WHO IS ACCREDITED?

Private Organization Accreditation

One Hope United offers a range of services aimed at our mission of "Protecting children and strengthening families" including early childhood education, early intervention and prevention, family preservation, foster care, residential, and adoption.
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ORGANIZATION TESTIMONIAL

Domestic Violence Intervention Services, Inc.

Donna Mathews, Associate Director

Becoming accredited and maintaining our accreditation through COA has helped us increase our professionalism and thereby provide better services to domestic violence, sexual assault, stalking, and dating violence survivors.
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Purpose

An organization-wide Performance and Quality Improvement system advances efficient, effective service delivery, effective management practices, and the achievement of strategic and program goals.

FOC
PQI 5: Case Record Review

The organization conducts case record reviews at least quarterly for each of its services to:
  1. minimize the risks associated with poorly maintained case records;
  2. document the quality of the services being delivered; and
  3. identify barriers and opportunities for improving services.

Interpretation: COA is not prescriptive about who can conduct case record reviews. While a peer review model is recommended, it is acceptable for PQI staff, a consultant, or another person or combination of persons to conduct the reviews. Please note that, regarding PQI 5.02, persons with clinical or service delivery experience may be needed to obtain the relevant qualitative data from the case records.

NA The organization is a network management entity.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the PQI 5 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the PQI 5 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the PQI 5 Practice standards.

Case records may pose a risk to the organization and corrective action has not been implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PQI 5 Practice standards.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Case record review procedures
    • Sample of case record review data collection tools
    • Description of sampling methodology
    • Two most recent quarterly reports from the case record review process
    • Results of external case record audits, if applicable
    • Interview:
      1. PQI personnel
      2. Relevant staff

  • PQI 5.01

    The quarterly case record review process: 
    1. includes a random sample of both open and recently closed cases; 
    2. uses uniform data collection tools to ensure consistency and permit comparison of data; and
    3. maintains objectivity by ensuring that reviewers do not review cases in which they have been directly involved as a service provider or supervisor. 

    Interpretation:  Organizations can get more from the case record review process by stratifying the random sample of open cases to account for length of service. For example, a program that serves clients for up to six months could divide the sample proportionally between cases that have been open less than one month, one to three months, three to six months, and more than six months. 

    Interpretation: Sampling: See recommended sampling guidelines. Organizations may choose a different sampling method as long as a rationale is provided.
     
    For generating random numbers, the Research Randomizer is an easy to use tool. The tool is made available for free by the Social Psychology Network and includes short tutorials. (Urbaniak, G. C., & Plous, S. (2013). Research Randomizer (Version 4.0) [Computer software]. Retrieved on June 22, 2014, from www.randomizer.org.)
     
    Closed Cases: COA does not define the percentage of closed cases that must be included in the sample. The majority of cases the organization reviews should be open, but the organizations must include a sample of closed cases to evaluate documentation related to discharge planning, case closing, aftercare, and the condition of the case record including whether or not records have been expunged as required by RPM 7.07. 

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • One of the standard's elements is not sufficiently developed, e.g., cases are not selected randomly for more than half of the organization's programs or services but includes both open and closed cases. 
    3
    Practice needs significant improvement; e.g., 
    • At least two of the standard's elements are not sufficiently developed; e.g., sample size is insufficient to enable the organization to draw conclusions from the data; or 
    • The organization only reviews open cases; or 
    • Little effort is being made to ensure objectivity; e.g., supervisors frequently were the sole reviewers of supervisee cases.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 5.02

    Quarterly reviews of case records evaluate the presence, clarity, quality, continuity, and completeness of required documents.

    Interpretation: Organizations should review Medicaid, Medicare, and other third party reimbursement contracts for specific documentation requirements. The penalties for incomplete records or improperly documented services can be substantial. Organizations are encouraged to integrate such requirements into their case record review process.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • One or two important documents are not included in the review; or 
    • Procedures need strengthening.
    3
    Practice needs significant improvement; e.g., 
    • A number of important documents are not included in the review; or 
    • Reviews are conducted no more than three times per year; or 
    • Reviews are not conducted for one of the organization's services; or 
    • The review process is poorly designed or haphazardly conducted; or
    • Case records may pose a risk to the organization and corrective action has not been implemented.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • PQI 5.03

    The organization identifies indicators and measures the quality of services for each of its programs or services in its quarterly case record review process.  

    Interpretation: Quality of services is a very broad category and varies according to the program, service population, service mandates, and any number of other factors and can include criteria for evaluating the appropriateness and/or effectiveness of the services provided to persons served.

    Some common measures include: 
    1. timeliness and comprehensiveness of individualized assessments; 
    2. length of service; 
    3. need for continued service; 
    4. family involvement; and 
    5. achievement of service goals, etc.
    Interpretation: Some organizations take a utilization management approach to case record review and, rather than review case records quarterly, conduct more frequent or ongoing reviews. A utilization management approach looks at the key decisions and process milestones, including, for example: 
    1. appropriateness of admissions and authorization decisions; 
    2. intake and referral processes; 
    3. service planning and service delivery milestones; 
    4. need for continued service; and 
    5. discharge decisions.
    Interpretation: Reviewing records from non-therapeutic group or community services: COA expects organizations to maintain a service record for programs and services that do not serve individual clients and, therefore, do not keep individual case records (e.g., services which use group or community interventions such as Community Change Initiatives (CCI), Social Advocacy (SOC), and Counseling, Support, and Education (CSE)).  

    Record reviews for these services should address:
    • an assessment of the continued need for the group or community intervention; 
    • basic contact and emergency information on persons served, as appropriate;
    • a service plan that includes expected outcomes for the group or intervention;
    • routine documentation of ongoing services; and
    • evidence of service monitoring.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Indicators for one program need strengthening; 
    • Data is aggregated and used to monitor service quality for 75% of the organization’s programs/services including all high risk programs.
    3
    Practice needs significant improvement; e.g.,
    • Data is not consistently collected, or is collected and aggregated but not used to monitor service quality; or 
    • Service quality data is collected for less than 75% of the organization's programs, or 
    • Service quality data is not being collected for at least one high-risk program.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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