staff (see Training Curriculum, page 1).
c. The HFW Facilitator carefully reviews the documented needs from the IP-CANS, as noted on page 1, to ensure they are at the forefront of our planning efforts.
d. Transition planning is meticulously developed based on feedback collected during Team meetings, emphasizing collaborative engagement (see Wraparound Team Meeting Template, page 1).

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

At Casa Esperanza, we are unwavering in our commitment to crafting individualized plans that reflect the unique circumstances and aspirations of each youth and their family.
a. The HFW Facilitator leverages the Plan of Care to pinpoint personalized strategies tailored to meet the specific needs of the youth and family (see Plan of Care, page 2).
b. Ongoing training provided by the HFW Fidelity Coach focuses on implementing flexible and individualized strategies, ensuring responsiveness to family preferences (see Training Curriculum, page 1).
c. The HFW Fidelity Coach offers continuous coaching to staff, emphasizing the importance of customizing the HFW process and Plan of Care to create a supportive environment (see Coaching Observation Form, page 1).
d. Monthly chart audits conducted by the HFW Clinical Supervisor serve to rigorously review the elements of the Plan of Care, maintaining our standards of care and quality assurance (see HFW Chart Audit, page 1).
e. Feedback from youth and families is consistently gathered through satisfaction surveys, overseen by the HFW Manager Supervisor, reinforcing our dedication to improvement and responsiveness (see Youth and Family Satisfaction Surveys, page 1).

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor plays a pivotal role in cultivating a comprehensive inventory of natural and community support resources available to families in need. This comprehensive catalog outlines the various types of support that families currently use or may require over time, covering essential domains such as health, housing, recreation, financial assistance, nutrition, legal affairs, communication, spiritual needs, education, and other critical areas of life.
a. The HFW Facilitator is responsible for compiling the support inventory for each family, ensuring it is updated monthly. This is documented through the Natural Supports Inventory Form, which provides a clear snapshot of available resources.
b. To empower staff, the HFW Fidelity Coach delivers specialized training focused on the engagement and integration of natural supports, as outlined in the Training Curriculum, page 2.
c. Maintaining high standards of care, the HFW Clinical Supervisor conducts monthly chart audits to thoroughly review the various elements of the plan of care, ensuring alignment with best practices; refer to the HFW Chart Audit on page 1 for further details.
d. Central to fostering improvement, the HFW Manager Supervisor actively seeks feedback from youth and families through satisfaction surveys designed to capture their experiences and perspectives; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

In creating a personalized Plan of Care, the HFW Facilitator collaborates closely with the youth and their family members to explore their unique cultural perspectives. This rich discussion encompasses various dimensions, including language, spirituality, religion, rituals, customs, food preferences, leisure activities, traditions, beliefs, and values, ensuring that every facet of their identity is honored.
a. The HFW Facilitator diligently elicits information that encapsulates the cultural perspectives of the youth and family, utilizing the Strengths-Needs-Culture-Discovery Form, page 3 to guide these conversations.
b. To enhance the skills of the staff, the HFW Fidelity Coach offers comprehensive training on effectively eliciting and incorporating family and cultural insights into both planning and service delivery, as detailed in the Training Curriculum, page 2.
c. Continuous improvement is achieved through feedback mechanisms, where the HFW Manager Supervisor collects valuable insights from youth and families via satisfaction surveys; refer to Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

The team planning process is marked by collaboration, as team agreements are developed in partnership with each youth and their family. The HFW Facilitator works shoulder to shoulder with them, weaving in input from the youth, their family, and their support network to create a meaningful agreement.
a. As a part of the engagement process, the HFW Facilitator formulates team agreements for each client’s HFW team, as documented in the Team Agreement form on page 1.
b. Feedback is essential for growth, and the HFW Manager Supervisor gathers insights from youth and families through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1 for more information.
c. The HFW Manager Supervisor also plays a crucial role in providing monthly updates on family feedback to the staff, utilizing the CQI Indicators Form on page 1.
d. To maintain accountability and quality, the HFW Clinical Supervisor conducts meticulous monthly chart audits, reviewing both the elements of the plan of care and the minutes from team meetings; see the HFW Chart Audit, page 1.

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

In a commitment to measurable progress, the Facilitator meticulously crafts a Plan of Care (POC) featuring clear, measurable, achievable, relevant, and time-bound strategies. To ensure accountability, action items are assigned to team members, along with specific deadlines, which are consistently tracked in HFW meetings until they are fully completed.
a. The HFW Facilitator integrates quantifiable strategies, benchmarks, time-oriented results, and individual strengths into the plan of care, as illustrated on pages 2-3 of the Plan of Care.
b. Weekly tracking of action items is the standard for the HFW Facilitator, ensuring progress is monitored, and adjustments are made promptly; refer to the Plan of Care, pages 2-3.
c. The HFW Facilitator is also empowered to adjust and tailor the Plan of Care form, adapting to any necessary changes in circumstances, as noted on pages 2-3 of the Plan of Care.
d. The HFW Family Specialist diligently completes the IP-CANS assessment and shares its findings at the team meeting; see IP-CANS, page 1 for details.
e. Information from the IP-CANS is thoughtfully incorporated into the Plan of Care, enhancing its relevance; see Plan of Care, pages 2-3.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW team remains steadfast in collaboration with youth and families, especially when encountering setbacks or limited progress. The HFW Manager Supervisor leads weekly staff meetings dedicated to reviewing the status and progress of each family, fostering a culture of accountability and support. For those facing challenges, the HFW staff conducts a thorough analysis of the underlying causes and develops actionable plans to overcome these barriers.
a. The HFW Fidelity Coach observes team dynamics and provides constructive feedback when challenges arise, utilizing the insights gathered in the Coaching Observation Form on page 2.
b. To facilitate access to resources, the HFW Manager Supervisor supplies protocols for reaching services that can assist families, detailed in the Fidelity Indicators policy on page 4.
c. Staff training is crucial, and the HFW Fidelity Coach equips team members with skills in safety planning, conflict resolution, and brainstorming techniques, as outlined in the Training Curriculum, pages 2-3.

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Understanding the significance of seamless transitions, HFW staff are proactive in preventing service gaps. Should a youth or family miss a meeting or activity, the HFW Family Specialist or HFW Parent Partner promptly reaches out to reconnect and reschedule, ensuring continuous support.
a. The HFW team is dedicated to facilitating smooth transitions, which are characterized by warm hand-offs to ongoing service providers, as described in the Transition Plan on page 1.
b. In partnership with the active participation of the youth and family, the HFW team celebrates successes through thoughtfully developed plans for recognition, as documented in the Commencement and Celebration of Success Plan on page 1.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will play a pivotal role in gathering insights and feedback regarding the satisfaction levels of youth and their families. This information can be meticulously documented and reviewed in the Treatment Tracker (tab 2) and detailed in the Expected Outcomes policy on page 1.

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist is tasked with the critical responsibility of tracking and assessing information on the functioning of youth in academic environments. Relevant data can be meticulously accessed in the Treatment Tracker, tab 2, along with the guidelines provided in the Expected Outcomes policy on page 1.

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

Under the supervision of the HFW Manager Supervisor, the HFW Facilitator and Family Specialist will diligently assess and evaluate the youth’s engagement and functioning within community settings. Comprehensive information can be found in the Treatment Tracker, tab 2, complemented by the Expected Outcomes policy articulated on page 2.

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will be responsible for collecting detailed information about interpersonal functioning using the IP-CANS assessment. Essential data and documentation should be referenced in the Treatment Tracker, tab 2, alongside directives specified in the Expected Outcomes policy on page 2.

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will actively gather insights that reflect increased caregiver confidence, a vital component for supporting youth. This information should be carefully cataloged in the Treatment Tracker, tab 2, in conjunction with the guidelines presented in the Expected Outcomes policy on page 2.

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will thoroughly monitor and evaluate the youth’s placement status monthly, ensuring it aligns to maintain a stable, least restrictive living environment. Updates or changes regarding a new placement will be promptly documented in the Treatment Tracker, tab 2, and reinforced in the Expected Outcomes policy on page 3.

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

To enhance the quality of care, the HFW Manager Supervisor will meticulously track the youth’s admissions to inpatient facilities monthly. This ongoing monitoring will be documented in the Treatment Tracker, tab 2, and is supported by the criteria outlined in the Expected Outcomes policy on page 3.

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will consistently oversee and evaluate the frequency of crisis visits experienced by the youth, ensuring a proactive approach to crisis management. Important insights regarding these visits can be found in the Treatment Tracker, tab 2, as well as in the Expected Outcomes policy on page 3.

