WHO IS ACCREDITED?

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.
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ORGANIZATION TESTIMONIAL

Nuevo Amanecer Latino Children's Services

Galo A. Rodriguez, M.P.H., President & CEO

Since Nuevo Amanecer Latino Children’s Services pursued its COA accreditation on October 14, 2004, this corporation has sustained a continuous quality improvement process by not looking whom to blame among the involved parties but improving what we have already done well… because good enough is not good enough.
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Purpose

The rights and dignity of clients are respected throughout the agency.

FOC
PA-CR 2: Confidentiality and Privacy Protections

The agency protects the confidentiality of information about clients and assumes a protective role regarding the disclosure of confidential information.

Interpretation: The agency must carefully reconcile its policies, procedures, and practices with all applicable confidentiality laws and regulations including, but not limited to, laws and regulations governing information about youth involved with the juvenile justice system, mental health consumers, victims of domestic violence, drug and alcohol treatment, and HIV/AIDS.

The agency’s procedures must reconcile legal restrictions on the release of identifying information about clients with mandatory reporting and duty to warn requirements. Written procedures should include guidance to personnel in determining the degree of danger a person may pose to him or herself or to the community.

Adult Guardianship (PA-AG) programs must have procedures in place to ensure the decision to release confidential information is made in an ethical manner. See PA-AG 8.02 for more information on ethical decision-making. The level of client involvement in the decision to release confidential information will vary based on the court order and state law.

Rating Indicators
1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3
Partial Implementation, Concerning Performance
  • A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
  • A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Please see Rating Guidance for additional rating examples. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Confidentiality policy and procedures
    • Sample release form for disclosure of confidential information
    State Administered Agency (Regional Office)
    • Communications with staff regarding completing releases of information (memo, in-service training documentation, staff meeting minutes) 
No On-Site Evidence
    All Agencies
    • Interview:
      1. Agency leadership
      2. Personnel at all levels
      3. Individuals or families served
    • Review case records

  • FP
    PA-CR 2.01

    The agency informs the client, prior to his or her disclosure of confidential or private information, about circumstances when the agency may be legally or ethically permitted or required to release such information without the client’s consent.


  • PA-CR 2.02

    When the agency receives a request for confidential information about a client, or when the release of confidential information is necessary for the provision of services, prior to releasing such information, the agency:

    1. determines if the reason to release information is valid;
    2. obtains the client’s informed, written authorization to release the information; and
    3. obtains informed, written authorization from a parent or legal guardian, as appropriate.

    Interpretation: In the context of this standard, “valid” means justifiable, legitimate, convincing, legally permissible, and in the best interest of the client.

    The agency obtains legal counsel regarding the confidentiality of records and the conditions under which they may be subpoenaed. Unless otherwise required by law, authorization to release confidential information is not necessary where the request for information is pursuant to a subpoena. The agency seeks additional legal counsel, as necessary, when others seek person-identifying information about an individual or family, or when the release of confidential information is necessary for the provision of services.

    When the client is a minor or an adult under the care of a guardian, the agency should follow any laws or regulations allowing or requiring the agency to obtain the authorization of clients’ parents or legal guardians.

    When permitted or required by law, regulation, or court order, confidential information may be released without the authorization of the client and legal guardian. However, the client and legal guardian should still be informed that the information will be released.


  • PA-CR 2.03

    Informed, written consent is obtained from the client, or a legal guardian, prior to recording, photographing, or filming.

    Interpretation: When required by law, consent may not be necessary. However, it is still expected that the agency inform clients prior to recording, photographing, or filming.

    Interpretation: For Early Childhood Education (PA-ECE) or Out-of-School Time Services (PA-OST), it is not necessary to obtain consent each time children or youth may be recorded, photographed, or filmed; consent may be provided at enrollment and maintained in program records or files. Consents should be reviewed and updated annually.


  • FP
    PA-CR 2.04

    The release form for disclosure of confidential information includes the following elements:

    1. the name of the person whose information will be released;
    2. the signature of the person whose information will be released, or the parent or legal guardian of a person who is unable to provide authorization;
    3. the specific information to be released;
    4. the purpose for which the information is to be used;
    5. the date the release takes effect;
    6. the date, event, or condition upon which the consent expires, not to exceed one year from when the release takes effect;
    7. the name of the person(s) or agency/agencies that will receive the disclosed information;
    8. the name of the person or agency that is disclosing the confidential information; and
    9. a statement that the person or family may withdraw their authorization at any time except to the extent that action has already been taken.

    Interpretation: In relation to element (f), the expiration event or condition should relate to the individual or to the purpose of the use or disclosure. The date, event, or condition upon which the consent expires must ensure that the authorization will last no longer than reasonably necessary. When the release of information is required for ongoing service provision, all elements of the form must be reviewed and updated annually at minimum to ensure that consent continues to be informed and appropriate.

    Interpretation: When a release form is used to authorize the exchange of information between multiple parties, the form must comply with all elements of the standard. All relevant parties must be authorized to disclose and receive the information specified, for the purpose indicated, in the consent.

    Interpretation: When permitted or required by law, regulation, or court order, confidential information may be released without authorization of the person or legal guardian. In this case elements (b) and (i) will not apply. However, the agency should still inform the person and/or legal guardian that the information will be shared, as referenced in CR 2.01 and CR 2.02, and maintain documentation of the disclosure in the client’s file.

    Interpretation: Blanket release forms signed by clients when service is initiated do not meet the requirements of this standard, except as put forth by federal regulation, for example, when making application to FEMA/DHS in a declared disaster.

    Interpretation: In credit counseling agencies this standard applies in situations where a client specifically requests release of information to a third party, such as a letter of reference regarding payment history, or in instances when a program specific release does not exist.  Debt management agreements or releases signed at the initiation of a debt management program allow for information sharing with all creditors included in the program or added to the program for the duration of service, unless state laws indicate otherwise.

    Interpretation: Release forms may also include a statement regarding the impact, if any, of refusing to sign the authorization, as well as rules regarding re-disclosure of information in accordance with applicable federal and state laws.   

    Research Note: Research suggests that agencies with clear confidentiality policies and consent form requirements have increased collaboration among providers, clients, and families. This increased collaboration can have a positive impact on the relationship between providers and family members and further open lines of communication for the future.


  • PA-CR 2.05

    The agency offers a copy of the signed release form to the person or family authorizing the disclosure of confidential information and places a copy in the case record.

    Interpretation: A copy of the completed release form should be offered to the person, and placed in the case record, even when it is permissible by law to release confidential information without the person’s authorization and signature.

    Interpretation: When there are concerns about the individual’s capacity to understand the confidential nature of the document, such as when the individual has been deemed incapacitated by the court, it may be inappropriate to provide the individual with a copy of the release form. Instead, the worker should include a copy of the release form in the case record and document reasons why the form was not provided.

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