COA - Council On Accreditation

	Services for Substance Use Conditions

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (SA):

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 the boxes located in the Service Narrative template.

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 persons and families 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 and families 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
SA 1 Screening and Intake	Screening and intake procedures		Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 2 Assessment	Assessment procedures List of any standardized assessment tool used	Copies of any standardized assessment tools used List of detoxification referral sources	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records Verify employment or formal arrangement with a physician
SA 3 Service Planning and Monitoring	Service planning and monitoring procedures	Documentation of case review	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 4 Service Philosophy, Modalities, and Interventions	Include Service Philosophy in Service Narrative Part 1: Program Information Procedures for use of non-traditional or unconventional practices, as applicable Table of contents of training curricula Policies for prohibited interventions	Documentation of training	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 5 Service Elements	Include description of services in Service Narrative Part 1: Program Information Service coordination procedures Procedures regarding the abuse of alcohol or drugs while participating in the program Crisis planning procedures	Description of public awareness campaign Informational material distributed to the public	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 6 Treatment for Substance Use Conditions	Include description of services in the Service Narrative Part 1: Program Information Treatment and referral procedures	Job description and resume of physician	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records Review physician’s personnel record or the formal consulting agreement, as appropriate
SA 7 Co-Occurring Substance Use and Mental Health Conditions	Description of how the service addresses treatment needs of persons with co-occurring substance use and mental health conditions	Copies of agreements with cooperating providers, as appropriate	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 8 Support Services	Description of child care services Procedures for the provision of support services		Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 9 Case Closing	Case closing procedures	Procedures that address continuation of services for persons whose third party benefits have ended	Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 10 Aftercare and Follow-Up	Aftercare/follow-up procedures		Interview: Clinical or program director Relevant personnel Individuals or families served Review case records
SA 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 The table of contents of training curricula that address all training topics Procedures and criteria used for assigning and evaluating workloads	Documentation of training Job descriptions Training curricula Documentation of workload assessment	Interview: Supervisors Personnel Review personnel files Verify the employment of, or contact with, other professionals

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
SA 2.04, SA 2.07, SA 4.03, SA 4.04, SA 6.02	SA 1.02, SA 4.02, SA 5.03, SA 6.01	SA 5.05

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.


	FAMILY Two or more people who consider themselves family and who assume obligations, functions, and responsibilities generally essential to healthy family life. Child care and child socialization, income support, long-term care, and other caregiving are among the functions of family life. The definition of "family" will rest with an individual's indication of who plays a family member role, including current or former foster family, adoptive family, extended family members, fictive kin, or significant others. Organizations that believe family is the central constellation in a child's life, and that family attachments are of primary importance for human development, will strive to work with professional staff to develop a common understanding of "family."


	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.


	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.


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


	ELIGIBILITY The degree to which an individual, family, group, or community meets the specific criteria and qualifications required to receive goods, benefits, or services.


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


	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."


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


	MAJOR LANGUAGE GROUP The presence of a substantial core of people in both the community and the client population that share a language.


	CLIENT See service recipient.


	GRIEVANCE See COMPLAINT


	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.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	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.


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	CONSUMER The individual, family, group, or community that seeks or receives services.


	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.


	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


	DETOXIFICATION The process by which drugs or other harmful substances are removed from a person's body for a time period sufficient to restore adequate physiological and psychosocial functioning.


	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.


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


	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.


	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."


	AFTERCARE Additional services provided beyond the period of primary care that offer continuity and supportive follow-up.


	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.


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