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.		  
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  MANAGEMENT

See ADMINISTRATION		  
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  PRACTICE

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

An obligation, responsibility, or debt. 		 
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  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.		  
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  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.		  
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  PEER REVIEW

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

A person or persons with the legal authority and responsibility to set policy and oversee the operations of an organization. Generally, the governing body is a group, such as a board of directors or board of trustees. While the exact responsibilities of the governing body depend on the nature and character of the organization, the governing body has minimum fiduciary responsibilities to the organization set by statute, regulation, and case law, and typically assume responsibilities for long term planning, risk management, and evaluation and effectiveness of management.		  
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  RISK MANAGEMENT

A systematic process of evaluating and reducing potential risks that may befall personnel, clients, an organization, or a facility. Risk management activities are directed toward reducing an organization's legal and financial exposure, especially to lawsuits.		  
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  HUMAN RESOURCES

A department or service that is responsible for recruiting, hiring, and retaining personnel and monitoring the regulations and services applicable to a particular organization.		  
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  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. 		 
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  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.		  
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  PROCEDURES

Written instructions that outline the steps for performing a task(s) or operationalizing an administrative or service delivery process. A procedure can be written as a step-by-step set of instructions or as a narrative description of a process. A procedure tells someone how to do something not just what to do.

Unlike policies, procedures do not need to be approved or reviewed by the governing body, and need not be associated with a specific policy. For example, whereas a broad anti-discrimination policy requires grievance or other procedures in order to be operationalized within an organization, assessment procedures do not require a governing body approved assessment policy.

Note: Procedures are sometimes referred to as administrative policies.

  
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  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.		  
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  GRIEVANCE

See COMPLAINT 		 
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  POLICY

A written statement of principles, values, or intent that provides a basis for consistent decision making and guides the actions of staff, management, and board of trustees. A policy is intentionally broad in its language and application. The following is an example of an anti-discrimination policy:

"[Organization Name] shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers, selection of vendors, and provision of services."

In contrast, a procedure is a detailed, step-by-step description of a process. It tells the reader how to do something. Generally, policies are implemented through procedures. For example, the above anti-discrimination policy would require a detailed grievance procedure in order to operationalize it within an organization.

The governing body has the fiduciary responsibility for setting organizational policy. Therefore, policies must be approved and periodically reviewed by the organization's governing body. However, the governing body typically delegates (via policy) the responsibility for policy development to management. In owner-operated for-profit companies, the owner can act as the company's governing body, depending on the company's corporate structure.

In a public agency the responsibility for setting and reviewing policies may belong to the agency's management team, elected officials, another governmental agency, or as is often the case, a combination of the above.

  
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  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		  
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  TRAINING

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

Ongoing review and oversight of a client's use of prescribed or over-the-counter medications by a physician or other prescribing clinician. 		 
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  MEDICATION

A prescribed or over-the-counter drug that is injected, taken orally, applied topically, or otherwise administered.		  
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  PROTOCOLS

Instruments and procedures used to accomplish a particular goal, activity, or purpose.		  
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  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.		  
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  CASE

A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.		  
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  INFORMED CONSENT

The explicit granting of permission by a consumer or his/her legal guardian to the service provider and organization to use a specific intervention or participate in research. The consent is predicated on full disclosure of the facts to enable the consumer to make a decision based on knowledge of the risks and alternatives.		  
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  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."		  
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  CERTIFICATION

Assurance from a state or professional association that a person or organization possesses certain attributes, knowledge, or skills. 		 
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  VENDOR

An organization or person that sells services. 		 
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  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. 		 
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Risk Prevention and Management
  
Private Org Public Agency  
Administration and Management Narrative (RPM):
  

UPDATE: TABLE OF EVIDENCE - 12/01/10

The Administration and Management 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 Risk Prevention and Management Administration and Management 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: Risk Prevention and Management (RPM)

Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.

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

1. Describe the organization's overall approach to risk prevention and management. How are risks identified? How are identified risks brought to the attention of management? Which types of risks are brought to the attention of the governing body?

2. Describe 2-3 examples of your organization’s response to risks identified by its annual risk and quarterly risk management review processes. Please describe the steps, the decision-making process, and actions taken to bring the issue to resolution.

3. Describe how the organization assures that it remains abreast of changing legal and regulatory requirements.

4. Describe your organization's information management system.

  1. Which systems, if any, are computerized and which are not (e.g., the financial management system, PQI, human resources)?
  2. Are case records maintained electronically or in hard copy?

5. Provide any additional information that would increase the Peer Team’s understanding of how your organization’s risk prevention and management processes contribute to the achievement of its mission and the reduction of its exposure to risk, loss, and liability.