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will closely monitor the youth’s progress and transition dates, ensuring a smooth and positive exit from the HFW program. This critical information regarding the exit process can be effectively tracked in the Treatment Tracker, tab 2, and detailed in the Expected Outcomes policy on page 3.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Upon the youth’s admission into the Home and Family Wellness (HFW) program, both the young individual and their family are welcomed through a comprehensive orientation. This session serves as a vital introduction, outlining the program’s core principles and the crucial legal and ethical considerations relevant to the family’s well-being. The orientation also clarifies the distinct roles of each team member, emphasizes the importance of natural supports—including connections to relevant tribal resources, when applicable—and addresses other critical aspects necessary for a successful journey within the HFW program.
a. At the commencement of the engagement phase, the HFW Manager Supervisor personally guides the orientation, elucidating the foundational principles and developmental phases integral to HFW. Refer to the Orientation Format on pages 1-3 for detailed insights.
b. During the initial engagement phase, the HFW Manager Supervisor explicates the legal and ethical considerations pertinent to the HFW program. More information can be found in the Orientation Format on pages 1-3.
c. In cases involving Indian children, the HFW Manager Supervisor offers additional orientation on the specific roles of team members. Refer to Orientation Format, pages 1-3, for comprehensive details.

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

Recognizing that youths entering the HFW program may face various safety concerns—including, but not limited to, tendencies toward runaway behavior, suicidal or homicidal thoughts, or other significant risk factors—a proactive initial crisis plan is developed before more formalized crisis and safety plans.
a. During the engagement phase, the HFW Facilitator or designated representative engages in open dialogue regarding potential crisis and safety concerns. Detailed procedures are available in the Crisis Plan on page 1.
b. The HFW Facilitator or designee is tasked with crafting a thoughtful crisis plan that equips both the youth and their family with essential resources and strategies to navigate challenges effectively during the engagement phase. Reference the Crisis Plan on page 1 for specifics.
c. The HFW Facilitator or designee provides crucial information concerning the crisis plan, including how to access a 24/7 response service, ensuring support is readily available when needed. See the Crisis Plan on page 1 for further details.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

Throughout the engagement process, the HFW Facilitator takes the time to meet with the family, creating a safe space to discuss their inherent strengths, pressing needs, cultural values, and overarching family vision.
a. The HFW Facilitator collaborates with each family to co-create a compelling Family Vision, capturing their aspirations and dreams. For more details, refer to the Strengths-Needs-Culture-Discovery form on page 3.
b. Within 90 days of the family’s entry into the program, the HFW Facilitator diligently develops a comprehensive plan that encompasses the family’s strengths, needs, cultural context, and broader vision. More information can be found in the Strengths-Needs-Culture-Discovery form on page 5.

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

During the engagement phase, the HFW Facilitator undertakes the important task of completing the Natural Supports Inventory. This process involves a collaborative effort among the youth, their family, and HFW team members to evaluate and identify natural supports within their networks and determine which can actively contribute to the team process.
a. Each youth and family is given a tailored Natural Supports Inventory by the HFW Facilitator, designed to include all relevant supports. Refer to the Natural Supports Inventory on page 1 for specifics.
b. In this collaborative setting, the HFW Facilitator identifies key partners from the Children’s System of Care to be included on the HFW team. More details can be found in the Natural Supports Inventory on page 1.
c. The HFW Facilitator carefully identifies potential team members and delineates their respective roles, ensuring clarity and purpose. See the Natural Supports Inventory on page 1 for additional information.
d. The HFW Facilitator meticulously documents all team-building activities, promoting transparency and cohesion within the group. Detailed records are available in the Wraparound Team Minutes on page 1.

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Meetings are scheduled with careful consideration of the availability and circumstances of both the youth and their families. Casa Esperanza prioritizes flexibility, encouraging its HFW staff to adapt their working hours, including evenings or weekends, to facilitate participation from both youth and families during these crucial meetings.
a. The HFW staff acknowledge their responsibility for maintaining flexibility in their working hours and practices. Comprehensive insights are available in the Facilitator Job Description on page 1.
b. All HFW staff undergo training that equips them with effective strategies to interact flexibly with the youth and families, ensuring inclusivity and accessibility. Refer to the Training Curriculum on page 1 for detailed information.

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Before formulating the HFW Plan of Care, it is essential to complete a series of collaborative tasks, including team agreements, a comprehensive inventory of team strengths, and a clear mission statement, in partnership with each family. These documents are meticulously recorded in the youth’s file, ensuring that every family member’s unique strengths identified during the engagement process are accurately reflected and updated as further strengths emerge.
a. The HFW Facilitator takes the lead in creating the team agreements, strengths inventory, and mission statement in collaboration with each youth and their family. For detailed guidance, refer to the Team Strengths Inventory, Team Agreement Form, and Team Mission Statement, all found on page
b. Throughout the HFW process, the HFW Facilitator remains vigilant in updating the strengths of the youth and family, as recorded in the Team Strengths Inventory on page 1.

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

In the lead-up to crafting the HFW Plan of Care, it is crucial to identify, articulate, and prioritize the underlying needs specific to each family. These identified needs are documented in the youth’s file. From these needs, measurable goals and outcomes are derived, emphasizing a strength-based rather than a deficit-focused approach to goal setting.
a. The HFW Facilitator is responsible for elucidating the underlying needs of the youth and family, using the Strengths-Needs-Culture-Discovery Form found on page 3 as a resource.
b. Measurable goals and outcomes are anchored in the recognized needs of the youth and family, as outlined on page 1 of the Measurable Goals and Outcomes Form.
c. Engaging the entire HFW team in the goal-setting process is a pivotal aspect of the approach, as documented in the Measurable Goals and Outcomes Form on page 1.
d. The HFW Facilitator conducts brainstorming sessions designed to foster creativity and collaboration in identifying impactful goals and outcomes, as noted in the Wraparound Team Minutes on page 1.
e. To enhance the team’s skills in Needs Focused Planning, the HFW Fidelity Coach provides targeted training, detailed in the Training Curriculum on page 1.
f. The development of the Plan of Care is inherently a team-based effort, fostering input and collaboration as documented in the Wraparound Team Minutes on page 1.

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Plan of Care is a comprehensive document that intricately weaves together the goals and objectives outlined by team members, ensuring it is tailored to the specific needs of the youth and family. This plan is meticulously documented in the youth’s file, circulated to all team members, and adheres to established effectiveness criteria.
a. The HFW Fidelity Coach provides training and coaching on effective team engagement to strengthen the collaborative process, as referenced in the Coach Observation notes on page 2 and the Training Curriculum on page 1.
b. The HFW Facilitator ensures that the goals and objectives align with the standards set forth by the Children’s System of Care, which is documented in the Plan of Care on page 1.
c. A complete version of the Plan of Care, encompassing all requisite elements, is shared with team members, referenced through the Plan of Care on page 1 and the Strengths-Needs-Culture-Discovery Form on page 5.
d. To maintain a high standard of care, the HFW Manager Supervisor conducts monthly audits of the chart for updates to the Plan of Care, as outlined in the HFW Chart Audit on page 1.

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

To prepare for potential challenges, individualized Crisis and Safety Plans are crafted and documented in the youth’s file. These plans are designed to specifically address safety concerns, identify high-risk situations, and outline crises, alongside proactive and reactive strategies selected collaboratively with family members. Importantly, the plans include clear guidance on who to contact for 24/7 support.
a. The development of the Crisis and Safety Plan is undertaken by the HFW Facilitator or their designee, based on insights gleaned from the initial Crisis Plan, as indicated in the Crisis and Safety Plan on page 1.
b. Input and feedback from the HFW team play a crucial role in crafting this plan, ensuring it reflects the collective knowledge and perspectives of all members, as documented in the Crisis and Safety Plan on page 1.
c. To ensure ongoing relevance and effectiveness, the HFW Facilitator reviews the Crisis and Safety Plan monthly or as necessary, affirming its adaptability to the family’s evolving needs, as noted in the Crisis and Safety Plan on page 1.

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator plays a pivotal role in guiding the team’s execution of the Plan of Care, ensuring that every component is realized effectively. Once the Plan of Care receives thorough review and approval, and each team member has been provided with their individual copies, the HFW Facilitator diligently monitors the various assignments and action items that emerge from this comprehensive plan.
a. The HFW Facilitator creates a collaborative environment where team members can engage in thoughtful discussions about the strategies outlined in the Plan of Care. This includes facilitating modifications to action items when necessary, as detailed in the Wraparound Team Minutes, page 1.
b. Training sessions led by the HFW Fidelity Coach equip the team with the knowledge and skills required to implement and adapt the Plan of Care effectively, ensuring that everyone is aligned and prepared for their roles, as illustrated in the Training Curriculum, page 1.

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes.

Description of Practice, Name of Supporting Documentation and Page #:

In a structured team meeting, the HFW team dedicates time to a thorough review of the Plan of Care, which encompasses evaluating strategies, assessing progress, and addressing action items. The HFW Facilitator plays a critical role in identifying emerging needs during this collaborative session, making necessary adjustments to the Plan of Care, and developing new strategies and action items to address them.
a. During these meetings, the HFW Facilitator meticulously reviews strategies, progress, and action plans, ensuring that all team members are informed and engaged, as recorded in the Wraparound Team Minutes, page 1.
b. The HFW Facilitator takes the lead in adapting the plan to meet newly identified needs and acknowledges when established goals have been successfully achieved, as documented in the Wraparound Team Minutes, page 1.
c. A record of task completions and newly assigned responsibilities is meticulously maintained by the HFW Facilitator, ensuring accountability and clarity, as seen in the Wraparound Team Minutes, page 1.
d. To accommodate changing circumstances, the HFW Facilitator updates necessary forms, ensuring they align with the current needs of the team, as noted in the Wraparound Team Minutes, page 1.

