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Starlight Children and Family Services
COMMUNITY TREATMENT FACILITY (CTF)

PLAN OF OPERATION
INCL. PROGRAM STATEMENT

Revised and Updated 06-06-06

STARLIGHT CHILDREN AND FAMILY SERVICES

COMMUNITY TREATMENT FACILITY(CTF)

PLAN OF OPERATION
INCL.PROGRAM STATEMENT

Revised and Updated 06-06-06

TABLE OF CONTENTS Relevant Section(s) of Regulations
PAGE

I.

II.

PROGRAM STATEMENT §1919 (1),(2) and (3)
• Mission, Philosophy & Goals
• Target Population
• Sendee Array

STAFFING §1919(4A-D)
A. Staffing Patterns,Job Descriptions & Cultural Competency ...
B. Mental Health Program Director
C. Organizational Chart & Professional Contracts
D. Staff Development Plan

2
2
4

5

11
13
111

119
134

III. ACCESS TO OTHER RESOURCES §1919(5)

196

IV. POLICIES AND PROCEDURES §1919 (6A-L)
A. Daily Observations & Interactions

206

B.

214

Admission

C. Discharge
D. Psychotropic Medication Control
E. Needs & Sendees Plan, Consumer Involvement

F. Needs & Services Plan, Monthly Review
G. Physical Restraint & Seclusion
H. Staff Training on Client Due Process Rights
1.

Visitation & Phone Use

J. Confidentiality
K. Transitioning Within Facility
L. Informing Client and Caretaker about the Program
V.

QUALITY ASSURANCE §1919(7A)
A. Staff Accountability for Youth’s Care

VI. UTILIZATION REVIEW §1919(8A-B)
A.

207

Unit Placement & Transfer

B. Oversight of Unit Placement & Transfer

221

229

236
See IV E

253
See 11 D

279
285
NA

287

364
SEE 344

500
NA
NA

VII. CONTRACTS §1919(9)

502

VIII. FACILITIES §1919 (10)

526

IX. BUDGET §1919 (11)

528

X.

536

APPENDICES

Starlight CTF Plan of Operation/Program Statement

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STARLIGHT CHILDREN AND FAMILY SERVICES

COMMUNITY TREATMENT FACILITY(CTF)

I. PROGRAM STATEMENT
Revised and Updated 06-06-06

Starlight Children and ¥amilj Services is pleased to submit a revised and up-to-date Plan of
Operation,including Program Statement for the Starlight Community Treatment Facility (Starlight CTF)
(original dated May 5, 1999). This updated plan and statement does not involve any changes to the basic
program sttucmre or location of the CTF. The CTF is one among a number of bundled components
designed to meet the needs of youth with serious emotional and behavioral disorders, including: a) a
Community Care Licensed Group Home Rate Classification Level(RCL) 13/14 residential treatment
program; b) an on-site seven day per week Medi-Cal certified intensive day treatment program; c) an

array of supportive mental health services;’ and, d) an on-site State Department of Education certified
non-public school,^ aU located in San Jose, California. Starlight Children and Family Service/ programs
obtain administrative and related support services from Stars Behavioral Health Group(SBHG) which
provides such services to mental health and foster care agencies throughout California.
The Starlight CTF continues to maintain capacity to serve up to thirty-six youth at a time, ages
11 to 18, with male and females on separate secure units. Contracts with any of California’s county
mental health, child welfare, and juvenile probation departments may be established to access the
program. The revised plan and statement provides a fresh overview of the Starlight CTF,notification of
facility improvements, and updates of required plan components, to augment the original Plan of
Operation which remains largely appHcable. In addition to the Program Statement, a brief overview
highlighting changes will be provided to each regulated section (TX) of the Plan of Operation as listed
in the Table of Contents.

MISSION

The mission of Starlight Children and Family
Community Treatment Facility (Starlight
CTF)is to provide an organized and strucmred multi-disciplinary treatment program for youth who
cannot be safely maintained in family homes or lower level group care because of the severity of their
emotional and behavioral problems and very high risk behaviors. The CTF offers an alternative to

hospitalization or incarceration of mentally iU minors in order to stabilize and support the transition of
these youth to less restrictive placements, including with family, foster families, or lower level group
homes as part of each youth’s long term permanency plan. The Starhght CTF integrates residential,
treatment, and educational services in a comprehensive and coordinated program in order to:
Help youth:

Help families:

Bring voice to their needs in supporting the

Become emotionally stable

youngster

Develop the skills necessaty? for successful

• Maintain or transition their youngster

adult lives

home

Find satisfying vocational activities and social
relationships

• Discover and utilize their strengths and
skills

'DTI and other mental health services are operated under Starlight Adolescent Center, Inc.
2 The non-public school is operated under Starlight High School, Inc.
Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

•

Discover supports and resources in the

Succeed in school

community

• Maintain or achieve permanent placement in a
family home

^ Achieve long-term self-sufficiency

PHILOSOPHY

StarUght CTF provides continuously monitored residential care combined with highly
individualized professional treatment and educadonal services in a safe and secure setting in order to
assist youth to gain the social and functional skills necessary for appropriate development and recovery,
return to community living, and positive social integration.

All Starlight Child and Yamily Services’ programs, including the Starlight CTF,are committed to
providing sendees for youth and famdlies that are:
1.
2.

Family-centered — focusing on family needs and supporting their involvement;

Strength-based — building on the talents, strengths and resources of youth, families and
communities;

3.

Normalizing — attending to the needs of all youth for safe and healthy living, recreational
outlets, positive social contact, personal expression, and maintenance of daily routines;

4.

Clinically-proGcient — recruiting, training, and super\dsing staff to provide quahty mental
health care through evidenced-based practices and/or emerging promising practices;

5.

Culturally-competent — understanding and responding to the diverse and distinctive
backgrounds of clients and families, whether related to age, gender, ethnicity, language,
reUgion, sexual orientation, family culture, and/or national origin;

6.