Attachments:

  1. All COA-approved NA Requests.
  2. 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
RPM 1
Legal and Regulatory Compliance
  • A letter signed by the Governing Body Chair and CEO certifying the organization is presently in compliance with license requirements, regulations and decrees
  • Include a description of the risk prevention and management system utilized by the organization to ensure compliance with applicable licenses, regulations and decrees in RPM Narrative Question 3

For Networks:

  • Procedures for ensuring provider compliance applicable licenses, regulations, and decrees for services provided by the network
 
  • See Governing Body Manual
  • Relevant licenses and legal regulation documents, as applicable to the organization
  • Reports from licensing/regulatory review, as applicable

For Networks:

  • Copies of relevant licenses and legal regulation documents, as applicable to the providers, at the office of the managing entity
  • Reports from licensing/regulatory review, as applicable
 
  • Interview:
  1. Governing Body
  2. CEO/CFO
 		  
RPM 2
Risk Prevention*
  • Procedures for conducting annual assessments of potential organizational risks
  • Procedures for quarterly review of incidents, accidents, and grievances
 
  • Quarterly (RPM 2.02) and annual (RPM 2.01) risk management reports, including analyses and improvement action plans, as applicable
  • Governing body and management meeting minutes where risk prevention and management activities are reviewed, improvement actions discussed, and implemented, as applicable
  • Policy outlining how the organization assumes the cost for legal assistance to personnel against whom claims are made (RPM 2.06)
 
  • Interview:
  1. Governing Body CEO/CFO
  2. Risk management personnel
 		  
RPM 3
Medication Control and Administration*		  
  • Case records
  • Medication logs
  • Documentation of medication management training provided to personnel
 
  • Interview:
  1. Direct service and supervisory personnel
  2. Medical personnel, as applicable
  • Facility observation
 		  
RPM 4
Insurance Protection
  • List of insurance policies with descriptions, amounts and dates of coverage

For Networks:

  • Procedures for identifying and verifying provider insurance
  • Copy of written communication to providers regarding required insurance
 
  • Current insurance policies
  • Minutes of meetings related to the organization's annual review and approval of insurance coverage
  • Documentation that the organization provides a written description to personnel regarding its: insurance types, coverage amounts, and assumes legal assistance costs, as relevant

For Networks:

  • Documentation of insurance verification
 
  • Interview:
  1. Governing Body members
  2. CEO/CFO
  3. Personnel at all levels

For Networks:

  • Interview:
  1. Provider Governing Body members
  2. Provider CEO/CFO
 		  
RPM 5
Information Management and Use		  
  • Information management procedures/guidelines
 
  • Interview:
  1. Finance personnel
  2. PQI personnel
  3. MIS manager
  4. Program directors
  5. Direct service personnel
  • MIS observation
 		  
RPM 6
Security of Information*		  
  • MIS case record procedures
  • HIPAA compliance policies and procedures, as applicable
 
  • Interview:
  1. Finance personnel
  2. PQI personnel
  3. MIS manager
  4. Program directors
  5. Direct service personnel
  • Case record room/files and MIS accessibility observation
 		  
RPM 7
Case Records*

For Networks:

  • Record content and maintenance procedures
 
  • Mock case record for each service section
  • Case records
 
  • Interview:
  1. Personnel
  2. Supervisors
  3. Program directors
  4. Persons served

For Networks:

  • Interview:
  1. Managing entity screening, assessment, and authorization staff, if these services are provided
  2. Providers who request authorizations from the managing entities
  • Interview:
  1. Provider personnel
  2. Provider supervisors
  3. Provider program directors
 		  
RPM 8
Access to Case Records*
  • Case record access policies and procedures
 		  
  • Interview:
  1. MIS Manager
  2. Case record clerk
  3. Program directors
  4. Direct service personnel
  5. Persons served
  • Case record room/files and MIS accessibility observation
 		  
RPM 9
Contracts and Service Agreements*
  • Contracting procedures
  • List of contracts/service agreements/memoranda of understanding (MOU)

For Networks:

  • List of contracts/service agreements/memoranda of understanding (MOU) between the network and providers
 
  • Actual contracts/service agreements/MOUs
  • Proof of accreditation, licensure, or certification for outside providers operating adventure-based activities
 
  • Interview:
  1. Governing Body
  2. CEO/CFO
  3. Contract manager(s)
  4. Vendors

For Networks:

  • Interview:
  1. Provider CEO/CFO
  2. Provider contract manager(s)
 		  
RPM 10
Quality Monitoring of Purchased Services*		  
  • Contracts
  • Contractor progress reports
 
  • Interview:
  1. Governing Body
  2. CEO/CFO
  3. Contract manager(s)
  4. PQI personnel
  5. Vendors

For Networks:

  • Interview:
  1. Provider CEO/CFO
  2. Provider contract manager(s)
 		  
   
 
Fundamental Practice Standards:
  Essential Life and Safety Health and Welfare Client Rights
RPM 2.02,  RPM 3.04,  RPM 9.05  RPM 2.05,  RPM 3.01,  RPM 3.02,  RPM 3.03,  RPM 3.05,  RPM 4.01,  RPM 7.02,  RPM 7.03,  RPM 8.03  RPM 8.01