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator actively fosters a sense of unity and trust within the team by consistently utilizing team agreements throughout all phases of the HFW process. These agreements are regularly revisited with team members to incorporate necessary updates and are prominently presented during team meetings.
a. The team agreements serve as a foundational tool at HFW Team Meetings, reinforcing shared values and expectations, as referred to in the Team Agreement Form, page 1.
b. The HFW Fidelity Coach provides effective training on building high-functioning teams, equipping team members with the skills to enhance collaboration and cohesion, as described in the Training Curriculum, pages 3 and 4.
c. The HFW Facilitator closely monitors the engagement and involvement of natural supports, ensuring that they are effectively integrated into the team process and documented in the Natural Supports Inventory, page 1.
d. To support the onboarding of new members, the HFW Facilitator utilizes the Orientation Format, ensuring that all newcomers are fully informed and integrated into the HFW process, as detailed in the Orientation Format, page 1.

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

The High-Fidelity Wraparound (HFW) team, consisting of the youth, family members, and a blend of formal and informal support systems, collaborates to assess whether the youth and family have successfully met the goals outlined in the HFW Plan of Care. This assessment is grounded in specific benchmarks and indicators that the youth and family previously identified and agreed upon within the Plan of Care.
a. The HFW Facilitator meticulously utilizes these established benchmarks from the Plan of Care to evaluate the readiness of the youth and family for transition; consult the Plan of Care on page 2 for detailed reference.
b. Drawing on insights from the family and the youth’s ongoing needs post-program, the HFW Facilitator crafts a comprehensive Transition Plan; see Transition Plan on page 1 for specifics.
c. During a collaborative team meeting, the HFW Facilitator takes the lead in establishing the Transition Plan, ensuring that input from all team members is actively integrated; please refer to the Wraparound Team Minutes on page 1 for additional context.
d. The HFW Facilitator is responsible for identifying specific services and supports that have been verified as available to the youth and family following their transition out of the program; detailed information can be found in the Transition Plan on page 1.

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The existing Crisis and Safety Plan, originally constructed during the HFW process, will serve as a robust foundation for the HFW Facilitator to modify and adapt according to the evolving needs of the youth and family both during and after the transition. If necessary, a new Crisis and Safety Plan may be developed to address these needs better.
a. The HFW Facilitator or a designated team member will update the existing Crisis and Safety Plan to accurately reflect any new requirements or contacts; for a detailed outline, refer to the Crisis and Safety Plan on page 1.
b. The HFW Facilitator or designee will engage in a collaborative effort to develop or modify the Crisis and Safety Plan during team meetings, gathering valuable insights and contributions from all team members involved; see Wraparound Team Minutes on page 1 for further details.
c. Utilizing the Team Meeting as an important platform, the HFW Facilitator or designee will conduct a thorough review of the Crisis and Safety Plan with the youth, family, and team members to ensure collective understanding and collaboration; consult the Wraparound Team Minutes on page 1 for a recap of discussions.

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

The transitions experienced by youth and families mark significant milestones in their journey, signifying profound progress. Throughout their involvement in the HFW process, these individuals have reached noteworthy goals that deserve thoughtful acknowledgment and celebration.
a. The HFW Facilitator will utilize the Commencement and Celebration of Success framework to engage with the family, openly discussing their envisioned approach to celebrating these accomplishments; see the Commencement and Celebration of Success Plan on page 1 for guidance.
b. To ensure a fitting tribute to their journey, the HFW Facilitator actively involves staff and team members to align with the family’s needs while planning the celebration; refer to the Commencement and Celebration of Success Plan on page 1 for further instructions.

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

In our dedicated quest to enhance the well-being of our community, Casa Esperanza is excited to announce the establishment of a vibrant and engaging advisory board for the Healing Families and Youth (HFW) program. This board will comprise enthusiastic volunteers, including youth and their families who have either completed the HFW process or are currently navigating it.
a. The HFW Manager Supervisor will orchestrate regular advisory group meetings, fostering a collaborative environment to gather invaluable insights and perspectives from families; please refer to the Advisory Group Agenda on page 1.
b. These advisory group meetings will serve as pivotal opportunities for the HFW Manager Supervisor to solicit constructive feedback from families regarding the decision-making process, aiming to refine and enhance our services, workforce implementation, and policy frameworks; additional details can be found in the Advisory Group Agenda, page 1.

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

In a crucial role within our organization, the HFW Manager, Supervisor, or an appointed representative will serve as a vital liaison on the HFW Community Leadership Team.
a. The HFW Manager-Supervisor, or designated representative will actively participate in Community Leadership Meetings; for a more detailed overview, refer to the Manager-Supervisor Job Description on page 2.

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

At Casa Esperanza, we recognize the significance of having a well-equipped and resourceful HFW team that is more than capable of delivering exceptional services to all youth and their families transitioning from the Short-Term Residential Therapeutic Program (STRTP).
a. The HFW Manager Supervisor conducts thorough evaluations of each youth and family to assess their eligibility, ensuring that we accept individuals regardless of the severity or nature of their needs; specifics can be referenced in the Eligibility Criteria on page 2.
b. Furthermore, the HFW Manager Supervisor is committed to staffing the organization with an adequate and skilled team, ensuring that we provide the appropriate intensity and frequency of services needed to support our families effectively; see the Organizational Chart on page 1 for additional information.

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Our contracts are strategically designed to incorporate high-fidelity direct services and supports tailored to address the immediate, unique needs of both youth and their families. For further details, please refer to the Fiscal Supports Policy on page 1. These contracts also mandate comprehensive workforce development and staffing, delineating specific roles and functions critical to our mission (as outlined in the Fiscal Supports Policy on page 1). Furthermore, they emphasize the necessity of robust data collection and management systems to enhance service delivery.
a. The HFW Manager Supervisor diligently reviews all contracts to ensure that adequate funding is earmarked to support the diverse needs of youth and families, as highlighted in the Fiscal Supports Policy on page 1.
b. In an effort to foster a stable and effective environment for HFW activities, the HFW Manager Supervisor assesses contracts to guarantee sufficient hiring and retention of qualified staff, in accordance with the guidelines outlined in the Fiscal Supports Policy on page 1.
c. Additionally, the HFW Manager Supervisor evaluates contracts to confirm that they allocate necessary resources for data collection and management systems, as referenced in the Fiscal Supports Policy on page 1.

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Flexible funds are available and included as a part of the funding plan for HFW., (b) Processes to access and manage flexible funds are articulated and at a minimum include:
     1) Timely access for families that meet urgent needs
     2) A defined approval process that includes the evaluation criteria defined above
     3) A process to appeal denied requests which include communication with teams, youth, and families, regarding why the funds were denied.

Description of Practice, Name of Supporting Documentation and Page #:

Flex funds, specifically designated for the vulnerable youth and families served by Casa Esperanza, represent a vital and flexible component of the program’s financial framework.
a. The HFW Manager Supervisor is tasked with the careful allocation of flex funds, ensuring that resources are distributed in a manner that meets the needs of those we serve; refer to the Fiscal Supports Policy on pages 1-2 for more information.
b. To facilitate the effective utilization of these funds, the HFW Manager Supervisor undertakes the responsibility of training staff on the processes involved in disbursing flex funds and maintaining accurate documentation, as detailed in the Fiscal Supports Policy on pages 1-2.

Procedures Ensure: (a) Flex fund use and availability is documented and transparently communicated to funders and providers, including information regarding the amount, purpose and HFW team recommendation of the request., (b) Flex funds are pooled and held to meet the needs of all families served

Description of Practice, Name of Supporting Documentation and Page #:

The overall approval process for all flex fund requests falls under the meticulous oversight of the HFW Manager Supervisor.
a. The HFW Manager Supervisor guarantees that each flex fund request is thoroughly documented, maintaining transparency and accountability, as outlined in the Fiscal Supports Policy on page 2.
b. In a bid to ensure equitable access, the HFW Manager Supervisor manages the flex funds as a collective pool, making them available to all families in need, as emphasized in the Fiscal Supports Policy on page 2.

Procedures Ensure: (a) Flex funds and program resources are funded by braiding of available System of Care funding to ensure their availability, (b) When funding limitations exist in a single funding source, alternate funding options are explored or reliance on other funding sources is increased to fill gaps, (c) Requirements of any single funding source do not prohibit families from accessing flexible funds to meet their needs

Description of Practice, Name of Supporting Documentation and Page #:

In a concerted effort to uphold the accessibility of flex funds for every family, the Executive Director collaborates closely with the HFW Manager and Supervisor.
a. Together, they conduct a thorough review of the program’s funding and, when necessary, actively seek to secure additional flex funds to address any shortfall, as outlined in the Fiscal Supports Policy on pages 2-3.
b. Should they encounter any funding constraints, the Executive Director and HFW Manager Supervisor proactively reach out to the Community Leadership Team and their county liaison to explore solutions, as detailed in the Fiscal Supports Policy on pages 2-3.
c. Through their joint efforts, the Executive Director and HFW Manager Supervisor ensure that sufficient flex funds remain accessible to all families, fostering a supportive environment for those we serve, as specified in the Fiscal Supports Policy on pages 2-3.