Collaborative — identifying and accomplishing goals through teamwork among program
staff, clients, families, communities and partners from mental health, social services,
probation, education and other organizations;

7.

8.

Flexible — applying resources in creative, yet accountable and cost-effective ways; and.

Accountable — documenting services well, monitoring quality, and tracking treatment
outcomes.

GOALS

The treatment staff of the Starlight CTF partner with each youth and family to plan and work
toward the achievement of individualized goals across four broad domains. The goals of treatment are
for clients to be:

• Safe at home or in family-Uke settings
• Attending and progressing in school

• Improcting in health and mental health
•

Out of trouble with the law

For example, a goal might be to reduce the occurrence of a high risk behavior such as assaults

toward peers from 4 or 5 times a week to none. In this example, the youth’s ability- to learn appropriate
ways to manage their anger and impulses (i.e., without lashing out to harm others) is monitored through
close-in supervision, incident reporting, and treatment team review that involves the client and their

caretakers (parent, legal guardian, conservator, etc.). In this example, the youth’s specific treatment goal
may have implications for all four outcome domains: safety while in the setting as well as readiness to
Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

discharge to a lower level of care; permission and capacity to be at school; mental health objectives such

as transforming rage, correcting thinking errors, and/or improving impulse control; and, staying out of
trouble with the law.

In addition to individual treatment goals, specific indicators are tracked for each of the above
outcome domains that reflect county and program-specific priorities and contracts as well as the profile
and challenges facing the Starlight CTF service population generally. The capacity to empirically
document outcomes across these domains is being built incrementally, with additional indicators added
over time as program resources permit. For example, A Client Outcome R' eport(COR),and an Independent
Uving Skills Scale (ILSS) included in the Appendix, are being implemented in FY 06-07.

A shared interest among agency parmers (from child welfare, mental health, probation,
education, and other community representatives) along with Starlight leadership and staff is for
treatment to move along as efficiently as possible. The course and length of treatment is determined by
each client’s individual needs and life simafion including, primarily, the nature, severity and degree of
entrenchment of their psychopathology, and available family and/or alternative community placements
and support resources. Starlight staff work diligently from the point of admission forward to advance
each youth’s permanency objectives, reduce the most dangerous and/or debilitating high risk behaviors,
and foster resiliency, life skills, and family/community connections. The length of stay varies for each
client with lengths of stay ranging recently from 20 to 772 days witli an average of 263 days (almost nine

months).^ A policy on utilisation review is provided (see VI: UTILIZATION RE\TEW, per §1919 (8),
TQM 2.00 Utilization Review Process).

Additional Starlight CTF program goals are:
a) Achievement of client, family and agency parmer satisfaction with services (multiple
measurements taken annually);
b) Realization of culmral competency objectives per an Annual Cultural Competency Plan (see II:
STAFFING, per §1919(4A) and §5600.2(g) of the W&I Code, FY 05-06 Culmral Competency
Annual Plan); and,
c) Advocacy, collaboration and coordination on behalf of clients with agency partners and

community resources in order to facilitate treatment success, permanency objectives, and
successful linkage to aftercare ser\tices.

The Starlight CTF is part of a continuum of Starlight Children and Pamilj
programs in
Santa Clara County focused on the needs of children and adolescents with serious emotional and

behavioral problems and their families. Santa Clara County CTF clients may discharge to a family home
or lower level placement with aftercare services provided by the Starlight Children andPamilj Services’
community-based intensive day treatment program and non-public school, or in-home, school-based
and outpatient mental health services.
TARGET POPULATION

The Starlight CTF senses adolescents ages 11 to 18, of both genders, that come from a variety
of backgrounds and a number of California counties. The youth served in the CTF suffer from severe
emotional dismrbance and have a history of very troubled and high risk behaviors including aggressti^e,
oppositional, provocative,impulsive, and self-destructive behaviors, often accompanied by intense
negativism and social withdrawal. Along with these behaviors, the youth typically suffer from strained
or impaired,if not entirely absent, interpersonal and family relationships, resulting in a vital need for
restorative social sup]3ort, and in some instances, family finding. Starlight CTF youth have experienced
^ Figures based upon CTF Report (Section 1912 Required Reporting),January 5,2006, for discharges occurringjuly 1, 2005 through
December 31, 2005.

Starlight CTF Plan of Operation/Program Statement

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one or more prior treatment failures in outpatient, extended care management, or less restrictive
settings. If not in the stable and intensive treatment environment of the Starlight CTF,the youth would
he in psychiatric hospitals or continue to move among placements, treatment settings, and shelters.
Their behavior may represent a potential danger to self, others and/or property, and their treatment
requires comprehensive evaluation, close staff supervtision, intensive therapy, remedial education, and
monitoring of the need for psychopharmacological inten^ention. AH Starhght CTF clients — whether
referrals originate from child welfare, mental health, special education, or juvenile probation — meet
medical necessity criteria for treatment in a structured and secure treatment environment per the
authorizing county’s mental health risk review and placement committee (such as Santa Clara County’s
(SCC)Interagenc): Placement Remjv Committee(IPRC) process). Starlight youth represent less than 1% of
the overall child/youth population of California in terms of the severity of their psychiatric disorders.
Over 50% of youth have functional assessment scores (C-GAS) upon admission that are below 35 on a
0 to 100 point rating scale, where 100 is optimal functioning and the range of 31-40 reflects major
impairments in multiple areas (e.g., persistent aggression without clear instigation, markedly withdrawn
and isolated, suicide attempts).
A comprehensive utilization report on Starhght CTF chents was produced and distributed in
early 2004 and provides a retrospective profile of chents sensed from 2000 through 2003 (data
summarized below). An updated report including outcome data whl be available after the close of FY
05-06.

