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
- Foster Care (PA-FC) Service Profile
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Self-Study Documents |
On-Site Documents |
On-Site Activities |
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PA-FC 1
Screening |
- Screening procedures
- Procedures for identification and collaboration in ICWA cases
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- Information about ICWA that is available to families
- Copies of tribal state agreements, when applicable
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- Program director
- Relevant personnel
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PA-FC 2
Assessment |
- Assessment procedures
- Procedures for initial health screening
- Assessment tool and/or criteria included in assessment
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- Data on the timeliness of assessments, if available
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- Program director
- Relevant personnel
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PA-FC 3
Service Planning and Monitoring |
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- Program director
- Relevant personnel
- Parents
- Children and youth
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PA-FC 4
Child and Youth Permanency |
- Include description of permanency planning process in Service Narrative Part 1: Program Information
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- Program director
- Relevant personnel
- Parents
- Children and youth
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PA-FC 5
Service Philosophy |
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- Program director
- Relevant personnel
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PA-FC 6
Child Placement |
- Matching and placement procedures
- Include description of activities to prevent placement moves, and supports and services for children that experience moves in Service Narrative Part 1: Program Information
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- Documentation of tribal participation in placement process, when applicable
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- Program director
- Relevant personnel
- Foster parents
- Parents
- Children and youth
- Review case records
- Review foster parent records
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PA-FC 7
Developing and Maintaining Connections |
- Visitation procedures
- Include description of services in Service Narrative Part 1: Program Information
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- Program director
- Relevant personnel
- Foster parents
- Parents
- Children and youth
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PA-FC 8
Services for Parents |
- Include description of services in the Service Narrative Part 1: Program Information
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- Informational materials provided to parents
- Community resource and referral list
- Contracts or service agreements with community providers
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- Program director
- Relevant personnel
- Parents
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PA-FC 9
Services for Children and Youth |
- Include description of services in Service Narrative Part 1: Program Information
- Guidelines or procedures for providing educational supports and collaborating with school systems
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- Community resource and referral list
- Contracts or service agreements with community providers
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- Program director
- Relevant personnel
- Foster parents
- Children and youth
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PA-FC 10
Physical and Mental Health Care |
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- Relevant case closing procedures regarding health information
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- Program director
- Relevant personnel
- Foster parents
- Parents
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PA-FC 11
Therapeutic Services |
- Include in description of services in Service Narrative Part 1: Program Information:
- Description of the needs of children served in the specialized, therapeutic program
- Team roles and functioning
- Therapeutic services
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- Agreements with therapeutic facilities and/or providers
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- Program director
- Treatment team members
- Foster parents
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PA-FC 12
Worker Contact and Monitoring |
- Procedures or guidelines for worker visits and monitoring
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- Protocols for preventing and responding to missing children and allegations of maltreatment in foster homes
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- Program director
- Relevant personnel
- Foster parents
- Parents
- Children and youth
- Review case records
- Observe system that maintains information about children’s current placements
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PA-FC 13
Transition to Independent Living |
- Include description of services in Service Narrative Part 1: Program Information
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- Program director
- Relevant personnel
- Youth
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PA-FC 14
Case Closing |
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- Review contract with public authority, as applicable
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- Program director
- Relevant personnel
- Parents
- Children and youth
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PA-FC 15
Aftercare and Follow-Up |
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- Program director
- Relevant personnel
- Parents
- Children and youth
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PA-FC 16
Recruitment and Retention of Foster Families |
- Include description of recruitment and support efforts in Service Narrative Part 1: Program Information
- Material that specifies required pre- and in-service training requirements
- Protocols for responding to emergencies
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- Table of contents of training curricula and training attendance records
- Sample of emergency protocols from foster homes, if foster parents develop individualized plans
- Documentation of tribal participation in foster parent recruitment, when applicable
- Material provided to foster parents describing their rights and responsibilities
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- Program director
- Relevant personnel
- Foster parents
- Review foster parent records
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PA-FC 17
Homestudies |
- Include description of homestudy process and/or procedures in Service Narrative Part 1: Program Information
- Homestudy tool and/or criteria included in homestudy
- Procedures for background and child abuse registry checks
- Criteria for selection of therapeutic foster parents, as applicable
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- Program director
- Relevant personnel
- Foster parents
- Review foster parent records
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PA-FC 18
Respite Care |
- Include description of services in Service Narrative Part 1: Program Information
- Procedures and criteria for matching the child with respite care providers
- Health and safety procedures and protocols
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- Outreach strategies and informational materials
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- Program director
- Relevant personnel
- Respite care providers
- Foster parents
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PA-FC 19
Personnel |
- name
- title
- degree held and/or other credentials
- FTE or volunteer
- length of service at the agency
- time in current position
- Description of average workload, including the average caseload size for the last four quarters
- Procedures or criteria used to assign and evaluate workload
- Table of contents for training curricula
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- Information and/or data describing staff turnover
- Training curricula
- Documentation of training
- Job descriptions
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- Supervisors
- Personnel
- Review personnel files
- Review case records as needed
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