Procedures Ensure: (a) The demographic composition of the population served is monitored and processes are in place to recruit/hire staff according to population needs, (b) When unable to recruit/hire according to cultural, racial, and linguistic needs, efforts are made to meet families’ needs for cultural representation through alternative means such as engaging natural or formal supports on the HFW team, (c) When unable to provide a staff member who can provide services in the family’s language, a translator or natural support person is utilized

Description of Practice, Name of Supporting Documentation and Page #:

At Casa Esperanza, the Executive Director diligently compiles extensive statistical data, providing insightful profiles of the youth residing at the facility. This framework serves as the foundation for cultivating a workforce that reflects the diverse demographics of the clients it serves.
a. The HFW Manager Supervisor plays a vital role in ensuring that our staff composition reflects the rich tapestry of the community’s demographics; refer to the Workforce Development and Human Resource Management Policy and Procedures, page 1, for more details.
b. When necessary, the HFW Manager Supervisor actively identifies and utilizes natural community supports to enhance cultural representation, reinforcing the values outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 1.
c. Recognizing the importance of clear communication, the HFW Manager Supervisor also provides essential translation services to bridge any language barriers, as detailed in the Workforce Development and Human Resource Management Policy and Procedures, page 1.

Leadership (including managers and supervisors) are committed to and have specific processes or structures in place to promote staff creativity and flexibility in providing services and meeting families’ needs: (a) Staff are trained on tribal sovereignty, traditions, and values, as well as how to ensure respectful communication, collaboration, and advocacy., (b) When serving an Indian child, HFW teams build partnerships with tribal representatives, encouraging participation in tribal traditions and ceremonies and understanding the value of services and supports that the Tribe can offer.

Description of Practice, Name of Supporting Documentation and Page #:

At Casa Esperanza, the HFW staff participates in specialized training focused on the Indian Child Welfare Act (ICWA). This training not only enhances their understanding of legal frameworks but also deepens their appreciation for Native American culture and heritage.
a. The HFW Manager Supervisor organizes comprehensive staff training sessions focused on the Indian Child Welfare Act, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 2.
b. In a commitment to culturally inclusive practices, the HFW Facilitator actively reaches out to local tribal partnerships and representatives, fostering collaborative engagements that weave together traditions and ceremonies into the HFW process; see Workforce Development and Human Resource Management Policy and Procedures, page 2, for further information.

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication, (d) Creating a clear sense of mission and compliance with HFW philosophy (principles, values, phases and activities)

Description of Practice, Name of Supporting Documentation and Page #:

The HFW program embraces a “Whatever It Takes” philosophy, emphasizing adaptability to meet the unique needs of each youth and their families. This innovative approach allows for creativity and flexibility in service delivery.
a. To uphold high standards of program quality, the Fidelity Coach provides in-depth training focused on methods of continuous improvement; see Training Curriculum, pages 4-6.
b. Additionally, the Fidelity Coach facilitates training on building Cohesion within teams; see Training Curriculum, pages 4-6 for more insights.
c. Open Communication is another crucial focal point of the training provided by the Fidelity Coach; see Training Curriculum, pages 4-6.
d. Lastly, trainings on Mission Alignment and Compliance with HFW Philosophy ensure that all staff members are oriented towards a shared vision; refer to Training Curriculum, pages 4-6 for details.

Procedures Ensure:(a) Each of the above roles or functions are met within the HFW program either through a unique position or through combining positions with clearly defined role descriptions and responsibilities., (b) The description and responsibilities of each role minimally includes the role purpose, functions and qualities (including skills, competencies and attributes) specific to each role or function. Examples of role descriptions can be found in the Wraparound Standards Toolkit, (c) Job descriptions for all required positions are specific to HFW and reflect the attitudes, skills, knowledge, and experience most likely to identify individuals who will be successful in the position., (d) The hiring process includes opportunities that allow candidates to demonstrate specific attitudes and skills essential to the position., (e) Employees are provided clear expectations for their performance and receive frequent feedback and coaching to support their success.

Description of Practice, Name of Supporting Documentation and Page #:

To maintain an exceptional standard of care and professionalism, every employee participates in a thorough 90-day performance evaluation. This assessment is crucial in determining whether staff members meet the evolving expectations and basic requirements of their positions.
a. The HFW program boasts uniquely defined roles, complete with clear descriptions and responsibilities; refer to the HFW Manager Supervisor Job Description, pages 1-2, for more information.
b. Job descriptions within the HFW framework detail the purpose, functions, and key qualities expected of each role; further specifics can be found in the HFW Facilitator Job Description, pages 1-2.
c. Following state guidelines, the HFW job descriptions are tailored specifically to the needs of the HFW program; see HFW Family Specialist Job Description, pages 1-2, for further reference.
d. The HFW Manager Supervisor provides valuable opportunities for staff to showcase their skills, as indicated in the Workforce Development and Human Resource Management Policy and Procedures, pages 3-4.
e. Ongoing feedback on performance is a regular practice, ensuring constructive dialogue between the HFW Manager, Supervisor, and team members, as emphasized in the Workforce Development and Human Resource Management Policy and Procedures, page 5.

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area, (b) Maintaining manageable workloads for staff, (c) Having clearly communicated and accessible promotion/advancement structures that are not prohibitive for those with lived experience, (d) Providing wage increases or leadership opportunities that do not require a position change to achieve

Description of Practice, Name of Supporting Documentation and Page #:

The Human Resources Department at Casa Esperanza is dedicated to building a robust, stable workforce by providing essential resources that enhance overall effectiveness.
a. To ensure competitive compensation, the HFW Manager Supervisor aligns wages with the cost of living and comparable agency salaries within the community, as detailed in the Workforce Development and Human Resource Management Policy and Procedures, page 6.
b. The HFW Manager Supervisor ensures that staffing levels are adequate to manage workloads effectively, promoting a balanced and supportive work environment as illustrated in the Organizational Chart, page 1.
c. Opportunities for professional growth, promotions, and advancement are actively announced, affirming a clear pathway for career development; see the Workforce Development and Human Resource Management Policy and Procedures, page 6.
d. Furthermore, the HFW Manager Supervisor offers avenues for leadership development and wage increases that do not necessitate a job change, fostering sustained employee engagement and satisfaction, as outlined in the Workforce Development and Human Resource Management Policy and Procedures, page 6.

Procedures Ensure: (a) All staff receive an initial HFW training using one of three options (select option that applies to your organization): click to expand options

Selected Option: 1) HFW staff are trained externally by attending the Statewide Standardized Foundational HFW training through the UC Davis RCFFP,

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor plays a pivotal role in coordinating a comprehensive staff training calendar, meticulously aligning HFW courses with UC Davis RCFFP offerings. This alignment ensures that all staff receive high-quality, relevant training essential to their roles within the HFW framework. Upon hiring, the HFW Manager Supervisor will carefully assess and identify the required and recommended courses tailored to each position. This ongoing process will include diligent tracking of staff progress to ensure timely completion.
a. HFW staff will enhance their expertise by participating in the Statewide Standardized Foundational HFW training conducted by UC Davis RCFFP, as outlined in the Workforce and Human Resource Management policy on page 1.
b. The HFW Fidelity Coach will facilitate continuous professional development by providing specialized training in courses that delve into Wraparound services and the essential skills associated with them; further information can be found in the Training Curriculum on page 1.
c. To ensure knowledge retention and skill enhancement, the HFW Fidelity Coach will also conduct annual booster training sessions, as detailed in the Training Curriculum on page 1.
d. Both the HFW Manager Supervisor and the Clinical Supervisor are mandated to partake in general training, alongside initial, ongoing, and booster training specific to their responsibilities, as specified in the HFW Manager Supervisor Job Description on page 3.
e. Additionally, the HFW Fidelity Coach will equip staff with essential training on the Indian Child Welfare Act (ICWA), as noted in the Training Curriculum on page 6.

Procedures Ensure: (a) Youth, families and peer partners with current or prior Wraparound experience are meaningfully incorporated into the delivery of required Wraparound trainings., (b) Community partners are invited to attend Wraparound trainings or are offered trainings on Wraparound to strengthen their participation on HFW teams or to strengthen their role in supporting HFW within the System of Care.

Description of Practice, Name of Supporting Documentation and Page #:

While training courses are compulsory for HFW employees, those offered by UC Davis RCFFP provide invaluable opportunities for all individuals involved in the HFW process to deepen their understanding and skills.
a. The HFW Fidelity Coach will enrich training sessions by integrating insights from former youth participants, families, and youth or parent partners, fostering a collaborative learning environment; further details are available in the Workforce and Human Resource Management policy, page 6.
b. The HFW Manager Supervisor will proactively inform community partners about available training sessions, whether conducted in-house, online, or within the broader community, ensuring widespread access to these developmental opportunities; refer to the Workforce and Human Resource Management policy on page 6 for more information.

