COA - Council On Accreditation

	Administrative and Service Environment

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Delivery Administration Narrative (ASE):

Update: Revised Table of Evidence - 06/01/10

The Service Delivery Administration Narrative should provide an overview of key practices that contribute to the performance and productivity of your organization. The Narrative supports, but should not duplicate, evidence provided elsewhere in your self-study.

The Administrative and Service Environment Service Delivery Administration Narrative should provide the Peer Review Team with a clear, concise description of how your administrative and service environments contribute to your organization’s productivity and effective service delivery.

Purpose Standard: Administrative and Service Environment (ASE)

The organization’s administrative and service environments are respectful, caring, safe, and accessible, and contribute to organizational productivity and effective service delivery.

Provide responses to the following questions that address your organization’s achievement of the Administrative and Service Environment Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

1. Describe the overall environment in which your organization operates and any environment-related security or emergency preparedness issues that may impact your organization.

(e.g., Our organization opened a new shelter three years ago in a more centralized location that was more accessible to the majority of our service population. However, the neighborhood has been identified as a high crime area with an increase in vandalism and break-ins over the past ten years. Since starting operations in the new location, our organization has taken the following precautions to ensure the safety of our personnel and service recipients…)

2. Cite 2-3 examples of activities or decisions that your organization has undertaken that contributed to the health and safety of persons served, personnel, and visitors.

(e.g., Over the past 12 months our organization has designed and implemented an extensive training program to ensure that all current and incoming staff receive comprehensive training on how to respond to medical threats and emergencies. As part of this program, we have scheduled training sessions on …)

3. Cite 2-3 examples of your organization’s efforts to coordinate with community resources, or otherwise adapt its services, to ensure that its facilities are accessible to its identified service population.

(e.g., Our organization continuously reassesses the accessibility of our facilities to guarantee that we are meeting the needs of our service recipients. Most recently we have partnered with the local public transportation system to create an additional bus stop in front of our program site so that service recipients can better access…)

4. Describe how regular safety inspections and maintenance reports are incorporated into your organization’s risk prevention and management reviews and how the results of these reports are integrated into its PQI activities.

(e.g., The CEO informed the Board about actions taken to resolve persistent flooding of the basement at the Southside Day Treatment Program site, and the PQI committee has begun strategizing about methods for improving…)

5. Provide any additional information that would increase the Peer Team’s understanding of how your organization creates a safe and respectful environment that contributes to organizational productivity and effective service delivery.

Attachments:

A list of licenses applicable to your programs and services including the oversight bodies that issue and monitor them.
All COA-approved NA Requests.
A list of all NAs applicable to your organization provided within the standards.

Note:

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.


	Self-Study Documents	On-Site Documents	On-Site Activities
ASE 1 Promotion of Health and Safety*	Smoking policies and/or procedures	Copies of resources and educational materials on healthy living available to service recipients	Interview: Program director Facility management staff Individuals or families served Observe facility See RPM 2
ASE 2 Accessibility		Documentation of legal compliance	Interview: Program director Relevant personnel Observe facility
ASE 3 Legal and Regulatory Compliance		Relevant licenses Certificates of Occupancy and other documentation of compliance For Networks: At the managing entity, relevant licenses for managing entity and providers	Interview: Program director Facility management
ASE 4 Facility Maintenance*	Maintenance procedures	Maintenance inspection reports	Interview: Facility management Observe facility See RPM 2
ASE 5 Tools and Equipment*	Maintenance procedures		Interview: Maintenance personnel Relevant personnel Observe facility See RPM 2
ASE 6 Safety and Security*	Safety procedures Procedures for serving perpetrators	Training documentation Record of fire drills held Procedures for vehicle use, inspection, maintenance, and operation Contracts, including safety expectations, with any outside transportation providers	Interview: Relevant personnel See RPM 2
ASE 7 Emergency Response Preparedness*	Emergency Response Plan Emergency preparedness procedures For Networks: Emergency Response Plan re: coordinating among service provider organizations and individual providers	Emergency preparedness training materials	Interview: Relevant personnel Review documentation of training in personnel files Observe facility See RPM 2 For Networks: Interview: Network CEO Network Emergency Response Coordinator
ASE 8 Special Health Precautions*	A description of the activities conducted or system in place used to ensure compliance with applicable legal and regulatory requirements associated with risk of exposure to contagious and infectious disease		Interview: Relevant personnel See RPM 2

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
ASE 3.02, ASE 5.01, ASE 6.01, ASE 6.02, ASE 7.01, ASE 7.02, ASE 7.04, ASE 8.01	ASE 1.01, ASE 1.02, ASE 4, ASE 6.03, ASE 6.04, ASE 6.05, ASE 8.02

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.


	ADMINISTRATION The personnel responsible for management functions of the organization, including fiscal management, human resources, and service delivery. Such personnel determine organizational goals, acquire and allocate resources to carry out a program, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	PERFORMANCE A measure of how well an organizational system provides services to consumers. Performance is often based on key indicators, such as rates of service, cost per consumer, degree of satisfaction with services, and extent of consumer access to services.


	PEER REVIEW An evaluation process in which professionals from similar backgrounds review the work of their associates.


	SERVICE POPULATION A group or target population that the organization's services are designed to serve in accord with its mission, and which includes the organization's service recipients. An organization's service population may be defined by geographic location, specific problems or needs, religion, ethnicity, culture, or other factors.


	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


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


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


	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.


	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.


	PREVENTION Actions taken to minimize and/or eliminate social, psychological, or other conditions. Prevention can occur at the individual, group, community, and societal levels and enhances opportunities to achieve positive fulfillment.


	MANAGEMENT See ADMINISTRATION


	ACCREDITATION The formal evaluation of an organization against accepted criteria or standards. A professional society, non-governmental organization, or a governmental agency may conduct accreditation activities. A COA-accredited organization has undergone a period of rigorous self-study and is capable of providing programs and services that meet or exceed COA standards.


	CONTRACT A formal written agreement between two or more parties that specifies the services, space, or products to be provided in exchange for some form of compensation. Also known as "purchase of service arrangement."