COA - Council On Accreditation

	Adult Day Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (PA-AD):

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 4.03/4.03)
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


	Self-Study Documents	On-Site Documents	On-Site Activities
PA-AD 1 Access to Service	Description of outreach efforts		Interview: Program director Relevant personnel
PA-AD 2 Screening and Intake	Screeningprocedures Procedures for identification and collaboration in ICWA cases	Indian Child Welfare Act information provided to families Copies of tribal-state agreements, when applicable	Interview: Program director Relevant personnel Persons served Review case records
PA-AD 3 Assessment	Assessment procedures Assessment tool and/or criteria	Job descriptions	Interview: Program director Relevant personnel Persons served Review case records
PA-AD 4 Service Planning and Monitoring	Service planning and monitoring procedures		Interview: Program director Relevant personnel Persons served Review case records
PA-AD 5 Service Philosophy	Include Service Philosophy in Service Narrative Part 1: Program Information		Interview: Program director Personnel Persons served
PA-AD 6 Service Elements	Include description of services in Service Narrative Part 1: Program Information	Activity schedules Education curricula Description of nutrition program Emergency protocols	Interview: Program director Relevant personnel Persons served Review case records
PA-AD 7 Support Services for Caregivers	Include description of services in Service Narrative Part 1: Program Information		Interview: Program director Relevant personnel Persons served Review case records
PA-AD 8 Service Environment	List of programs and activities Policies for prohibited interventions	Program rules and behavioral expectations	Interview: Program director Relevant personnel Persons served Observe facility
PA-AD 9 Care and Supervision	Both the defined and actual ratios for the past two quarters	Evidence of annual review of caseloads	Interview: Program director Relevant personnel Persons served
PA-AD 10 Case Closing	Case closing procedures	Procedures that address continuation of services for persons whose third party benefits have ended Review contract with public authority, as applicable	Interview: Program director Relevant personnel Persons served Review case records
PA-AD 11 Aftercare and Follow-Up	Aftercare and follow-up procedures		Interview: Program director Relevant personnel Persons served Review case records
PA-AD 12 Personnel	Program organization 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 Table of contents of training curricula Procedures and criteria used for assigning and evaluating workload	Training curricula Documentation of training Job descriptions Verify employment or contract of recreational therapist, nurse, and other necessary professionals	Interview: Supervisors Relevant personnel Review personnel files

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
PA-AD 12.05	PA-AD 2.03, PA-AD 4.01, PA-AD 6.05, PA-AD 8.04, PA-AD 12.08, PA-AD 12.09

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.


	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.


	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.


	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.


	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.


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


	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.


	OUTREACH Contact initiated by a provider to identify persons in need of services, to provide information to them about services and benefits, and to encourage the use of appropriate services.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	INDIAN CHILD As defined in the Indian Child Welfare Act (ICWA), "Any unmarried person who is under age eighteen and is either (a) a member of an Indian tribe or (b) eligible for membership in an Indian tribe and is the biological child of a member of an Indian tribe." For purposes of compliance with ICWA, the definition provided in the Act shall apply. For purposes of access to services and resources, other more inclusive definitions may apply (e.g. Indian Education Act, tribal definitions, etc.).


	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.


	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.


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


	CASELOAD The aggregate number of clients and/or consumers of service (including individuals, families, and groups) for whom a given employee is responsible. See also WORKLOAD


	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.


	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.


	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.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


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