Procedures Ensure: (a) All staff are provided with an initial apprenticeship that covers values, skills, and knowledge related to HFW principles, phases and activities, and the effective use of flex funds to meet a family’s needs., (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Fidelity Coach, alongside the HFW Manager, Supervisor, and HFW Clinical Supervisor, offers staff numerous opportunities to receive both initial and ongoing coaching and supervision, enhancing their professional growth.
a. The HFW Manager, Supervisor, or their designee will facilitate opportunities for staff to shadow experienced team members during their apprenticeship, covering essential competencies specific to their roles, as indicated in the Competency Checklist, Facilitator Tab.
b. As part of their commitment to professional support, the HFW Fidelity Coach, HFW Manager Supervisor, and HFW Clinical Supervisor are accessible to the team around the clock, reflecting their dedication to the staff’s development and well-being; please refer to the HFW Manager Supervisor Job Description on page 3 for further details.

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Procedures Ensure: (a) Data is utilized to improve practice with youth and families, including giving staff timely feedback from data or reports relevant to their service provision and using data to identify staff training needs., (b) Data is utilized to identify and address program needs to better serve families and improve overall program effectiveness., (c) Data is utilized to identify and communicate system barriers to the Community Leadership Team which impacts the HFW implementation.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor has a crucial role in supervising data collection and reporting initiatives at Casa Esperanza, ensuring that program practices are both effective and transparent.
a. Utilizing insights from outcomes data, the HFW Manager Supervisor will proactively implement strategies to enhance service delivery, as detailed in the Treatment Tracker, Outcomes Tracker tab.
b. By analyzing data from the Outcomes Tracker, the HFW Manager Supervisor is equipped to identify any program deficits and take swift action to enhance program performance, whether through additional training or adjustments to existing procedures; further information can be found in the Treatment Tracker, Outcomes Tracker tab.
c. The HFW Manager Supervisor will harness data from the Outcomes Tracker to pinpoint systemic issues and convey these insights to the Community Leadership Team, fostering a culture of continuous improvement and accountability, as referenced in the Treatment Tracker, Outcomes Tracker tab.

Date Started: October 16, 2025

Date Submitted: February 24, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (b) Staff receive ongoing training and coaching in identifying needs, developing needs statements that are reflective of the underlying reasons why problematic situations or behaviors are occurring, and utilizing needs-focused planning over problematic behavior-focused planning., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate school attendance and performance. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate the frequency of hospital visits. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. No

Description of Practice, Name of Supporting Documentation and Page #:

Policies and procedures are in place to record and evaluate when and why families exit HFW.No

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team.

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: (a) Program quality and improvement, (b) Cohesion (minimally including creating a positive team environment), (c) Open communication

Human resources management in the organization has implemented strategies and processes that result in the maintenance of a stable workforce which minimally include: (a) Matching wages to cost of living in the location of the organization/service implementation area

Procedures Ensure: (b) Staff have access to supervision or coaching 24/7 as needed.

Description of Practice, Name of Supporting Documentation and Page #: (e) N/A (Providers only)

Date Started: February 25, 2026

Date Submitted: February 26, 2026

Certification Status: Under Review

Procedures Ensure: (a) First contact with families is made as soon as possible, but no later than 10 calendar days after referral (or self-referral in the case of AAP eligible child)., (b) Teams complete a Wraparound Plan of Care within 30 calendar days from start of services, (c) Teams review the plan within the context of a HFW team meeting at least every 30-45 calendar days, (d) Teams update the plan of care, distribute to all team members, and document the updated plan in the child or youth’s file at least every 90 days and more often as needed, (e) Staff and their supervisors are provided with feedback on their ability to meet timelines for CQI purposes, (f) Staff are trained to timely engagement strategies that include encouraging alternate strategies when contact with the family is difficult

Description of Practice, Name of Supporting Documentation and Page #:

Tender Loving Care Home For Boys, Inc., dba Corinthians Helping Hand STRTP follows California’s High-Fidelity Wraparound fidelity indicators to ensure consistent and reliable processes with families and within our organization. This occurs through the following documents:
a. The HFW Manager Supervisor will track the first contact after referral; see Treatment Tracker, page 1.
b. The HFW Manager Supervisor will track the Plan of Care completion; see Treatment Tracker, page 1.
c. The HFW Manager Supervisor will track when the Plan of Care is reviewed at the team meeting; see Treatment Tracker, page 1.
d. The HFW Manager Supervisor will track when the Plan of Care is updated; see Treatment Tracker, page 1.
e. The HFW Manager Supervisor will review the Treatment Tracker with the staff and supervisors weekly at their staff meetings; see Treatment Tracker, page 1.
f. Staff receive training from the Fidelity Coach on Engagement and Team building exercises; see Engagement and Team Building Activities, pages 1-2.

Procedures Ensure: (a) Elicitation and use of families’ perspectives, including Tribes in the case of an Indian child (including development and documentation of the Family Vision and Team Mission statements), (b) Family values, culture, expertise, capabilities, interests and skills are elicited and clearly documented in the youth’s case file, (c) Supervisors/Coaches routinely observe HFW team meetings and review documentation to gather and provide feedback to staff to reinforce practice expectations, build skills, and increase confidence, (d) Feedback from families is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) to share their experience of the Wraparound process.

Description of Practice, Name of Supporting Documentation and Page #:

To ensure effective implementation of HFW, family perspectives on values, culture, expertise, capabilities, interests, skills, strengths, and needs are collected during meetings and visits and documented in the youth’s case file, as evidenced by the following documents:
a. The HFW Facilitator elicits information to gather the youth and family’s perspectives; see Strengths-Needs-Culture-Discovery Form, pages 1-2.
b. The HFW Facilitator ascertains the family’s values and perspectives; see Strengths-Needs-Culture-Discovery Form, pages 2-3.
c. The HFW Fidelity Coach observes and documents their observations at meetings to provide feedback to the staff; see Coaching Observation Form, page 1.
d. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) A strengths inventory is developed and updated for every member of the team, includes other resources in the family’s local community, and is posted at HFW team meetings., (b) The identification of individualized strengths must include, but not be limited to, the strengths identified in the IP-CANS, (c) Staff receive ongoing coaching and training in providing strengths-based, solution-focused services., (d) Feedback from families regarding their experience of strengths-based services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Manager is responsible for developing a strengths inventory form based on the strengths identified through the IP-CANS assessment.
a. The HFW Facilitator conducts a strengths inventory for each team member; see Team Strengths Inventory, page 1.
b. The HFW Family Specialist uses the strengths from the IP-CANS; see IP-CANS, page 1.
c. Staff receive training in solution-focused, strength-based training; see Training Curriculum, page 1.
d. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) Underlying needs are identified and prioritized before goals and strategies are established for the youth and family., (c) The identification of individualized needs must include, but not be limited to, the needs identified in the IP-CANS, (d) Transition is planned according to team and family agreement that needs are sufficiently met.

Description of Practice, Name of Supporting Documentation and Page #:

Utilizing both the Strengths Inventory and the IP-CANS, the family’s perceived needs will be identified and documented.
a. The HFW Facilitator uses the needs to identify and prioritize goals; see Strengths-Needs-Culture-Discovery Form, page 3.
b. The HFW Fidelity Coach provides training in needs-focused planning; see Training Curriculum, page 1.
c. The HFW Facilitator reviews the needs from the IP-CANs; see IP-CANS, page 1.
d. The HFW Facilitator develops transition planning based on feedback from Team meetings; see Wraparound Team Meeting Template, page 1.

Procedures Ensure: (a) Forms/documentation allow for sufficient flexibility in creating individualized plans for each child/youth and family., (b) Staff receive ongoing training and coaching in providing flexible, creative, and highly individualized services and strategies., (c) Facilitators receive ongoing training and coaching in leading the HFW team to customize the HFW process and the HFW plan of care according to each youth and family’s individual needs, strengths, values, culture, and preferences., (d) HFW plans of care are routinely reviewed and assessed for use of individualized strengths, needs, outcomes, and strategies and for the presence of strategies that capitalize on the assets of the family’s community and informal networks., (e) Family feedback regarding their experience of receiving customized services is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Tender Loving Care Home For Boys, Inc., dba Corinthians Helping Hand STRTP, is committed to devising individualized plans tailored to each youth and their respective family.
a. The HFW Facilitator uses the Plan of Care to identify individualized strategies; see Plan of Care, page 2.
b. The HFW Fidelity Coach provides training on flexible and individualized strategies; see Training Curriculum, page 1.
c. The HFW Fidelity Coach provides ongoing coaching in customizing the HFW process and plan of care. See Coaching Observation Form, page 1.
d. The HFW Clinical Supervisor conducts monthly chart audits to review the plan of care elements; see HFW Chart Audit, page 1.
e. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) A natural and community supports inventory is developed and updated for every family., (b) Staff receive ongoing training and coaching identification, engagement, and integration of natural supports in the HFW process and in decreasing reliance on formal supports., (c) HFW plans of care are routinely reviewed and assessed for the inclusion of natural supports in the plan and for use of community and natural supports in the assigning of strategies and action items., (d) Family feedback regarding their experience of having natural supports engaged on their team is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor is accountable for establishing a comprehensive inventory of natural and community support resources available to families. This catalog will detail the types of support presently utilized or potentially required across key domains, including health, housing, recreation, financial assistance, nutrition, legal affairs, communication, spiritual needs, education, and other vital areas.
a. The HFW Facilitator completes the supports inventory for each family and updates it monthly; see Natural Supports Inventory Form.
b. The HFW Fidelity Coach provides training to staff on engaging and integrating natural supports; see Training Curriculum, page 2.
c. The HFW Clinical Supervisor conducts monthly chart audits to review the plan of care elements; see HFW Chart Audit, page 1.
d. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) A strengths, needs, culture discovery is completed before the HFW plan of care is developed and is clearly documented in the child or youth’s case file, (b) Staff receive ongoing coaching and training in the elicitation and use of family and culture in planning and service delivery and in providing culturally respectful and relevant strategies., (c) Feedback from families regarding their experience of culturally relevant and respectful services and strategies is routinely elicited (e.g., through satisfaction surveys, use of the WFI or TOMS, quality assurance phone calls, etc.) and used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Before finalizing the Plan of Care, the HFW Facilitator and the team convene with the youth and their family to discuss their cultural perspectives. These may include language, spirituality, religion, rituals, customs, food preferences, leisure activities, traditions, beliefs, and values.
a. The HFW Facilitator elicits information to gather the youth and family’s cultural perspectives; see Strengths-Needs-Culture-Discovery Form, page 3.
b. The HFW Fidelity Coach provides training to staff on eliciting and using family and culture in planning and service delivery; see Training Curriculum, page 2.
c. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.

