COA - Council On Accreditation

	Adult Guardianship

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (AG):

Update: Revised Table of Evidence - 12/01/11

Part 1: Program Information

Organizations may complete one template for all programs, or a separate template that addresses each program being reviewed under this section. Provide responses in each box provided.

Organizations being accredited for the first time: Please provide information for the last year.

Organizations being reaccredited: Please provide information for the period since the last accreditation review.

1. Describe any significant changes, challenges, awards received, changes in funding, or obstacles faced by the organization.

2. Provide an overview of the different program(s) being accredited under this section. The overview should describe:

the programs' service philosophy and approach to delivering services;
eligibility criteria;
any unique programs or special services provided to specific populations;
major funding streams; and
any additional information referenced in The Table of Evidence.

3. If service components are provided to individuals through contract in cooperation with other organizations or through a formal, coordinated service delivery system provide a list that identifies the providers and the services for which they are responsible. Do not include services provided by referral.

4. Provide any other information your organization would like the peer review team to know about these programs.

Attachments

A list of all program sites, including the following information for each program site: a) name of program/site director; b) address; c) phone number; d) hours of operation; e) number of FTEs; f) average monthly number of clients served; and g) directions or a map to each program site from the main organization office
A demographic profile of persons served by the program(s) being reviewed under this service section with percentages representing the following: a) racial and ethnic characteristics; b) gender; c) age; d) major religious groups; and e) major language groups. Include an explanation of how the program ensures that it is providing culturally competent services
As applicable, a list of groups or classes including, for each group or class: a) the type of activity/group; b) whether the activity/group is short-term or ongoing; c) how often the activity/group is offered; d) the average number of participants per session of the activity/group, in the last month; and e) the total number of participants in the activity/group, in the last month
A list of any programs that were opened, merged with other programs or services, or closed
Two quarterly reports from the case record review process conducted for this service, with any related corrective action plans (See PQI 4.02/4.03)
Two quarterly reports of accidents, incidents, and grievances related to this service (See RPM 2.02)
All COA-approved NA Requests
A list of all NAs applicable to your organization provided within the standards

Part 2: Program Outputs and Outcomes

Provide a response in each box describing how the program is making progress toward achieving its aims, and achieving better results for participants.

1. A summary of where the organization is in the development of its program for measuring program quality and outcomes, specific to the service.

2. A list or description of program outputs and desired outcomes and any outputs and outcomes being measured including measurement tools used.

Note: Program outputs may include consumer satisfaction, number of clients served, number of visits, timeliness of assessments, etc.

3. An overview of the organization's process for analyzing data.

4. Examples of program improvements made based on the outcomes data.

Attachments

Outcomes measurement/data collection procedures
Outcomes results reported for the previous two quarters


	Self-Study Documents	On-Site Documents	On-Site Activities
AG 1 Service Philosophy	Include Service Philosophy in Service Narrative Part I: Program Information		Interview: Program director Relevant personnel
AG 2 Community Outreach	Include a description of the community outreach program in Service Narrative Part I: Program Information	Informational materials on guardianship and guardianship law Workforce analysis and documentation of actions taken	Interview: Program director Relevant personnel Review case records
AG 3 Screening and Intake	Screening and intake procedures		Interview: Program director Relevant personnel Review case records
AG 4 Assessment	Assessment procedures Assessment tools and/or criteria included in the assessment		Interview Program director Relevant personnel Review case records
AG 5 Guardianship Planning, Monitoring, and Accountability	Service planning and monitoring procedures Include description of due-date tracking procedures in Service Narrative Part I: Program Information	Documentation of supervisory case review Documentation of timely reporting to the court or other regulatory bodies	Interview: Program director Relevant personnel Review case records
AG 6 Conflict of Interest	Adult Guardianship conflict of interest policy Procedures for assessing service needs and indentifying appropriate service providers Procedures for submitting court petitions		Interview: Program director Relevant personnel Review case records
AG 7 Frequency of Contact	Procedures and criteria used to assign and evaluate workload Procedures governing frequency of contact	24-hour coverage schedules for a recent three-month period Workload data for direct care personnel for the past six months	Interview: Program director Relevant personnel Review case records
AG 8 Guardian of the Person	Include description of services in Service Narrative Part I: Program Information Procedures for ethical decision-making Service monitoring and re-assessment procedures	Database of community programs and services including information on how to access them	Interview: Program director Relevant personnel Review case records
AG 9 Guardian of the Estate	Service planning and monitoring procedures Include description of due-date tracking procedures in Service Narrative Part I: Program Information	Documentation of supervisory case review Documentation of timely reporting to the court or other regulatory bodies	Interview: Program director Relevant personnel Review case records
AG 10 Case Closing	Case closing procedures		Interview: Program director Relevant personnel Review case records
AG 11 Personnel	Program staffing chart that includes lines of supervision List of program personnel that includes: name title degree held and/or other credentials FTE or volunteer length of service at the organization time in current position Table of contents of guardianship worker training curricula	Training curricula Documentation of training Job descriptions	Interview: Supervisors Personnel Review personnel files

