WHO IS ACCREDITED?

Private Organization Accreditation

Lutheran Social Services of New England is a high-performing nonprofit organization. LSS is a powerful difference maker and go-to resource, driving ourselves to constantly anticipate futures that are different from the past. For 140 years, LSS has been caring for people in need in New England.
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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

Individuals who participate in Opioid Treatment Programs improve social, emotional, and vocational functioning, achieve optimal productivity, and attain the recovery they seek.

PA-OTP 19: Program Administration

The ageny’s administrative activities support program operations.

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 service delivery 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
    • A description of program administration
    • Record-keeping procedures
No On-Site Evidence
    • Interview:
      1. Clinical or program director
      2. Individual in charge of the record-keeping system
    • Observe record keeping system

  • PA-OTP 19.01

    The agency conducts annual reviews of program policies and procedures.


  • PA-OTP 19.02

    A record-keeping system documents and monitors client care in conformity with all federal and state reporting requirements relevant to opioid treatment.


  • PA-OTP 19.03

    The agency develops and maintains record-keeping systems to:

    1. improve the quality of documentation;
    2. safeguard confidentiality; 
    3. comply with the approved central registry system, when available;
    4. provide PDMP reports, when applicable, and
    5. record all patient information, patient care, and related services.

    Research Note: Research shows that electronic record systems are linked to improved client outcomes, increased client participation, enhanced care coordination and quality measurement, lower costs, and fewer medical errors. Recognizing that these systems support the integration and coordination of care, federal regulatory bodies are encouraging opioid treatment programs (OTPs) to implement electronic record systems to facilitate compliance with best practice standards. However, despite the benefits, there are ceratin barriers that OTPs must consider related to the privacy, security, and confidentiality of client information in order to adhere to Federal and state privacy and confidentiality laws, including 42 CFR Part 2 and the Health Insurance Portability and Accountability Act (HIPAA).

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