Procedures Ensure: (a) Team agreements are created for each HFW team and documented in the youth’s file., (b) Feedback from families and HFW team members regarding their experience of team engagement and collaboration is routinely elicited (e.g., through meeting observation, satisfaction surveys, use of the WFI or TOM 2.0, quality assurance phone calls, etc.)., (c) This feedback is used for continuous quality improvement including providing feedback to staff and their supervisors for training and coaching purposes., (d) HFW plans of care and meeting minutes are routinely reviewed and assessed for the shared ownership and follow through on strategies and action items.

Description of Practice, Name of Supporting Documentation and Page #:

Team agreements are developed in collaboration with each youth and their family. The HFW Facilitator works jointly to establish the agreement, integrating input from the youth, their family, and their support network.
a. The HFW Facilitator creates team agreements for each client’s HFW team during the engagement process; see Team Agreement form, page 1.
b. The HFW Manager Supervisor receives feedback from the youth and family through satisfaction surveys; see Youth and Family Satisfaction Surveys, page 1.
c. The HFW Manager Supervisor provides staff with input monthly from family feedback; see CQI Indicators Form, page 1.
d. The HFW Clinical Supervisor conducts monthly chart audits to review the plan of care elements and meeting minutes; see HFW Chart Audit, page 1.

Procedures Ensure: (a) The HFW plan of care includes specific, measurable strategies and action items with timeframes., (b) Action item completion is tracked by facilitators and updated at HFW team meetings, or more often as needed., (c) Forms and processes allow strategies and action items to be adjusted or changed as needed. These changes are communicated to all team members., (d) There is a process in place for who will complete the IP-CANS and how the IP-CANS will be shared amongst all team members (please specify in your description who will be responsible for completion of the IP-CANS assessment), (e) Data from the IP-CANS is used to support tracking and team decision-making, but does not replace using tracking of needs, goal completion, and action item completion to plan for transition.

Description of Practice, Name of Supporting Documentation and Page #:

The Facilitator creates a POC with clear, measurable, achievable, relevant, and time-bound strategies. Action items are assigned to team members with deadlines and tracked at HFW meetings until completed.
a. The HFW Facilitator incorporates measurable strategies, benchmarks, time-based results, and strengths into the plan of care; see Plan of Care, pages 2-3.
b. The HFW Facilitator tracks action items weekly; see Plan of Care, pages 2-3.
c. The HFW Facilitator can adjust and modify the Plan of Care form to accommodate changes; see Plan of Care, pages 2-3.
d. The HFW Family Specialist completes the IP-CANS and shares it at the team meeting; see IP-CANS, page 1.
e. The HFW Facilitator incorporates information from the IP-CANS into the Plan of Care, see Plan of Care, pages 2-3.

Procedures Ensure: (a) Teams are supported to keep working with a youth and family even when faced with setbacks or limited progress until the HFW team (with preference given to family voice and choice) agrees that services should end., (b) There are clear processes for teams to access help when facing challenges including how to request additional coaching or supervision, how to access/request flexible funding, and how to access additional support., (c) Facilitators receive ongoing training and coaching in post-crisis safety planning, conflict resolution, and in leading teams in effective brainstorming and ongoing plan revision.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW team collaborates with youth and families when setbacks or limited progress are identified. The HFW Manager Supervisor convenes weekly meetings with staff to review each family’s status and progress. For those experiencing challenges, the HFW staff analyzes underlying causes and formulates plans to address these barriers.
a. The HFW Fidelity Coach observes and provides feedback to the team when faced with setbacks or limitations; see Coaching Observation Form, page 2.
b. The HFW Manager Supervisor provides protocols for accessing services to help families; see Fidelity Indicators policy, page 4.
c. The HFW Fidelity Coach provides training for staff on safety planning, conflict resolution, and brainstorming; see Training Curriculum, pages 2-3.

Procedures Ensure: (a) HFW teams are able to provide adequate transitions and families do not experience sudden loss of services due to adverse events or due to administrative requirements., (b) Transitions out HFW are celebrated according to the youth and family’s culture, values, and preferences and administrative structures are supportive of engaging in celebration including access to flex funds, accommodating staff time for community resourcing, developing community partnerships, and ensuring staff are available to attend celebrations.

Description of Practice, Name of Supporting Documentation and Page #:

HFW staff endeavor to prevent gaps in service. If a youth or family misses a meeting or activity, the HFW Family Specialist or HFW Parent Partner contacts the family to reconnect and reschedule.
a. The HFW team ensures that transitions occur with a warm hand-off to the ongoing service providers. See Transition Plan, page 1.
b. The HFW team, with the active participation of the youth and family, develops a celebration of success. See Commencement and Celebration of Success Plan, page 1.

Policies and procedures are in place to record and evaluate children, youth, and parent satisfaction with their Wraparound experience. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will be responsible for gathering this information; see the Treatment Tracker, tab 2, and the Expected Outcomes policy, page 1.

Policies and procedures are in place to record and evaluate school attendance and performance. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will be responsible for school functioning information; see the Treatment Tracker, tab 2, and the Expected Outcomes policy, page 1.

Policies and procedures are in place to record and evaluate youth utilization of emergency medical services, frequency of contact with law enforcement, and engagement and community activities. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator and Family Specialist, under the supervision of the HFW Manager Supervisor, will be responsible for assessing community functioning. See the Treatment Tracker, tab 2, and the Expected Outcomes policy on page 2.

Policies and procedures are in place to record and evaluate the interpersonal functioning of families. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will collect information on the IP-CANS; see the Treatment Tracker, tab 2, and the Expected Outcomes policy on page 2.

Policies and procedures are in place to record and evaluate the caregiver’s confidence in their abilities and connectedness to resources in their community. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Family Specialist will be responsible for gathering this information; see the Treatment Tracker, tab 2, and the Expected Outcomes policy, page 2.

Policies and procedures are in place to record and evaluate the frequency of and types of placement changes when they occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will monitor the youth’s placement status every month, unless updated information about a new placement becomes available; see the Treatment Tracker, tab 2, and the Expected Outcomes policy, page 3.

Policies and procedures are in place to record and evaluate the frequency of hospital visits. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will monitor the youth’s admissions to inpatient facilities monthly; see the Treatment Tracker, tab 2, and the Expected Outcomes policy on page 3.

Policies and procedures are in place to record frequency of crises and level of involvement of professional support when crises occur. Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will monitor the youth’s crisis visits monthly; see the Treatment Tracker, tab 2, and the Expected Outcomes policy on page 3.

Policies and procedures are in place to record and evaluate when and why families exit HFW.Yes

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor will monitor the youth’s progress and transition date; see the Treatment Tracker, tab 2, and the Expected Outcomes policy on page 3.

Procedures Ensure: (a) The HFW process is fully explained to every family including an overview of the principles and phases, legal and ethical considerations, and the role of each team member including the family, natural supports, and Tribes in the case of an Indian child.

The explanation minimally includes: (a) an overview of the principles and phases, (b) legal and ethical considerations, (c) the role of each team member including the family and natural supports and Tribes in the case of an Indian child

Description of Practice, Name of Supporting Documentation and Page #:

Upon admission to the HFW program, the youth and family receive an orientation, covering the fundamental principles guiding the program, legal and ethical considerations, the roles of each team member, the significance of natural supports (including tribes, if relevant), and other essential aspects.
a. The HFW Manager Supervisor provides the orientation of the principles and phases of HFW at the beginning of the engagement phase; see Orientation Format, pages 1-3.
b. The HFW Manager Supervisor provides the orientation of the legal and ethical considerations of HFW at the beginning of the engagement phase; see Orientation Format, pages 1-3.
c. The HFW Manager Supervisor provides the orientation the role of team members in the case of an Indian child; see Orientation Format, pages 1-3.