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
AG 7.01, AG 7.02, AG 7.03, AG 8.08	AG 6.01, AG 6.04, AG 8.04, AG 11.02	AG 3.01, AG 5.01, AG 8.02, AG 9.06

RELATED FILES


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	SERVICE PHILOSOPHY The theoretical framework that describes and explains an organization's approach to service.


	PROGRAM A system of services offered by an organization. For example, an organization providing a mental health service may offer several mental health programs to different populations, e.g., a mental health program for adolescent teens. The word "program" can be used interchangeably with the word "service" or to describe specific programs.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


	OUTREACH Contact initiated by a provider to identify persons in need of services, to provide information to them about services and benefits, and to encourage the use of appropriate services.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.


	INTAKE The client's entry point for services at which eligibility is assessed against established criteria and a preliminary evaluation of the presenting problem occurs.


	ASSESSMENT An evaluation, which utilizes professional expertise and skills in the collection and analysis of data to understand and describe the nature of service needs of an individual, family, or group. Assessment, as in needs assessment, is also used to determine priorities of program planning and service development for the organization as a whole. See also DIAGNOSIS.


	CRITERIA Systematically developed, objective, and quantifiable statements used to assess the appropriateness of specific decisions, services, and outcomes.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	MONITORING An evaluation involving a periodic review of consumer services, organizational activities, or conduct. Specifically, monitoring is an activity of case coordination, whereas more broadly, monitoring is an evaluation technique used in overall quality assurance.


	CASE REVIEW A regular and periodic examination of a consumer's service needs, service delivery goals and objectives, intervention plans, prognoses, and the timelines required to achieve them. The direct service provider and supervisor frequently conduct the case review, but it may also involve others, as in an interdisciplinary or inter-organizational case conference. The client, or the parent or legal guardian in the case of a minor, are included in his/her periodic case review by the team.


	CONFLICT OF INTEREST A conflict between an individual self-interest and the public good. Example: an organization that operates a day treatment program awards a food services contract to a local restaurant that is owned by a governing body member. From a legal standpoint, "conflict of interest" is a term used in connection with fiduciaries and their relationship to matters of private interest or gain to them. When used to suggest disqualification of a fiduciary from performing his or her sworn duty, the term refers to a clash between public interest and private pecuniary interest of the concerned individual.


	WORKLOAD The amount of work assigned to or expected from a person within a specified period of time. See also CASELOAD.


	CASE CLOSING A voluntary or involuntary process which occurs when an organization no longer assumes responsibility for providing services to a particular individual, group, or family. Also known as "termination" or "discharge."


	SUPERVISION Assumption of responsibility for directly overseeing and evaluating the work or work products of personnel within an organization. Also includes inspecting the act or process of accomplishing a function or activity.


	PROGRAM PERSONNEL All direct service and administrators or supervisors of direct services that are involved in the operation of the organization's social service programs. "Program personnel" does not include MIS, accounting, facilities, clerical, or other staff that are not involved in the provision or oversight of direct services.


	VOLUNTEER An individual who performs services for an organization for civic, charitable, or humanitarian reasons, without promise, expectation, or receipt of compensation for services rendered. Such service must be offered freely and without pressure or coercion, direct or implied, from an employer. If the individual is otherwise employed by the same employer for which s/he volunteers, the individual cannot volunteer to perform the same type of services that s/he is paid to perform as an employee.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	JOB DESCRIPTION Explicit obligations and specific tasks required of personnel as a condition of employment. Such descriptions are in writing and may include educational, experiential, and skill requirements associated with the job.