Ages

Gender

33% 11 thru 14

57% Male

52% 15 and 16

43% Female

Ethnicity

15% 17 and 18

Referral Sources

45% Anglo American
34% Hispanic/Latino

44% Juvenhe Probation

18% African American

25% Mental Health

2% Other Ethnicity

31% Child Welfare

(AB 3632)

1% Asian American

Immediate Prior

Placement

51% Juvenile Hall
16% Psychiatric Hospital
17% Group Home
10% Family Home

Prior Psychiatric
Hospitahzations

Prior Group Home

Diagnoses

Placements

(More than one possible)

15% None

19% None

72% Emotional Disorders

29% One or Two

35% One or Two

52% Behavioral Disorders

25% Three or Four

25% Three or Four

20% Psychotic Disorders

31% Five or More

21% Five or More

6% Shelter

SERVICE ARRAY

The comprehensive array of services - residential, rehabihtative, treatment, and schooling —
available to chents during placement at Starhght CTF are:
1.

Residential Care:Starhght Community Treatment Facihty (CTF) is a 36-bed, 7-day, 24hour residential miheu simated on a three acre semi-rural property in south San Jose,
Cahforma. The facihty was a hospital retrofitted to support two secure hving units for girls
and boys separately, classrooms, group meeting rooms, offices, a dining room and
recreational spaces. The facihties include a computer lab and hbrary, an on-site gymnasium, a
swimming pool, recreational space for creative and expressive arts, sports and leisure
equipment, and an outdoor playing field. The program model for residential mhieu
treatment is a community practice standard that integrates social learning theory into an
overaU bio-psycho-social approach with treatment further focused and enhanced through
evidence-based practices within a mental health funded Day Treatment Intensive (DTI)
program (see next section). Within the parameters of the overaU program model, services are
highly individuahzed and each chent and available parent(s), guardian, or conservator is

Starlight CTF Plan of Operation/Program Statement

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engaged in the development of an individualized Needs and Services Plan (NSP) which is
reviewed and updated monthly. The DTI Mental Health Clinicians coordinate the NSPs with
the DTI treatment plans, which are also required, in order to assure that all the various
treatment staff are focused and working together with the youth and family toward the same
set of priority treatment goals, and to coordinate discharge and transition planning (see IV:
POLICIES AND PROCEDURES per §1919 (6C, E-F)).

For the medical aspect, visiting and on-caU physicians/psychiatrists provide
medical oversight, comprehensive evaluation, and medication support services. Nurses
maintain professional standards for daily medical management and provide 24-hour
supervtision and guidance to youth in such matters as personal hygiene, dressing, sleep
regulation, and taking prescribed medications. Nurses orient youth to the unit and staff upon
admission, and help youth complete personal property inventories. Only Registered Nurses
(RNs), Licensed Vocational Nurses (LVNs) and Licensed Psychiatric Technicians (I^PTs)
administer medications (either orally or intramuscularly) as prescribed by the physician; nursing
staff also follow-up and monitor lab work. X-rays, off-site medical exams (e.g., hearing, ttision,
etc.) and other medical needs as prescribed by the attending physician (see IV; POLICIES AND
PROCEDURES, per §1919 (6A-J) and V:
ASSURANCE per §1919 (7), SBHG TQM
Manual, for more information about medical and nursing practices).
Ihe safety of all clients, staff, and visitors is always a primary concern. The ratio of
direct treatment staff to cHents is at least 1:5 daytime and 1:10 nighttime, per California State
Department ofSocial Services Community Care Licensing Standards (see II: STAFFING, per
§1919 (4A), ConsoHdated Staffing Pattern). In addition to high staff to client ratios, on-call
admimstrative, nursing, youth counseling, and rehabilitation staff are available for emergency
coverage and intervention. Starlight leadership make every effort to assure very high
standards of staff compliance and ethical conduct, such as with respect to preventing
mstirntional abuse or neglect. All staff have background checks and are fingerprinted prior
to starting work with minors (see II: STAFFING, per §1919 (4A), LIC 500); subsequently.
Department ofJustice (DOJ) records are checked twice a year in accordance with Santa
Clara County (SCC) policy. Both clients and staff receive information and trainings about
then: rights and responsibilities to maintain safe, respectful relationships. Staff collaborate
regularly with the county Mental Health Advocag and Protection(MHAP)unit to conduct due
process rights workshops with Starhght youth and investigations as necessary (see IV:
POLICIES.WD PROCEDURES,per §1919 (6 I), MHAP Client’s Rights Presentation).

Nurses, youth counselors, and resident managers aU serve as coaches (encouraging,
motivating), teachers (modeling, guiding), counselors (listening, intervening), house-parents
(scheduling, monitoring), and limit-setters (enforcing, disciplining) to the youth. Residential
milieu staff have direct, therapeutic, and monitored relationships with the youth, essentially
providing surrogate parenting to chents while they live in the CTF. Milieu staff focus on:
•Providing continuous supervision to youth;
• Fostering positive relationships;

• Supporting client mastery of the activities of daily h\ting;
• Stimulating coping skills and social skills development;
• Scheduling daily life including recreational and celebrator}? oudets; and,
• Deescalating high risk behaviors to avoid use of restrictive interventions.
A Points and Levels (P&L) system allows youth to start immediately to experience
successes and earn privileges beyond basic care. Clients entering residential treatment are
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typically seriously impaired in almost aU areas of living and often profoundly de-motivated,
recoiling from life under their mental illness, stigmatization, and social isolation. In order to

regain normal levels of social, emotional, behavioral, and educational functioning, they need
to learn a number of skills and change a number of behaviors, and feel supported in doing
so. Points and Levels (P&L) break down this process into a series of small steps. To
encourage clients to make these steps, privileges and rewards are given to reinforce desired
behaviors. “Catch a kid doing something right” is the motto. Each skill mastered is called a

“merit badge.” The P&L system is the most effective way for youth to practice changing
maladaptive behaviors - when staff applies creative, positive incentives with kindness and
respect, not as a means of punishment. Our training program emphasizes the correct use of

P&L (see 11: STAFFING, per §1919 (4D),SBHG Residential Treatment Program Handbook).
Information about the P&L System, as well as all other aspects of the program, is provided
to chents (see IV: POLICIES AND PROCEDURES, per §1919 (6L), Student Handbook).