Procedures Ensure: (a) Initial crisis and safety concerns are discussed during engagement. If pressing concerns are brought forward, the team develops an immediate crisis response plan which is provided to the family and is documented in the chart., (b) The crisis plan is used to inform, but not replace, the HFW Safety Plan developed during the Plan Development phase., (c) All families are provided with information regarding how to access 24/7 crisis response when needed.

Description of Practice, Name of Supporting Documentation and Page #:

The youth who enters HFW may encounter safety concerns, including but not limited to runaway behavior, suicidal or homicidal ideation, or other risk factors, which require an initial crisis plan ahead of the more formal crisis and safety plan.
a. The HFW Facilitator or designee discusses crisis and safety concerns during engagement; see Crisis Plan, page 1.
b. The HFW Facilitator or designee designs the crisis plan to provide information on resources and plans to help the youth during the engagement phase; see Crisis Plan, page 1.
c. The HFW Facilitator or designee provides information on the crisis plan on how to access 24/7 response; see Crisis Plan, page 1.

Procedures Ensure: (a) A Family Vision is completed with every family and documented in the youth’s chart during the Engagement phase., (b) A Strengths, Needs, Culture Discovery document is initiated with every youth, and family, is included in the youth’s chart, is updated at least every 90 days, and the team adds new strengths, needs, and cultural preferences as they are discovered. The document is provided to new team members as they are identified.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator meets with the family during the engagement process to discuss their strengths, needs, cultural preferences, and family vision.
a. The HFW Facilitator creates a Family Vision with each family; see Strengths-Needs-Culture-Discovery form, page 3.
b. The HFW Facilitator develops the Strengths, Needs, Culture, and Discovery plan within 90 days of the family’s entrance to the program; see Strengths-Needs-Culture-Discovery form, page 5.

Procedures Ensure: (a) A natural supports inventory is completed with all youth and families and is documented in the child or youth’s case file., (b) Children’s System of Care partners who should be included on the HFW team are identified and engaged., (c) The HFW team works with the youth and family to identify potential team members (including formal, natural supports and Tribes, in the case of an Indian child) and discusses their role on the team., (d) Engagement and team building activities are documented in the youth’s file (for example, but not required, in meeting minutes or in case notes).

Description of Practice, Name of Supporting Documentation and Page #:

During the engagement phase, the Facilitator completes the Natural Supports Inventory. This involves the facilitator meeting with the youth, their family, and HFW team members to evaluate and identify natural supports within the youth and family, and to determine which of these supports could be included in the team process.
a. The HFW Facilitator completes the natural supports inventory with all youths and families; see Natural Supports Inventory, page 1.
b. The HFW Facilitator identifies the Children’s System of Care partners to be on the HFW team, see Natural Supports Inventory, page 1.
c. The HFW Facilitator identifies potential team members and their roles; see Natural Supports Inventory, page 1.
d. The HFW Facilitator documents the team-building activities; see Wraparound Team Minutes, page 1.

Procedures Ensure: (a) Staff are flexible in working hours and scheduling meeting times and locations to accommodate family and Wraparound Team needs., (b) Staff are trained to work collaboratively with families and the other members of the HFW team to schedule meetings that are in alignment with family needs and preferences as well as maximize participation.

Description of Practice, Name of Supporting Documentation and Page #:

a. The HFW staff understand their need for flexibility in working hours; see Facilitator Job Description, page 1.
b. The HFW staff are trained on using flexible strategies with the youth and family; see the Training Curriculum, page 1.

Procedures Ensure: Before the Wraparound plan of care is developed: (a) Before the HFW plan of care is developed, team agreements, a team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file., (b) The youth’s and family members’ strengths identified in engagement are updated to reflect any additionally discovered strengths as they are identified and are documented in the youth’s file.

Description of Practice, Name of Supporting Documentation and Page #:

Before the HFW Plan of Care is developed, team agreements, team strengths inventory, and a mission statement are completed with each family and documented in the youth’s file. Youth and family members’ strengths identified in engagement are updated to reflect additional strengths as they are identified.
a. The HFW Facilitator develops the team agreements, strengths inventory, and mission statement with each youth and family; see Team Strengths Inventory, page 1; Team Agreement Form, page 1; and Team Mission Statement, page 1.
b. The HFW Facilitator updates the youth and family strengths during the HFW process; see Team Strengths Inventory, page 1.

Procedures Ensure: (a) Before the HFW plan of care is developed, underlying needs are identified and prioritized for each family and are documented in the youth’s file., (b) Measurable goals and outcomes are developed from these identified needs (as opposed to behavior or deficit-based goal development), (c) These goals and outcomes are developed collaboratively with the youth, family, and the rest of the HFW team., (d) Multiple individualized brainstormed strategies are documented in the youth’s file (e.g., in the HFW Plan of Care, in a form, in meeting minutes, or in progress notes) that can be referred to as needed., (e) Facilitators are trained to lead teams in identifying, prioritizing, and selecting strategies and developing action items., (f) These steps are utilized to develop the individualized HFW Plan of Care in a team-based, collaborative environment.

Description of Practice, Name of Supporting Documentation and Page #:

Before the HFW Plan of Care is developed, underlying needs are identified and prioritized for each family and documented in the youth’s file. Measurable goals and outcomes are derived from these needs (as opposed to behavior- or deficit-based goal development).
a. The HFW Facilitator develops the youth and family’s underlying needs; see Strength-Needs-Culture-Discovery Form, page 3.
b. The HFW Facilitator uses measurable goals and outcomes based on the youth and family’s needs; see Measurable Goals and Outcomes Form, page 1.
c. The HFW Facilitator engages the HFW team members in developing the goals and objectives; see Measurable Goals and Outcomes Form, page 1.
d. The HFW Facilitator provides brainstorming sessions to identify goals and outcomes; see Wraparound Team Minutes, page 1.
e. The HFW Fidelity Coach provides training in Needs Focused Planning, see Training Curriculum, page 1.
f. The Plan of Care uses a team-based approach, see Wraparound Team Minutes, page 1.

Procedures Ensure: (a) Facilitators receive ongoing training and coaching to engage the team in a planning process that elicits multiple perspectives, builds trust and shared vision, and demonstrates the HFW principles., (b) The Plan of Care comprehensively integrates goals and objectives identified by all Children’s System of Care partners., (c) The Plan of Care is documented in the child/youth’s file, is distributed to all team members, and meets all the criteria defined above (items 1-6), (d) Procedures are in place to review Plans of Care for continuous quality improvement and to provide feedback to staff and supervisors/coaches for training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The Plan of Care comprehensively integrates goals and objectives identified by the team members. The Plan of Care is documented in the youth’s file, is distributed to all team members, and meets the criteria.
a. The HFW Fidelity Coach provides training and coaching on engaging the team; see Coach Observation notes, page 2, and Training Curriculum, page 1.
b. The HFW Facilitator uses the goals and objectives of the Children’s System of Care; see Plan of Care, page 1.
c. The Plan of Care is sent to all team members with the required criteria, see Plan of Care, page 1, and Strengths-Needs-Culture-Discovery Form, page 5.
d. The HFW Manager Supervisor audits the chart monthly for updates to the Plan of Care, see HFW Chart Audit, page 1.

Procedures Ensure: (a) An individualized crisis and safety plan is documented in the youth’s file, which identifies potential safety, high risk and crisis situations with proactive and reactive crisis management strategies chosen by the family members and including who should be called for support 24/7., (b) The development of the plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Crisis and safety plans are reviewed for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

Individualized Crisis and Safety Plans are documented in the youth’s file, identifying safety, high-risk, and crises, along with the proactive and reactive strategies selected by family members. These plans also specify who to contact for 24/7 support.
a. The HFW Facilitator or designee develops the Crisis and Safety Plan based on the initial Crisis Plan; see Crisis and Safety Plan, page 1.
b. The HFW Facilitator or designee develops the plan with the feedback of the HFW team; see Crisis and Safety Plan, page 1.
c. The HFW Facilitator reviewed the Crisis and Safety Plan monthly or as needed for updates, see Crisis and Safety Plan, page 1.

Procedures Ensure: (a) The facilitator leads the team to review strategies and action items at HFW team meetings (e.g., use of meeting agendas and meeting minutes that address action item completion and document progress), track individual assignments, check-in to support meeting timelines and deliverables, and adjust strategies and action items as needed., (b) Staff receive training and coaching on implementing the plan of care in alignment with the HFW principles. Training and processes address celebrating successes as they occur.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator will oversee the team’s implementation of the Plan of Care. Upon completion, review, and approval of the Plan of Care, and once all team members have received copies, the HFW Facilitator will monitor individual assignments and action items stemming from the Plan of Care.
a. The HFW Facilitator provides opportunities for the team to review the plan of care strategies and how to modify action items as needed; see Wraparound Team Minutes, page 1.
b. The HFW Fidelity Coach provides training on implementing and adapting the plan of care, see Training Curriculum, page 1.

