CLIENT

See service recipient.		  
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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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  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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  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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  LEGAL GUARDIAN

A person who has legal responsibility for the care and management of a person incapable of administering his/her own affairs. In the case of a minor child, the guardian is charged with the legal responsibility for the care and management of the child and of the minor child's estate.		  
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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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  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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  CONFIDENTIALITY

An ethical and practice principle that requires the protection of information shared within a professional-client relationship. An organization that upholds confidentiality prohibits personnel from disclosing information about persons served without their written consent.		  
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  SAMPLE

A portion or representative percentage of a greater whole.		  
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  CLINICAL

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

See COMPLAINT 		 
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  SERVICE PHILOSOPHY

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

The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.		  
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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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  ASSISTIVE TECHNOLOGY

The commercial or custom-designed devices, modifications, accommodation strategies, and/or related technical services that help persons with disabilities increase, maintain, or improve their functional capabilities.		  
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  REFERRALS

Resource suggestions provided to consumers to address problems or needs that are beyond the scope of the organization's mission.		  
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  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."		  
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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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Client Rights
  
Private Org Public Agency  
Service Delivery Administration Narrative (PA-CR):
  

UPDATE: TABLE OF EVIDENCE - 04/01/11

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

The Public Agency Client Rights Service Delivery Administration Narrative should provide the Peer Review Team with a clear, concise description of how your agency’s practices promote respect for personal dignity, confidentiality, and privacy.

Purpose Standard: Public Agency Client Rights (PA-CR)

The rights and dignity of clients are respected throughout the agency.

Provide responses to the following questions that address your agency’s achievement of the Public Agency Client Rights Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

1. Cite 2-3 examples of activities or decisions that your agency has undertaken to protect and promote client rights.

(e.g., The past four years have brought a steady increase in the Chinese population to the neighborhood surrounding our program site. To accommodate the changing demographic of our service population, we have hired two bilingual caseworkers, fluent in both Mandarin and English…)

2. Identify a part of your client rights practices that has been:

  1. the most difficult to advance, and indicate the reasons why; and
  2. the least difficult to advance, and indicate the reasons why.

(e.g., Due to several recent changes in leadership at our agency, we have been working on drafting more comprehensive grievance procedures to replace the informal system that was previously in place. Drafting the procedures, training staff, and incorporating results into PQI and risk management practices has taken longer than anticipated as personnel get settled in their new positions…)

3. Describe how your agency reconciles its confidentiality and privacy practices with legal requirements on the release of identifying information, mandatory reporting, and duty to warn.

(e.g., The results of last year’s employee satisfaction survey identified confidentiality guidelines as an area of primary concern among direct service personnel. In response, we have designed an extensive training program on our agency’s confidentiality policies including the relationship between our policies and legal regulations governing information about mental health consumers, victims of domestic violence, child abuse …)

4. Describe how grievances of applicants, persons served, and other stakeholders are incorporated into your agency’s annual risk assessment and PQI activities.

(e.g., Departmental leadership meets with the program director following the receipt of any formal grievance to discuss the development of action steps, timelines, and the assignment of responsibility as necessary…)

5. Provide any additional information that would increase the Peer Team’s understanding of how your client rights practices promote respect for the rights and dignity of clients throughout the agency.

Attachments:

  1. All COA-approved NA Requests.
  2. A list of all NAs applicable to your agency provided within the standards.

Note:

Agencies being accredited for the first time: Please provide information for the last two years.

Agencies being reaccredited: Please provide information for the period since the last accreditation review.

    Self-Study Documents On-Site Documents On-Site Activities
PA-CR 1
Protection of Rights and Ethical Obligations*		  
  • Rights and responsibilities document provided to individuals and families at initial contact
  • Fee schedule for individuals and families served
  • Policy for providing services to minors without the consent of the parent or legal guardian
 
  • Interview:
  1. Relevant personnel
  2. Individuals or families served
 		  
PA-CR 2
Confidentiality and Privacy Protections*		  
  • Consent and release forms in the case records
 
  • Interview:
  1. Clinical or program director
  2. Relevant personnel
  3. Individuals or families served
  • Review case records
 		  
PA-CR 3
Grievance Procedures*
  • Grievance policy or procedures for individuals and families served
 
  • Grievance reports for the last two quarters
 
  • Interview:
  1. Clinical or program director
  2. Relevant personnel
  3. Individuals or families served
 		  
PA-CR 4
The Rights of Persons with Developmental Disabilities*
  • Include service philosophy in Service Narrative Part 1 of each applicable service section (PA-CR 4.01, PA-CR 4.02, and PA-CR 4.07)
  • Procedures for use of interventions that limit movement, diminish sensory experience, limit personal freedom, or cause personal discomfort, as applicable
  • Include service planning procedures with the service planning and monitoring evidence of each applicable service section (PA-CR 4.03, PA-CR 4.04, and PA-CR 4.05)
  • Procedures for helping persons access assistive technology
  • Procedures for providing or making referrals for family support services
 
  • Training curricula, educational material and/or other material provided to persons served regarding sexuality and relationships
 
  • Interview:
  1. Clinical or program director
  2. Relevant personnel
  3. Persons served
  • Review case records
 		  
   
 
Fundamental Practice Standards:
  Essential Life and Safety Health and Welfare Client Rights
PA-CR 4.02  PA-CR 1.09,  PA-CR 4.06  PA-CR 1.05,  PA-CR 1.07,  PA-CR 2.01,  PA-CR 2.04