Private Organization Accreditation

Catholic Charities alleviates human suffering and improves the quality of life of 100,000 people annually, regardless of religious background. A staff of 600 provides support and services related to housing, food, mental health, children's services, addiction treatment, and domestic violence services.


Bonnie Bagley

Volunteer Roles: Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

I have found that being a COA Volunteer builds my professional skills and experience in ways that more traditional workshops do not. The opportunity to learn about best practices through the COA standards and then see how agencies implement them is truly a growth experience.
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Individuals who participate regularly in Adult Day Services achieve and maintain an optimal level of well-being, functioning, and health, and remain in their preferred community residence.

CA-AD 4: Service Planning and Monitoring

Each individual participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

Rating Indicators
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,  
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (CA-HR 6.02) and training (CA-TS 2.03); or
  • In a few instances client or staff signatures are missing and/or not dated; or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In a number of instances client or staff signatures are missing and/or not dated (CA-RPM 7.04); or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or
  • Documentation is routinely incomplete and/or missing; or
  • Assessments are done by referral source and no documentation and/or summary of required information present in case record; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Service planning and monitoring procedures
No On-Site Evidence
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Persons served
    • Review case records

  • FP
    CA-AD 4.01

    A service plan is developed in a timely manner, with the full participation of the individual, or parent or legal guardian, and an expedited service-planning process is available when a crisis or urgent need has been identified.

    Interpretation: Service planning is conducted in such a way that individuals and families retain as much personal responsibility and self-determination as possible and/or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and assuming more responsibility for making decisions. When the service recipient is an adult under the care of a guardian, the organization should follow applicable provincial laws or regulations requiring involvement or consent of service recipients’ legal guardians.

  • CA-AD 4.02

    The service plan is based on the assessment, and includes:

    1. service goals, desired outcomes, and timeframes for achieving them;
    2. services and supports to be provided, and by whom; and
    3. the signature of the service recipient or his/her legal guardian.

  • CA-AD 4.03

    During the service planning process the organization explains:

    1. available options;
    2. how the organization can support the achievement of the individual’s desired outcomes; and
    3. the benefits, alternatives, and risks or consequences of planned services.

  • CA-AD 4.04

    Family members and significant others, as appropriate and with the consent of the individual, are advised of ongoing progress and are invited to participate in case conferences.

  • CA-AD 4.05

    The service plan addresses, as appropriate and with the consent of the service recipient:

    1. the family’s unmet service and support needs;
    2. possibilities for maintaining and strengthening family relationships; and
    3. the need for support of the individual’s informal social network.

  • CA-AD 4.06

    The worker and service recipient regularly review progress towards achievement of service goals and sign revisions to service goals and plans.

  • CA-AD 4.07

    The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:

    1. service plan implementation;
    2. the service recipient’s progress towards achieving service goals and desired outcomes; and
    3. the continuing appropriateness of the individual’s service goals.

    Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard.

    Timeframes for the review should be adjusted depending upon issues and needs of persons receiving services, and frequency and intensity of services provided.

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