Procedures Ensure: (a) Reviews of strategies, progress, and action items occurs in a HFW team meeting setting., (b) The facilitator leads the team to adjust the plan accordingly as successes occur, as new needs are identified, or as new strategies and action items are selected, and the updated plan is documented in the youth’s file., (c) The facilitator documents and communicates completion of tasks and new assignments, team attendance, use of formal and natural supports, use of flex funds, and updates to the plan. These updates are communicated to all team members, at a minimum, through the use of team meeting minutes., (d) Forms are able to be updated and individualized to meet the youth, family, and team’s changing needs.

Description of Practice, Name of Supporting Documentation and Page #:

During the HFW team meeting, the Plan of Care is reviewed, encompassing strategies, progress, and action items. The Facilitator identifies any emerging needs during this session and subsequently adjusts the Plan of Care by developing new strategies and action items.
a. The HFW Facilitator reviews the strategies, progress, and action plans during the team meeting; see Wraparound Team Minutes, page 1.
b. The HFW Facilitator provides leadership to adjust the plan to the newly identified needs and when goals are achieved; see Wraparound Team Minutes, page 1.
c. The HFW Facilitator documents task completion and new assignments; see Wraparound Team Minutes, page 1.
d. The HFW Facilitator updates the forms to meet changing needs; see Wraparound Team Minutes, page 1.

Procedures Ensure: (a) Team agreements are utilized, reviewed regularly, and present at HFW team Meetings., (b) Facilitators receive ongoing training and coaching on building, engaging, and maintaining effective teams., (c) Use of natural supports are monitored over time and teams are provided feedback through coaching and supervision., (d) There are processes for orienting new team members (including formal and natural supports) to the team which include explaining the HFW process, reviewing current plans and strategies, and engaging in team building exercises.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Facilitator uses team agreements throughout the HFW phases, regularly reviews them with team members, updates them as needed, and presents them at team meetings.
a. The HFW Facilitator uses the team agreements at the HFW Team Meetings, see Team Agreement Form, page 1.
b. The HFW Fidelity Coach provides training on effective teams; see Training Curriculum, pages 3 and 4.
c. The HFW Facilitator monitors the use and involvement of natural supports; see Natural Supports Inventory, page 1.
d. The HFW Facilitator uses the Orientation Format to bring new members up to speed on the HFW process; see Orientation Format, page 1.

Procedures Ensure: (a) The facilitator leads the team in identifying when the youth and family are ready for transition based on benchmarks and indicators that the team has been monitoring and adapting throughout the HFW process., (b) Once this determination has been made, the facilitator leads the team in creating an individualized transition plan that identifies needs, services, and supports, distributes the plan to all team members, and documents the plan in the youth’s file., (c) The development of the individualized transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (d) The team verifies that services and supports identified in the transition plan will persist past formal HFW and that the family is able to access them, including post adoption services if applicable.

Description of Practice, Name of Supporting Documentation and Page #:

The HFW team, which includes the youth, family, and both formal and informal supports, will determine when the youth and family have successfully achieved the goals established in the HFW Plan of Care. This determination is based on agreed-upon benchmarks and indicators identified by the youth and family in the Plan of Care.
a. The HFW Facilitator uses benchmarks from the Plan of Care to determine the youth and family’s readiness for transition; see Plan of Care, page 2.
b. The HFW Facilitator develops the Transition Plan based on the youth and family’s ongoing needs after the program; see Transition Plan, page 1.
c. The HFW Facilitator creates the Transition Plan within the team meeting with the input of the team members; see Wraparound Team Minutes, page 1.
d. The HFW Facilitator identifies specific services and supports that are verified and will be available to the youth and family after the program; see Transition Plan, page 1

Procedures Ensure: (a) The individualized crisis and safety plan is updated to reflect transition (or a new transition crisis and safety plan is completed) and documented in the youth’s file. The plan identifies potential crisis situations that may occur after transition and includes proactive and reactive crisis management strategies that maximize use of natural support and that are chosen by the family., (b) The development of the crisis and safety transition plan occurs in a team based, collaborative environment and facilitators receive training and coaching to this process., (c) Processes are in place to review crisis and safety plans for individualized strategies, proactive and reactive progression of strategies, cultural relevancy, and the use of natural supports for continuous quality improvement and training and coaching purposes.

Description of Practice, Name of Supporting Documentation and Page #:

The existing Crisis and Safety Plan, created during the HFW process, will serve as a foundation for the HFW Facilitator to adapt to the needs of the youth and family during and after the transition. If warranted, a new Crisis and Safety Plan may be formulated.
a. The HFW Facilitator or designee updates the existing Crisis and Safety Plan to reflect any new needs or contacts; see Crisis and Safety Plan, page 1.
b. The HFW Facilitator or designee develops the Crisis and Safety Plan within the context of the Team meeting to receive collaboration from the team members; see Wraparound Team Minutes, page 1.
c. The HFW Facilitator or designee uses the Team Meeting as an opportunity to review the Crisis and Safety Plan with the youth, family, and team members; see Wraparound Team Minutes, page 1.

Procedures Ensure: (a) Transitions out of the Wraparound process are celebrated according to the family’s culture, values, and preferences., (b) Administrative structures are supportive of engaging in celebration (e.g., access to flex funds, time for community resourcing, community partnerships, ensuring staff are available to attend celebrations, etc.).

Description of Practice, Name of Supporting Documentation and Page #:

The transitions for youth and families represent significant milestones. During their participation in the HFW process, youth and families achieve notable progress, meriting appropriate acknowledgment and celebration.
a. The HFW Facilitator uses the Commencement and Celebration of Success format to discuss with the family their approach to the celebration; see Commencement and Celebration of Success Plan, page 1.
b. The HFW Facilitator engages the staff and team members to accommodate the family’s needs in their celebration; see Commencement and Celebration of Success Plan, page 1.

Procedures Ensure: (a) There are mechanisms in place for families to participate in decisions regarding local HFW implementation, (b) Family feedback is used in the decision-making regarding service planning and implementation, policy and procedure development, workforce development and quality improvement

Description of Practice, Name of Supporting Documentation and Page #:

In our pursuit of better serving our community, Tender Loving Care Home for Boys, Inc., dba Corinthians Helping Hand STRTP, will establish a dynamic advisory board for HFW. This board will consist of volunteer youth and their families who have either completed or are currently engaged in the HFW process.
a. The HFW Manager Supervisor will hold periodic advisory group meetings to gather information from the families; see Advisory Group Agenda, page 1.
b. The HFW Manager Supervisor will use the advisory group meetings as opportunities to receive feedback from families on the decision-making process to improve services, workforce, implementation, and policies; see Advisory Group Agenda, page 1.

County Procedures Ensure : N/A (Providers only)

Provider Procedures Ensure : (a) There is an identified representative who actively participates on the Community Leadership Team

Description of Practice, Name of Supporting Documentation and Page #:

The HFW Manager Supervisor or a designated representative will take on a pivotal role as our organization’s liaison on any HFW Community Leadership team.
a. The HFW Manager Supervisor or designee will attend Community Leadership Meetings; see Manager Job Description, page 2.

County Procedures Ensure: N/A (Providers only)

Provider Procedures Ensure : (a) Youth that meet established eligibility criteria are able to receive services and are not excluded based on the severity or nature of their needs., (b) Staffing is planned to ensure appropriate case load assignments that support the intensity and frequency of services necessary to meet families’ complex needs and enable staff to provide 24/7 support to families in crisis.

Description of Practice, Name of Supporting Documentation and Page #:

At Tender Loving Care Home for Boys, Inc., dba Corinthians Helping Hand STRTP, we understand the importance of having a well-resourced HFW team prepared to provide exceptional services to all youths and their families transitioning from the STRTP program.
a. The HFW Manager Supervisor conducts an evaluation of the youth and family based on the eligibility, and accepts youths regardless of the severity or the nature of their needs; see Eligibility Criteria, page 2.
b. The HFW Manager Supervisor staffs the organization with sufficient staff to provide the intensity and frequency of services necessary; see Organizational Chart, page 1.

Contracts outline rates that reflect the inclusion of: (a) High fidelity direct services and supports to meet the immediate individualized needs of youth and families, (b) Required workforce development and staffing including required roles or functions from Workforce Development standard 9.3, (c) Required data collection and/or data management systems.

Description of Practice, Name of Supporting Documentation and Page #:

Contracts ensure the inclusion of high-fidelity direct services and supports to meet the immediate, individualized needs of youth and families; see Fiscal Supports Policy, page 1. They also require workforce development and staffing, including specified roles or functions (see Fiscal Supports Policy, page 1), as well as required data collection and/or data management systems.
a. The HFW Manager Supervisor reviews contracts to ensure that funding is included to provide support for the youth and family’s needs; see Fiscal Supports Policy, page 1.
b. The HFW Manager Supervisor reviews contracts so that sufficient staff can be hired and retained to support HFW activities; see Fiscal Supports Policy, page 1.
c. The HFW Manager Supervisor reviews contracts so that funding allows for data collection and data management systems; see Fiscal Supports Policy, page 1.

County Procedures Ensure: N/A (Providers including AAP funded providers only)

Description of Practice, Name of Supporting Documentation and Page #:

Procedures Ensure: N/A (Providers including AAP funded providers only and if cost-savings are unavailable)