Dietaty' and food services are an integral part of a youngster’s treatment program.
Special protocols for dietary services support the psychotherapeutic needs of youth and
include actictities such as barbecues, ethnic and cultural food service, and training in meal
preparation. Close coordination between dietary and clinical staff is necessary regarding
medication interactions on appetite, nutritional uptake, and healthy weight management. In
order to provide the support necessary for good eating habits, "family style" dining is used,
with assigned staff eating with the youngsters, serving as supervisors, role models, and
interventionists around dining issues.

Since the 1999 Plan of Operation, the residential component of Starlight CTF has
undergone significant upgrades to interventions, programming, and training in two key areas:
1) with respect to the management of dangerous behavior; and, 2) to overall flow, shift

transitions, and oppormnities provided youth during evening and recreational programming.
With respect to the management of dangerous behavior, SBHG and Starlight leadership
engaged in a series of quality improvement efforts corresponding to the passage of Senate
Bin 130 regarding the use of restrictive iaterventions. These included: a) substantial
evolution to agency policy and procedures on the management of dangerous behavior (see
IV: POLICIES AND PROCEDURES,§1919 (6G), NSG 1.70, Management of Dangerous
Behavior); b) voluntary discontinuation of the use of mechanical restraints (stiU allowed by

law in a CTF); c) extensive staff trainings on the new MDB policy including a corresponding
shift from Professional Assault Response Training(PART) to PRO-ACT with greater focus
on prevention, de-escalation, and evasion of aggression; d) ongoing Health and Safety CQI
Committee attention and improvement projects focused on high risk behaviors,including
safety contests and more recently, systematic review of incident debriefings; e)
enhancements to the core training curriculum for residential treatment staff to improve their
understanding of client behavior, how to bitild relationships with clients, and use of practical
intervention skills (see II: STAFFING §1919 (4D)); and, f) clarification of language applied to
restrictive interventions to create more consistent and reliable incident reporting and data for
quality management (for further analyses, summary of quahty improvement projects, and
areas of continued improvement regarding use of restrictive interventions, please see V:
QU.LLITA^ ASSUIL\NCE, per §1919(7), Starlight CTF Management of Acuity (QI Report)).

In spring 2005, and in response to youth feedback on satisfaction sunmys. Starlight
leadership engaged all staff and clients in rounds of interactive planning discussions in order
to identify ways to improve the miheu program, resulting in the development of the Real
Life program. This evening curriculum includes normalizing recreational activities and
outings, educational groups, and opportunities for family to join youth at the facility for
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KLD.v.06-06-06

workshops and celebratory events. External community resources are brought into the mix
of offerings and the program is coordinated through a daily community meeting process
with the transition from the day’s DTI program through the evening meal and determination
of each youth’s appropriate level of involvement (see X: APPENDICES, Real Life Program, as
well as policy on Ghent Outings).
2. Day TreatmentIntensive(DTI):DTI services and other mental health services identified
below (nos. 3-7) are provided by Starhght Adolescent Center, Inc. through contracts with the
departments of mental health of counties utihzing the CTF. The DTI program is offered 7
days per week (1:30 pm to 6:00 pm daily).and is a multi-disciphnary treatment service
designed to reduce youth’s psychiatric symptoms and risk behaviors, increase functioning
and coping skills, and enable youth to relate to peers and adults in a satisfying and self
esteem promoting manner. Individual therapy, family therapy and groups are provided by
Mental Health Clinicians and Rehabhitation Therapists (each within their scope of practice
and expertise) to meet the treatment needs of youth presenting with different diagnoses
(chnical pathways), risk factors, or skill development needs. As a full day Medi-Cal certified
program, DTI services involve over 4 continuous hours daily of programming with at least 3
hours of groups, and a daily Community Meeting of staff and clients together to support
milieu conamunication, planning, and problem-solving. A licensed or registered clinician with
a scope of practice of psychotherapy must be present and available in the milieu during all
DTI hours and a schedule is posted weekly on each unit to keep clients informed about tire
program (see X: APPENDICES,2006 Starlight Schedule for a copy of the master integrated
schedule that includes DTI among aU service components). DTI services are funded through
Medi-Cal’s Early Periodic Screening, Diagnoses and Treatment(EPSDT) program, AB 3632 funds,
or County General Funds (CGF).
DTI rehabilitative and treatment groups are organized into one of four types.

• Psychotherapy — promoting psychosocial adaptation, realization of human
potential, healthy intta- and inter-personal process, and resolution of internal or
external conditions resulting from client emotions, behavior, and/or thinking
that negatively impact others;

• Skill-building — facilitating the identification of the symptoms,internal barriers
and personal skills needed to overcome specific psycho-social experiences, and
to practice specific new skills and adaptive behaviors;
• Adjunctive — stimulating client self expression, rehabilitation, and personal
growth through art, music, drama,recreation, etc.; and,
• Process-oriented — dealing with program business, peer issues, and milieu
relationship dynamics and problem solving.
Starlight CTF is one among a number of SBHG-affihated programs making use of

evidence-based practices such as ART/EQUIP groups based on A.ggression Replacement

Training (ART).'* This proven skill-building curriculum is especially helpful to older youth
and young adults with histories of oppositional-defiant, aggressive behavior, and conduct
disorder. ART/EQUIP groups provide training on moral judgment, anger management,
correction of thinking errors, and pro-social skills using coaching, technology (e.g., videos
■* Gibbs, J.C., Potter, G.B., & Goldstein, A.P. (1995) The EQUIP Program: Teaching Youth to Think a?idAct Responsibly Through a
Peer-Helping Approach. Research Press: ISBN 0-87822-356-8.
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and computer games),and a positive peer culture. In the curriculum, a strong, pro-social
group identity becomes the foundation for mastering ART skills and an antidote to the kinds

of “deviancy traming” that can arise when youth with conduct problems come together. A
number of concrete social skills are addressed through the social skills training component
of ART. These include: learning how to express complaints constructively, caring for
someone who is sad or upset, deahng with negative peer pressure, avoiding fights, preparing
for stressful conversations, helping others, responding to someone who is angr}^ at you,
coping with failure, and expressing care and appreciation to others. Through ART/EQUIP,
participants learn that “caring is cool” and that they are capable of compassion and helping
others. Aggression is reduced and clients are empowered to handle angry feelings
responsibly. The SBHG ART/EQUIP program recently received a 2006 National Council of
Community b' ehavioral H' ealthcare(NCCBH)Service Excellence Award.

