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 organization. The Narrative supports, but should not duplicate, evidence provided elsewhere in your self-study.

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

Purpose Standard: Client Rights (CR)

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

Provide responses to the following questions that address your organization’s achievement of the 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 organization 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 organization, 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 organization 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 organization’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 organization’s annual risk assessment and PQI activities.

(e.g., Departmental leadership meets with the program director following the receipt of any formal grievance. The director includes all complaints in the annual risk assessment which is then shared with the board for 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 organization.

Attachments:

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

Note:

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.