COA - Council On Accreditation

	Opioid Treatment

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (OTP):

Part 1: Program Information

Organizations 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.

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.

1. Describe any significant changes, challenges, awards received, changes in funding, or obstacles faced by the organization.

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 organizations 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 organization 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 organization 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 organization 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 organization 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 organization'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


	Self-Study Documents	On-Site Documents	On-Site Activities
OTP 1 Access to Service	Access procedures	Blank consent form	Interview: Clinical or program director Relevant personnel Persons served Review case records Observe facilities
OTP 2 Screening and Intake	Screening and intake procedures		Interview: Clinical or program director Relevant personnel Persons served Review case records
OTP 3 Assessment	Assessment procedures Assessment tool and/or criteria included in assessment		Interview: Medical personnel Clinical personnel Persons served Review case records
OTP 4 Service Planning and Monitoring	Service planning and monitoring procedures	Documentation of case review	Interview: Clinical personnel Medical personnel Persons served Review case records
OTP 5 Service Philosophy	Include Service Philosophy in Service Narrative Part 1: Program Information Procedures for use of non-traditional or unconventional practices, as applicable Table of contents of training curricula Policies for prohibited interventions	Documentation of training	Interview: Clinical or program director Relevant personnel Persons served
OTP 6 Community Services		Description of the public education and community relations program	Interview: Personnel involved with the public education and community relations program
OTP 7 Service Elements	Include description of services in Service Narrative Part 1: Program Information	Referral procedures Service agreements and formal referral arrangements	Interview: Clinical or program director Relevant personnel Persons served Review case records
OTP 8 Medical Services	Include description of services in Service Narrative Part 1: Program Information Procedures for obtaining medication blood levels Procedures for making referrals to medical, psychiatric, or pain management services Procedures for evaluating the benefits derived from treatment Table of contents of training curricula		Interview: Medical director Relevant personnel Persons served Review case records
OTP 9 Toxicology Testing for Continued Drug Use	Policies and procedures related to toxicology testing and record keeping Medical protocols		Interview: Medical personnel Relevant personnel Individual responsible for ensuring compliance with regulations regarding toxicology reports Persons served Review case records
OTP 10 Take-Home Privileges for Unsupervised Use of Medication	Policies, procedures, and criteria regarding take-home privileges Material that is given to persons served that addresses safe storage of take-home medication		Interview: Direct service personnel Relevant personnel Persons served who have earned take-home privileges Persons served who have not earned take-home privileges Review case records
OTP 11 Dosage Requirements	Procedure for dosing and administration of opioid treatment medication that address weekend, holiday, travel, and after-hours administration		Interview: Medical director Relevant personnel Persons served Review personnel files
OTP 12 Detoxification Treatment	Include description of detoxification process in Service Narrative Part 1: Program Information Procedures related to detoxification		Interview: Medical director Relevant personnel Review case records
OTP 13 Interim Maintenance Treatment	Include description of interim maintenance treatment in Service Narrative Part 1: Program Information Procedures for transferring persons from interim to comprehensive maintenance treatment Procedures for notifying state health officer when a person’s maintenance status changes Documentation that addresses interim maintenance treatment program restrictions		Interview: Clinical or program director Relevant personnel Persons served Review case record
OTP 14 Opioid Treatment During Pregnancy	Procedures that address the provision of prenatal care for pregnant women served Information about education and support groups Procedures for withdrawal from methadone for pregnant women Procedures that address monitoring pregnant women and addicted newborns	Copies of information provided directly to persons served regarding potential risk for pregnant women Referral procedures Educational curricula and written materials that address potential risk for pregnant women	Interview: Medical director Relevant personnel Persons served Review case records
OTP 15 Withdrawal	Procedures for medical withdrawal that address withdrawal AMA Procedures for administrative discharge		Interview: Medical director Relevant personnel Persons served Review case records
OTP 16 Case Closing	Case closing procedures	Procedures that address continuation of services for persons whose third party benefits have ended	Interview: Medical director Relevant personnel Persons served Review case records
OTP 17 Aftercare and Follow-Up	Aftercare procedures		Interview: Medical director Relevant personnel Persons served Review case records
OTP 18 Diversion Control	Diversion control plan		Interview: Clinical or program director Security personnel Observe the security system
OTP 19 Program Administration	Include description of program administration in Service Narrative Part 1: Program Information Record-keeping procedures		Interview: Clinical or program director Individual in charge of the record-keeping system Observe record-keeping system
OTP 20 Personnel	Table of contents of training curricula Procedures and criteria used for assigning and evaluating workloads	Documentation of training Training curricula Policy and procedures addressing employee health and vaccinations and other documents as necessary Documentation of workload assessment	Interview: Supervisors Personnel Review personnel files
OTP 21 Personnel Qualifications	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 organization time in current position	Job descriptions	Interview: Supervisors Personnel Review personnel files Verify the employment or contact with qualified clinicians

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
OTP 1.02, OTP 3.05, OTP 3.06, OTP 14.03, OTP 14.04, OTP 14.06, OTP 20.04	OTP 2.03, OTP 8.02, OTP 8.05, OTP 10.03, OTP 10.05, OTP 11.01, OTP 11.02, OTP 11.03, OTP 12.04, OTP 14.02	OTP 1.03, OTP 9.06, OTP 15.03

RELATED FILES


	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.


	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.


	ACCREDITATION The formal evaluation of an organization against accepted criteria or standards. A professional society, non-governmental organization, or a governmental agency may conduct accreditation activities. A COA-accredited organization has undergone a period of rigorous self-study and is capable of providing programs and services that meet or exceed COA standards.


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


	ELIGIBILITY The degree to which an individual, family, group, or community meets the specific criteria and qualifications required to receive goods, benefits, or services.


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


	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."


	PEER REVIEW An evaluation process in which professionals from similar backgrounds review the work of their associates.


	MAJOR LANGUAGE GROUP The presence of a substantial core of people in both the community and the client population that share a language.


	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.


	CLIENT See service recipient.


	GRIEVANCE See COMPLAINT


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	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.


	CONSUMER The individual, family, group, or community that seeks or receives services.


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


	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


	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.


	CLINICAL PERSONNEL Qualified and trained professionals who provide the treatment services of an organization. Clinical personnel who assume case responsibilities must meet the applicable regulatory requirements and the minimum standards set by their respective professional organizations. Clinical personnel generally include clinical social workers (MSW or DSW/PhD in social work), clinical or counseling psychologists (PhD or PsyD), psychiatric nurses (MSN), certified marriage or family therapists, certified pastoral counselors, and board eligible or certified psychiatrists. Where additional disciplines or degrees are acceptable, it is stated in the standard for each service section. "Clinical personnel" and "mental health personnel" may be used interchangeably.


	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.


	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.


	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.


	MEDICATION A prescribed or over-the-counter drug that is injected, taken orally, applied topically, or otherwise administered.


	REFERRALS Resource suggestions provided to consumers to address problems or needs that are beyond the scope of the organization's mission.


	PROTOCOLS Instruments and procedures used to accomplish a particular goal, activity, or purpose.


	ADMINISTRATION The personnel responsible for management functions of the organization, including fiscal management, human resources, and service delivery. Such personnel determine organizational goals, acquire and allocate resources to carry out a program, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.


	DETOXIFICATION The process by which drugs or other harmful substances are removed from a person's body for a time period sufficient to restore adequate physiological and psychosocial functioning.


	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.


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


	EMPLOYEE Paid member of an organization. Foster parents are not considered employees and are specifically referenced in relevant standards.