Part 1: Program Information
Agencies 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.
Agencies being accredited for the first time: Please provide information for the last year.
Agencies 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 agency.
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 agencies 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 agency 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 agency 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 PA-PQI 4.02/4.03)
- Two quarterly reports of accidents, incidents, and grievances related to this service (See PA-RPM 2.02)
- All COA-approved NA Requests
- A list of all NAs applicable to your agency 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 agency 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 agency'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
- Guardianship (PA-GSM) Service Profile
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Self-Study Documents |
On-Site Documents |
On-Site Activities |
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PA-GSM 1
Community Collaboration |
- Include description of community outreach in Service Narrative Part 1: Program Information
- Procedures for sharing case information
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- Informational material available to the community
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- Program director
- Relevant personnel
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PA-GSM 2
Service Philosophy |
- Include Service Philosophy in Service Narrative Part 1: Program Information
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- Program director
- Relevant personnel
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PA-GSM 3
Child and Youth Permanency |
- Procedures for exploring permanency options with the family
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- Program director
- Relevant personnel
- Service recipients
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PA-GSM 4
Homestudy |
- Description of homestudy process
- Homestudy tool and/or procedures
- Procedures for background checks
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- Program director
- Relevant personnel
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PA-GSM 5
Assessment |
- Procedures for conducting assessments
- Assessment tools and/or criteria included in assessment
- Procedures for identification and collaboration in ICWA cases
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- Indian Child Welfare Act information provided to families
- Copies of tribal state agreements, when applicable
- Information available to workers regarding available guardianship subsidies
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- Program director
- Relevant personnel
- Service recipients
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PA-GSM 6
Service Planning and Monitoring |
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- Program director
- Relevant personnel
- Service recipients
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PA-GSM 7
Pre-Guardianship Services |
- Include description of Pre-Guardianship Services in Service Narrative Part 1: Program Information
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- Informational materials provided to brith parents
- Orientation and informational materials provided to prospective guardians
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- Program director
- Relevant personnel
- Service recipients
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PA-GSM 8
Support Services |
- Include description of support services in Service Narrative Part 1: Program Information
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- Community resource and referral list
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- Program director
- Relevant personnel
- Guardians
- Children
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PA-GSM 9
Case Closing |
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- Program director
- Service recipients
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PA-GSM 10
Personnel |
- name
- title
- degree held and/or other credentials
- FTE or volunteer
- length of service at the agency
- time in current position
- Chart that specifies caseload size, per worker, for the past six months
- Procedures or criteria used for assigning and evaluating workload
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- Supervisors
- Personnel
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