Another evidenced based practice is planned for implementation at Starhght
during FY 06-07. Dialectical b' ehavioral Therapy (DBT)involves once weekly individual
psychotherapy along with other interventions (e.g., group therapy, telephone contact, and
environmental restrucmring). DBT is appropriate for chents who have long-standing
problems with intense emotions (e.g., anger, shame, guilt, anxiety, sadness) that they have
trouble modulating (their emotional arousal is rapid, peaks at a high level, and takes
more

time to return to baseline than for most people). DBT has been shown to be effective with

chents who engage m self-harmful and hfe-threatening behaviors, reducing such behavior,
associated crisis and psychiatric hospitahzation, and premature drop-out from treatment.

The focus of DBT is to actively teach skills within the context of the therapeutic relationship
that will help the chent manage otherwise disorganizing emotions.

3. Case Management(CM):This includes assisting residential youth to gain access to needed
medical, educational, social, prevocational, vocational, rehabihtative and other community
resources through plan development, communication, coordination, referral, and ser\uce

monitoring to assure access. Case management involves maintaining consultative
professional relationships with outside agency parmers and is funded through EPSDT AB
3632 or CGF.

4. MentalHealth Services(MHS):Interventions outside of DTI program hours are designed
to reduce disabling symptoms and/or improve functioning consistent with goals of learning,
development, rehabihtation and self sufficiency. Services may include assessment, pi
an

development, individual or group therapy, rehabihtation groups, and collateral contacts with
significant persons in the chent’s hfe in support of the chent’s treatment goals. For CTF
youth these services include family finding and related collateral efforts apphed to advance
permanency plans. MHS are funded through EPSDT,AB 3632, or CGF.

5. Medication Support Services(MSSf. These are services provided by a hcensed physician
such as psychiatric evaluations and the administration and monitoring of psychiatric
medications. Medications are prescribed to reduce acute and extreme symptoms and safely
stabhize chents so that they can benefit from aU aspects of their treatment program. Staff
psychiatrists and nurses oversee medication use according to professional protocols and with
ongoing, expert, external pharmaceutical consultation. For more information see IV:
POLICIES AND PROCEDURES, per §1919 6D,Medication Administration, and X:

APPENDICES,SBHG Practice Philosophy Regarding the Use of Psychotropic Medications
with Youth). MSS are funded through EPSDT,AB 3632, or CGF.
^ Linehan, M (1993) Cognitive Behavioral Treatment ofBorderline Personaliy Disorder. Guildford Press, NY
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6. Therapeutic Behavioral Services(TBS):TBS are brief, intensive, one-on-one behavioral
interventions to children and youth with a serious behavioral and emotional disturbance that
put them at risk of being hospitalized, placed in high level residential treatment, losing a
stable placement, or not being able to move to a lower level placement. The behavioral
coaching is highly focused on the specific problems that lead to hospitahzation and/or, in
the case of a CTF,risk of loss of placement and/or inability to step-down to a lower level of
care. TBS are provided as one component of a mental health service plan; to be eligible
youth must be referred by their Mental Health Clinician. Funding is only through EPSDT.

7. Crisis Intervention (Cl). Crisis inten^ention services are available during times of
psychiatric crisis which are unplanned simations that demand an immediate response and the
expertise of professional staff The inter\^ention is a quick emergency response enabling the
client to cope with the crisis while maintaining their stams (avoiding hospitahzation) to the
extent possible, and are hmited to stabihzing the presenting emergency. Although the
specific crisis occurrence is unplanned, Starhght Mental Flealth Clinicians consider chent

safety and stabihty during admission and/or at any point in servfice as needed to bring all
treatment team participants together to understand and agree on how a chent’s crisis might
be avoided and/or best managed. Funding is through EPSDT,AB 3632, or CGF.
8. Starlight High School(SHS):SFIS is a state certified non-pubhc school(NPS), operated
by Starhght High School, Inc., providing comprehensive educational programming for
grades 6 to 12 with both core academic and elective subjects. Pursuant to federal Individuals
with Disabilities Education Act(IDEA)regulations, each youth receives an Individualised
Education Plan (lEP) for special education by credentialed instructors. Instructors are

experienced in working with emotionaUy dismrbed youth and with maximizing educational
achievement among youth with learning disabhities. Sendees include speech and language
therapists when needed. AU CTF youth must go to school ever}' day, unless medicaUy
excused. Credits earned at the NPS transfer back to the pubhc school and count toward high
school graduation. Some youth earn their high school diploma while at the NPS.
Additionally, Starhght High School offers a Workabihty Program, proving CTF youth with
employment readiness training and job experiences both at Starhght and in the community.
The Starhght High School(SHS) curriculum is approved by the state and local
school district and includes subject areas provided by regular pubhc high schools. The
curriculum is reviewed and upgraded every three years. SHS participates in the State
Department of Education’s SchoolAccountability Report Card(SARC),including education of
foster care youth, with mandated posting of results (http://www.starsgroup.org/schoolsV
About one third of Starhght High School smdents enter the program with the abihty to read,
write and solve mathematical problems at grade level. The majority does not and the need
for remedial education is written into each chent’s lEP. Moreover, smdents entering
residential treatment are not always able to maintain the same achievement level they once
did. Medication trials and unresolved emotional conflicts frequently cause temporary lapses
in the ability to perform academically. Therefore, teachers choose lessons and assignments
tailored to meet the smdent’s functioning level for each day from a curriculum which can be
apphed flexibly to “meet smdents where they are” — whether remedial or grade level:
• Social Science (3 yrs)- World History, U.S. History, U.S. Government, Economics
• linghsh (4 yrs)- Literamre, Language Arts, Reading, Writing
• Mathematics (2 yrs)- General Mathematics, Algebra, Geometty'
• Science (2 yrs)- Life Science, Physical Science
• Health and Physical Education (4 yrs)- wide variety' of subjects

