COA - Council On Accreditation

	Group Living Services

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Service Narrative (CA-GLS):

UPDATE: REVISED TABLE OF EVIDENCE - 09/01/09

Part 1: Programme Information

Organisations may complete one template for all programmes, or a separate template that addresses each programme being reviewed under this section. Provide responses in each box provided.

Organisations being accredited for the first time: Please provide information for the last year.

Organisations 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 organisation.

2. Provide an overview of the different programme(s) being accredited under this section. The overview should describe:

the programmes' service philosophy and approach to delivering services;
eligibility criteria;
any unique programmes 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 organisations 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 organisation would like the peer review team to know about these programmes.

Attachments

A list of all programme sites, including the following information for each programme site: a) name of programme/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 programme site from the main organisation office
A demographic profile of persons and families served by the programme(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 programme insures 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 programmes that were opened, merged with other programmes or services, or closed
Two quarterly reports from the case record review process conducted for this service, with any related corrective action plans (See CA-PQI 4.02/4.03)
Two quarterly reports of accidents, incidents, and grievances related to this service (See CA-RPM 2.02)
All COA-approved NA Requests
A list of all NAs applicable to your organisation provided within the standards

Part 2: Programme Outputs and Outcomes

Provide a response in each box describing how the programme is making progress towards achieving its aims, and achieving better results for participants.

1. A summary of where the organisation is in the development of its programme for measuring programme quality and outcomes, specific to the service.

2. A list or description of programme outputs and desired outcomes and any outputs and outcomes being measured including measurement tools used. Note: Programme outputs may include consumer satisfaction, number of clients served, number of visits, timeliness of assessments, etc.

3. An overview of the organisation's process for analyzing data.

4. Examples of programme improvements made based on the outcomes data.

Attachments

Outcomes measurement/data collection procedures
Outcomes results reported for the previous two quarters
Group Living Services (CA-GLS) Grouping Chart


	Self-Study Documents	On-Site Documents	On-Site Activities
CA-GLS 1 Access to Service	Access, screening, and intake procedures		Interview: Programme director Relevant personnel Residents Family members
CA-GLS 2 Family Connections	Material that describes family involvement activities and efforts	Documentation of family involvement	Interview: Programme director Relevant personnel Residents Family members Review case records
CA-GLS 3 Assessment	Assessment procedures Assessment tool and/or criteria included in assessment		Interview: Programme director Relevant personnel Residents Review case records
CA-GLS 4 Service Planning and Monitoring	Service planning and monitoring procedures	Documentation of case review	Interview: Programme director Relevant personnel Residents Review case records
CA-GLS 5 Child and Youth Permanency	Description of the planning process		Interview: Programme director Relevant personnel Persons served Review case records
CA-GLS 6 Service Philosophy, Modalities, and Interventions	Include Service Philosophy in Service Narrative Part 1: Programme 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: Programme director Personnel Residents
CA-GLS 7 Community Connections	Include description of activities in Service Narrative Part 1: Programme Information		Interview: Direct service personnel Residents Review case records Observe a variety of activities
CA-GLS 8 Health and Dental Services	Health related procedures	Health education material	Interview: Programme director Relevant personnel Persons served Review case records
CA-GLS 9 Education Services	Procedures for enrolling participants in school Procedures for developing educational plans	Procedures for coordinating with local school district	Interview: Direct service personnel Education personnel Local school district representative Review case records
CA-GLS 10 Services for Substance Use Conditions	Include description of services in Service Narrative Part 1: Programme Information List of referral resources for substance abuse services	Documentation of training	Interview: Programme director Relevant personnel Residents Review case records
CA-GLS 11 Privacy Provisions	Privacy policy and procedures		Interview: Programme director Relevant personnel Residents Observe facility
CA-GLS 12 Group Living Environment	Include description of services in Service Narrative Part 1: Programme Information		Interview: Programme director Relevant personnel Residents Review case records
CA-GLS 13 Residential Facilities			Interview: Residents Observe facility
CA-GLS 14 Care and Supervision	Resident/personnel care and supervision ratios Procedures and criteria used for assigning and evaluating workloads	Resident/personnel care and supervision ratios and coverage schedules for the past year Documentation of workload assessment and data for workload size for the past six months	Interview: Programme director Relevant personnel Residents Observe facility
CA-GLS 15 Transition from the Service System	Transition planning procedures		Interview: Programme director Relevant personnel Residents Review case records
CA-GLS 16 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: Programme director Relevant personnel Residents Review case records
CA-GLS 17 Aftercare and Follow-Up	Aftercare/follow-up procedures		Interview: Programme director Relevant personnel Residents Family members Review case records
CA-GLS 18 Personnel	Programme staffing chart that includes lines of supervision. List of programme personnel that includes: name title degree held and/or other credentials FTE or volunteer length of service at the organisation time in current position Table of contents of training curricula	Job descriptions Documentation of training Training curricula	Interview: Supervisors Personnel Review personnel files

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights
CA-GLS 6.03, CA-GLS 6.04, CA-GLS 8.01, CA-GLS 14.03, CA-GLS 14.05	CA-GLS 1.03, CA-GLS 1.06, CA-GLS 3.04, CA-GLS 3.05, CA-GLS 6.02, CA-GLS 8.04, CA-GLS 8.05, CA-GLS 14.04	CA-GLS 11.01, CA-GLS 11.02, CA-GLS 11.03, CA-GLS 11.04, CA-GLS 11.05

RELATED FILES


	SERVICE One or more organisation-operated programmes or activities that have a common general objective and deploy the organisation’s material and human resources in a planned and systematic manner. An organisation that publicly promotes or identifies itself in writing as offering a service, is licenced 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, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, residential neighbourhoods, business districts, recreational sites, and health and human service sites.


	PROGRAMME A system of services offered by an organisation. For example, an organisation providing a mental health service may offer several mental health programmes to different populations, e.g., a mental health programme for adolescent teens. The word “programme” can be used interchangeably with the word “service” or to describe specific programmes.


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


	SERVICE PHILOSOPHY The theoretical framework that describes and explains an organisation’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 recognised standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	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.


	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 utilises 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 programme planning and service development for the organisation as a whole. See also DIAGNOSIS.


	PERSONNEL The body of employees and/or volunteers that carries out the organisation’s tasks under the organisation’s administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards.


	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 socialisation, income support, long-term care, and other care giving 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, or significant others. Organisations 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.”


	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, organisational 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-organisational 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 organisational duties. Policies and procedures often guide practice.


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


	SUBSTANCE ABUSE The misuse of a chemical substance in a manner that is detrimental to an individual’s physical or mental health.


	SUPERVISION Assumption of responsibility for directly overseeing and evaluating the work or work products of personnel within an organisation. 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 organisation 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.


	PROGRAMME PERSONNEL All direct service and administrators or supervisors of direct services that are involved in the operation of the organisation’s social service programmes. “Programme 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 organisation 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.