COA - Council On Accreditation

	Residential Treatment Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (PA-RTX):

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
Residential Treatment Services (PA-RTX) Grouping Chart


	Self-Study Documents	On-Site Documents	On-Site Activities
PA-RTX 1 Needs Based Access to Service	Admission criteria Scope of services statement	Admission material describing items individuals can bring with them and prohibited items	Interview: Program director Intake personnel Review case records
PA-RTX 2 Family Connections	Include in Service Narrative Part 1: Program Information overview of family involvement activities, requirements, and opportunities throughout the course of treatment	Family handbook, clinical, or educational example material describing family involvement activities, requirements, and opportunities	Interview: Program director Relevant personnel Residents and family members Review case records
PA-RTX 3 Assessment	Assessment procedures Interdisciplinary assessment tools and/or criteria including mental health, substance use and trauma screening		Interview: Program director Relevant personnel Residents Review case records for individualized strengths based assessments
PA-RTX 4 Service Planning and Monitoring	Service planning procedures showing assessment based planning Monitoring procedures	Documentation of case review	Interview: Program director Relevant personnel Residents Review case records for plans based on needs assessment, diagnosis, and treatment goals
PA-RTX 5 Child and Youth Permanency	Description of permanency planning process that supports timely goal setting and achievement		Interview: Program director Relevant personnel Residents Review case records
PA-RTX 6 Service Philosophy, Modalities, and Interventions	Include Service Philosophy in Service Narrative Part 1: Program Information Procedures related to use of non-traditional or unconventional practices, as applicable Table of contents of training curricula, as applicable Policies for prohibited interventions	Documentation of training	Interview: Program director Personnel Residents Review case records
PA-RTX 7 Coordinated Customized Team Approach	Include in Service Narrative Part 1: Program Information overview of how teams align to coordinate and customize daily living, treatment, and care		Interview: Program director An interdisciplinary team or observe team meeting Residents Review case records
PA-RTX 8 Service Array	Include Service Narrative Part 1: Program Information overview of service and support components	Activity schedules showing opportunities for choice and options according to needs, interests, skills and functioning	Interview: Program director Relevant personnel Residents Review case records Observe the program
PA-RTX 9 Health and Dental Services	Overview of health resources, related procedures, and oversight	Health screening, assessment and education material	Interview: Program director Relevant personnel Residents Review case records Verify employment of physician either directly or via contract
PA-RTX 10 Education Services	Opportunities and enrollment procedures for residents with education goals Procedures for coordination with community-based education programs	Individual education plans	Interview: Program director Relevant personnel Residents Review case records for education goals and plan Contact community education programs that serve residents
PA-RTX 11 Preparation for Community Membership	Include in Service Narrative Part 1: Program Information description of opportunities for residents to prepare for community membership		Interview: Program director Relevant personnel Residents
PA-RTX 12 Services for Substance Use Conditions	List of substance use resources and services continuum	Documentation of residents with co-occurring conditions	Interview: Program director Relevant personnel Residents Review case records
PA-RTX 13 Special Risk Population	Include in Service Narrative Part 1: Program Information description of special risk populations and services		Interview: Program director Relevant personnel Residents Review case records
PA-RTX 14 Residential Facilities			Interview: Program director Relevant personnel Residents Observe facility
PA-RTX 15 Privacy Provisions	Privacy policy and procedures		Interview: Program director Relevant personnel Residents Observe facility
PA-RTX 16 Care and Supervision	Resident/personnel care and supervision ratios Supervision and scheduling criteria Criteria and procedures used to assign and evaluate workloads	Resident/personnel care and supervision coverage schedules for the past year Workload data for direct care personnel for the past six months	Interview: Program director Relevant personnel Residents Review case records
PA-RTX 17 Transition from the Service System	Transition activities list and planning procedures		Interview: Program director Relevant personnel Residents Review case records
PA-RTX 18 Case Closing and Aftercare	Case closing procedures indicating planning beginning at intake Aftercare and follow-up procedures	Procedures for determination of responsibility when third-party payments or benefits end Review contract with public authority, as applicable	Interview: Program director Relevant personnel Residents Review case records
PA-RTX 19 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 agency time in current position	Job descriptions	Interview: Supervisors Personnel Review personnel files Verify employment or contract with psychiatrist, psychologist, and other professionals

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
PA-RTX 3.01, PA-RTX 3.03, PA-RTX 6.03, PA-RTX 6.04, PA-RTX 8.05, PA-RTX 9.01, PA-RTX 16.04, PA-RTX 19.03	PA-RTX 1.04, PA-RTX 2.03, PA-RTX 3.05, PA-RTX 3.06, PA-RTX 4.01, PA-RTX 6.02, PA-RTX 7.03, PA-RTX 9.04, PA-RTX 9.05, PA-RTX 9.06, PA-RTX 16.01, PA-RTX 16.02, PA-RTX 19.05	PA-RTX 15.01, PA-RTX 15.02, PA-RTX 15.03, PA-RTX 15.04, PA-RTX 15.05

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.


	COMMUNITY A specific group of people living in the same locality and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, tribal affiliation, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, tribes, residential neighborhoods, business districts, recreational areas, and health and human service sites.


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


	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.


	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.


	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


	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.


	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."


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


	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.


	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.


	NEEDS ASSESSMENT An initial survey undertaken to determine the special service needs of a defined population.


	DIAGNOSIS The process by which a social, physical, or mental health problem and its underlying cause are identified and a plan of action formulated toward resolution of the problem. The diagnostic process involves collection and analysis of relevant information. See also ASSESSMENT.


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


	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.


	INTERDISCIPLINARY TEAM A group of persons from different professions, disciplines, service areas, organizations, and/or personnel levels who collaborate to make decisions about and provide a range of services for the same consumer or consumer group. The service delivered would not be possible or as efficient if one organization or one professional alone provided the services.


	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."


	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.


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


	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.


	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.


	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.


	PSYCHOLOGIST A qualified professional who has a doctoral degree from a program of psychology accredited by or recognized as meeting the standards set by the American Psychological Association. A master's degree in psychology is an acceptable credential for the provision of counseling services provided that licensure is attained.