• Iflectives (Varies)- Career Education, Fine Arts, Foreign Language, Computers
Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

IL STAFFING

The CTF is overseen by the Facility Administrator who is accountable for aU CTF operations,
interagency collaborations, setting positive leadership tone, hiring and termination of department heads,
and assuring that aU chent and family rights are upheld. The Medical Director is a trained psychiatrist
who is responsible for: a) ensuring medical and psychiatric care standards including care coordination; b)
providing psychiatric services including comprehensive assessments and medication support services; c)
24/7 emergency availability in support of milieu staff and clients; and, d) helping to assure that
chent/family rights are upheld. The Mental Flealth Program Director (aka Clinical Director) is
responsible for: a) ensuring nursing, psychological and behavioral treatment quahty and standards; b)
assisting with interagency collaborations; c) assisting in recmiting and hiring clinical department heads
and staff; d) care coordination and providing clinical guidance to mhieu staff; e) overseeing that each
chent’s treatment is carried out per the serttice plan, including directing review and changes as needed to
assure chent progress; and, f) helping to assure that chent/family rights are upheld. The Fachity
Admimstrator manages the Clinical Director, Director of Residential Services and the Director of
Medical Records; the Chnical Director in turn manages the Director of Nursing, Director of Treatment

Services, Director of DTI Rehabhitation, and Director of Staff Development, and others.
AU professional treatment staff of Starhght CTF are degreed and hcensed/registered and meet
CTF §1921 requirements for Social Workers, Marriage and Family Therapists, RNs,LVNs,LPTs,
Mental Health Workers, Psychologists and Psychiatrists. Youth Counselors and Rehabhitation Aides are
expected to have an Associates degree in a behattioral science and at least two years experience. Nursing
services are provided under the supervision of a fuU-time Registered Nurse with experience in
psychiatric nursing. There is at least one hcensed nurse on duty every shift. In addition, there are no less
than two fuU time equivalent(FTE) nursing staff per 36 chents on each 8-hour shift, during each 24
hour period, on a 7 day (weekly) basis.
Documents in this section:

A. Staffing Patterns,Job Descriptions, and Cultural Competency
• Consohdated Staffing Pattem-30 Beds
The staffing pattern is adjusted based upon census, which averaged 29.4/mo.,Jan-Mar
06. Staff are added to a.m. and p.m. shifts when a unit’s census reaches 18.
• Current Nursing Staffing Pattern
. Current LIC 500

• Current Job Descriptions

Service staff who work directly with CTF youth, regardless of funding source for
positions, but not including school personnel.
• FY 05-06 Cultural Competency Annual Plan
Progress on this plan whl be reported to SCC MH after end of fiscal year.
B,

Mental Health Director

• Pamelah Stephens. MFT.Lie # 28122
Hired as MH Director (aka Chn. Dir.) 11-25-02; promoted to CTF Admin. 12-16-05

• James B. Sondecker. mW.Lie # 19298
Hired as MH Director (aka Chn. Dir.) 04-17-06
C. Organi2ational Chart and Contracted Providers
• Starlight Children and Family Services Organizational Chart

Including CTF Chain of Command and Leadership Positions
• SBHG Management Services - executives, directors, areas of expertise and functions
• Consulting Professionals
Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

Gary Crouppen,PhD, clinical psychologist - clinical consultation

Robert Daigle, MD,physician - medical assessments, histor)? and physicals
Barbara Kammerlohr, Ed.D,educator - special education consultant

Michael Kreutzer, MD,psychiatrist — medical director, assessments, medication support
Mar)' Ann Niehardt, PhD,clinical psychologist - PRO-ACT trainer of Starlight trainers
D.

Staff Development (Training) Plan
• Starlight Children and Family Services Staff Development Plan
Plan sections describe new training resources focused on CTF staff
•

General Orientation: 40 Hours

Schedule of topics and trainers
• SBHG Residential Treatment Program Model Handbook
• Tan-May Monthly Training Calendars
• Stars Behavioral Health Group Training Modules (list)

Starlight’s training program is supported by SBHG Management Services
• Training Announcements (examples)
• Relationship-Based Training for Youth Counselors

Example of curriculum of recently implemented training

Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

III. ACCESS TO OTHER RESOURCES
Documents in this section:

• CAD 1.50 Emergency Medical Transfers
• NSG 1.00 Accidents/Emergency Care
• NSG 2.80 Consulting Medical and Emergency Services
•

NSG 3.50 Crisis Intervention

Starlight is contracted with county mental health to provide crisis interr'^ention services for
our CTF cKents. Also see IV: POLICIES AND PROCEDURES,NSG 1.70 Management of

Dangerous Behavior, D.2.h., regarding circumstances in which the Medical, Nursing or
CHmcal Director might pursue psychiatric hospitalization.
• Educational Placements and Classes: Not Applicable

Starlight CTF youth are enrolled in Starlight High School, a certified non-public school.

Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

IV. POLICIES AND PROCEDURES

SBHG and Starlight leadership have developed over 160 written policies and procedures since
the program began operations in 2000. Included with this submission is a selection of those that

correspond to the regidator)' section for the Plan of Operations (itemi2ed below,including some policies
that were recently updated). Please contact the Executive Director for additional policies and procedures
if needed.

A.

B.

