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 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 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
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Self-Study Documents |
On-Site Documents |
On-Site Activities |
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PA-FPS 1
Access to Service |
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- Procedures for collaborating with agencies that refer families for service, if applicable
- Materials provided to the public and/or other agencies informing them about the agency’s services
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- Program director
- Relevant personnel
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PA-FPS 2
Screening |
- Screening procedures
- 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
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- Program director
- Relevant personnel
- Families served
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PA-FPS 3
Assessment |
- Assessment procedures
- Assessment tools and/or criteria included in assessment
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- Qualifications of personnel who conduct assessments
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- Program director
- Relevant personnel
- Families served
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PA-FPS 4
Service Planning and Monitoring |
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- Program director
- Relevant personnel
- Families served
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PA-FPS 5
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-FPS 6
Family-Focused Approach to Service Delivery |
- Include description of services in Service Narrative Part 1: Program Information
- Include description of typical or preferred length of service in Service Narrative Part 1: Program Information
- Procedures and/or criteria for extending services
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- Program director
- Relevant personnel
- Families served
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PA-FPS 7
Family Supports and Services |
- Include description of services in Service Narrative Part 1: Program Information
- Procedures for linking families to services and providing ongoing monitoring and follow-up
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- Coverage schedule for crisis intervention services
- Qualifications of personnel providing services to individuals with serious mental health needs, if applicable
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- Program director
- Relevant personnel
- Families served
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PA-FPS 8
Assessing the Need for Out-of-Home Care |
- Procedures for assessing the need for out-of-home care
- Assessment tools and/or criteria included in assessment
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- Qualifications of personnel involved in assessing the need for out-of-home care
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- Program director
- Relevant personnel
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PA-FPS 9
Case Closing |
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- Contract with public authority, if applicable
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- Program director
- Relevant personnel
- Families served
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PA-FPS 10
Aftercare and Follow-Up |
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- Program director
- Relevant personnel
- Families served
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PA-FPS 11
Personnel |
- Program staffing chart that includes lines of supervision
- List of personnel that includes:
- name
- title
- degree held and/or other credentials
- FTE or volunteer
- length of service at the agency
- time in current position
- Table of contents of training curricula
- Average caseload size, per worker, for the last month
- Procedures and criteria used for assigning cases, and for assigning and evaluating workloads
- Description of how agency ensures adequate staff coverage and compensates personnel appropriately
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- Job descriptions
- Documentation of training
- Training curricula
- Supervision schedule
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- Supervisors
- Personnel
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