CCL Topics §1919(6A-L)
Daily Obsert^ations and Interactions
Admission

Corresponding Starlight P&P
• NSG 5.50 Nursing Documentation
• NSG 5.60 Client Rounds and Supentision

• CAD 1.00 Admission Policjf for the CTF
• CAD 1.10 Admission of New Youths

• NSG 6.50 Psychiatric Evaluations

• Comprehensive Biopsychosocial Evaluation (Form)
C.

Discharge

• CAD 1.40 Discharge Policy
• CAD l.SOTransfer Summary

D.

Psychotropic Medication Control

• NSG 4.50 Med. Admin, for Dependents of the Court
• NSG 7.70 Telephone Orders

Needs & Services Plan, Consumer

• NSG 4.00 Interdisciplinary Treatment Plan
• Treatment Plan (Form)

E.

Involvement

• NSG 5.00 Needs and Services Plan/Assessment

• NSG 7.40 Treatment Planning, Nursing
F.

Needs & Services Plan, Monthly Review

• NSG 4.00 Interdisciplinary Treatment Plan (in E,above)

G.

Physical Restraint and Seclusion

• NSG 1.70 Management of Dangerous Behavior
• LEG 1.65 CHent Rights Denial and Restoration

II.

Staff Training on Client Rights

• See II, Staffing, D., topics under General Orientation

I.

Visitation and Phone Use

• ADM 2.90 Visitors

• LEG 1.66 Right to Phone Access
J

Confidentiality

• HR F-3 Confidentiality of Client Information

K.

Transitioning VC'ithin Facility

• Not applicable. All areas of the facility are secure.

I..

Informing CHent/Caretaker

• Admission Agreement
• Insurance Authorization

•
•
•
•

Agency Group Home Agreement
Informed Consent(Forms)
Personal Rights (Forms)
Client Preferences (Form)

• HIPAA NPP Acknowledgement of Receipt
• Complaint/Grievance (Forms)
• PGM 1.40 Student Handbook

• Student Handbook (April 2005)
• MHAP Client Rights Training Presentation
Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

V. QUALITY ASSURANCE

Starlight applies the SBHG TotalQuality Management(TQM)program and the delivery, quality, fidelity,
and outcomes of services are addressed in this context. TQM fulfills delegated responsibilities by county
mental health and other oversight agencies to address the accuracy, completeness,consistency,and conformity
of services to quahty standards and regulations. Starlight’s TQM program encompasses five methods of
quality management- key indicators, probes, quality assurance, utilization review, and peer review - applied
to continuous quahty^ improvement(CQI), along with results from outcome studies and satisfaction surveys.
Detailed information about these methods can be found in the enclosed TQM Manual (also see VI:
UTILIZ.\TION REVIEW,per §1919 (8)).

Information produced in TQM is reviewed by Starhght’s CQI Committees which include both
standing committees (i.e.. Management Practices, Medical and Nursing Practices, and Health and
Safety), as well as the regular participation of the Starhght Quality Assurance(QA)Director in
departmental meetings (i.e.. Residential Services, DTI Rehab, Treatment Sendees, and Non-Pubhe

School). The Starhght QA Director reports to the Executive Director of Starlight Children and Family
Services which, gives them both the authority and independence from department heads required to
provide quahty assurance oversight (see II: STAFFING §1919 (4C), Organizational Chart). The QA

Director oversees information gathering, analyses, flow, distribution, and reporting and is supported by
SBHG Management Services (Clinical Consulting Team). The staff of Starhght further amphfies youth
and family voice in quahty review by running periodic surveys and/or focus groups to gather input on
specific topics in need of attention and development. CQI Committee review of quahty indicators may
result in the formation of a Quahty Improvement Team (QIT) sponsored by

an

agency leader that

brings select staff together to analyze a trend, problem-solve,implement, and then monitor a quahty
improvement project. A Quarterly CQI Council provides an opportunity for ah stakeholders to come
together and review quahty indicators, identify options, and set priorities for quahty improvement.
Starhght also works on the cultural competency of service dehveiy' through an annual process which
results in a written plan (see II: STAFFING, per §1919(4A)and §5600.2(g) of the W&I Code,FY 05-06

Cultural Competency^ Annual Plan). Starlight, along with aU SBHG programs, is committed to conducting all
business in compliance with the highest ethical standards and ah apphcable laws, rules, and regulations. A
Corporate Compliance Handbook, Compliance Officer md Compliance Help Hne(866-782-7722) are available for

any/ah staff or consumers with questions or issues regarding legal, regulatory or ethical matters pertaining to
the workplace and service dehvery process.

Tabled below are TQM methods cross-walked to regulated program elements.
Regulated Elements
Performance Outcomes

TQM Methods

Correcting Deficiencies

Key inchcators, probes, cultural competency plan, outcomes
Corporate comphance, quahty assurance, utihzation review, peer
Key inchcators, probes, corporate comphance,annual program
Key inchcators, probes, quahty assurance, utihzation review, peer

Subcontractor Monitoring

Corporate comphance, annual program review

Professional Staff

Contract Requirements

Documents in this section:

• SBHG Total Quahty Management Manual

Whhe multiple and varied TQM methods address both hcensed mental health professionals
and child care staff accountabihty for the ser\dces and care provided youth, see in particular
the CTF key indicators and the probes apphcable to residential services, particularly under
Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

headings of safety and security, consumer quality of life, medical and nursing practices, and
cUmcal and program practices.
Starlight Annual TOM Plan for FY 05-06
Programs articulate specifically how they implement the SBHG TQM program and the
quality initiatives completed in the prior year as well as planned for the coming year.
TQM 1.00 Annual Program Reviews and Consultation Reports
Starlight Community Treatment Facility Management of Acuip^ (QI Report)

Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

VI. UTILIZATION REVIEW
Based upon a covinty’s Mental Health Plan(MHP)Utilization ReHew (UR)may be either primarily a

county-run and/or delegated responsibility. For Santa Clara County, UR is primarily managed through the
county’s Interageng Placement Review Committee(IPRC) process in which multi-agency referrals are screened for
appropriateness of RCL 13/14 including CTF placements. Subsequent to placement, UR is managed primarily
internally, per policy and procedure,with renewal of authorization for Day Treatment Intensive required by
the county every 90 days (see also V: QUALITY ASSURANCE,per §1919(7),SBHG TQM Manual for more
information about medical necessity determinations).
Document in this section;

• TQM 2.0 Utilization Review Process poUcy and procedure.
Note: §1919 (8A-B) is not apphcable as the CTF is entirely secure and youth are not
transferred between secure and non-secure portions of the facility.

Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

VII. CONTRACTS

Currendy, Starlight Children and Yamilj Services has a contract to provide mental health services to
CTF clients and receive supplementary funding for the CTF. Santa Clara County has ser\red as the “host
county” allowing other counties, such as Alameda, to contract with them directly for CTF access. This
win change in the upcoming fiscal year with Starlight contracting directly with other county mental

health administrations, and/or child welfare and juvenile probation, seeking to access the treatment
program for their most troubled youth (youth now come from over ten different counties). Copies of
these county MFI contracts will be submitted to CCL when finalized.
Document in this section:

• Santa Clara Valley Health and Flospital System Mental Health Department Fourth
Amendment to FY 05-06 Agreement

Starlight CTF Plan of Operation/Program Statement

KI.D.v.06-06-06

VIII. FACILITIES

Enclosed is an up-to-date detailed map of the Starlight building and grounds that encompasses
the CTF Program, Starlight High School, Community Sendees, and Shared (Pubhe) Space. The CTF is
now entirely secure with residential quarters, group/honor rooms, classrooms, bathrooms, cafeteria, and
seclusion rooms located within locked doors. The 1999 Plan of Operation description of the restraint
and seclusion room remains accurate, with the exceptions that Starlight staff no longer make use
mechanical restraints (discontinued winter, 2005).

A number of security and aesthetic improvements were made recendy to the Starlight facility
and others are being planned. At the top of the Ust is the locking of the doors to the CTF portion of
the building (note: residential units were aheady locked) that separates the CTF from the reception area
and our community services programs. This additional, second layer of locked doors (installed spring
2006) further decreases AWOL risk of youth, thereby increasing confidence in building security among
referring agencies such as juvenile probation. The added locked doors were agreed upon by the Santa
Clara County (SCC) Mental Health Department and negotiated with the SCC Fleet and Facilities
Department, with approval and fire clearance from the SCC Fire Department.
On the units, nursing stations were removed as they created a bottleneck near the entrance
doors as well as a physical hazard for youth who would chmb on top of them. Removing them has
created more open space and a friendlier, living space feeling on the residential units. Nurses now
operate solely out of separate, secure medication rooms (already in existence) when they are not on tiie
unit. Low areas of unit ceilings have been reinforced with metal plates installed on the comers to
prevent youth from jumping and grabbing a hold of prior exposed aluminum frames. Additional
cosmetic, comfort, educational, and entertainment improvements include stepped-up maintenance
schedules, refurbishing of youth rooms, embeUishments to group rooms and honors lounges both on
and off residential units, reconfiguration of school spaces to ease congestion, provision of better
computing technology to both staff and youth, and landscaping enhancements.

A further security enhancement involves improvements to exterior fencmg (e.g., around the
yard). An agreement has been achieved with the SCC Fleet and Facilities Department to erect sHghtly
higher fences with a new kind of material that prevents youth from gaining hand-holds and foot-holds
on the fencing. This project will be worked on during FY 06-07.
Finally, there is a plan under discussion with county mental health (project timeline TBD)to create an
intensive services unit(ISU) that would house, treat, and school youth (fuUy integrated program) of both
genders who are in an unstable condition (e.g., bizarre, disorganized and psychotic behaviors, active
aggression, self-harm). This unit would provide short-term psychiatric stabilization ofincoming or already
enrolled CTF clients and an opportunity to more effectively manage the CTF mikeu on behalf of the
treatment needs of all the youth. The availability of this unit would help program staff maintain quality control
over a client’s transition back to the CTF fcom an unstable period or crisis/hospitalization episode (also see V:
QUALITY ASSURANCE,per §1919(7),Starlight CTF Management of Acuity(QI Report)). CCL will be notified
again regarding this development as plans are finalized with SCC MH and building authorities.
Document in this section:

• Starlight Floor Plan and Evacuation Routes

Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

IX. BUDGET

Services provided to youth in the CTF are reimhursed through the responsible funding and
oversight agency as follows, based upon the type of servdce provided per regulated eligibility criteria,
service documentation standards, and provider scope of practice:
1.

Community Treatment Facility

CTF room and board with milieu treatment and staffing funded through Social Services.
2.

Starlight High School

High school educational programming funded through Education.
3. MentalHealth Services

Day Treatment Intensive (DTI), Case Management(CM), Mental Health Services (MHS),
Medication Support Services (MSS),Therapeutic Behavioral Services (TBS) and Crisis
Intervention (Cl) funded through Mental Health.
Document in this section:

•

Group Home Program Rate Applications fSR l-.SI

Starlight CTF Plan of Operation/Program Statement

KLD.v.06-06-06

’ •
i

X. APPENDICES
Documents in this section:

Client Outcomes Report(COR^ Form
Independent Living Skills Scale (ILSS^ Form
Real Life Program Description
Client Outings Policy and Procedure
2006 Starlight Schedule (Girls and Boys Dorms)
Practice Philosophy Regarding the Use of Psychotropic Medications with Youth

Starlight CTF Plan of Operation/Program Statement

KJ.D.v.06-06-06

starlight Adolescent Center

Floor Plan and tvacuation Koutes
!*

In Case of Emergency, Call 9-1-1

1%

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NOTE: Floor plans are posted

throughout the facility for reference

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SOC/TBS Counseling

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Fire Extinguisher

H

Fire Alarm Pull

Locked Doors

Residential Units (current)
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SHARED SPACE

Evacuation Route

Visitor Areas

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CTF - Future Residential

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