WHO IS ACCREDITED?

Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.
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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

Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.

FOC
RPM 7: Case Records

Case records contain sufficient, accurate information to:

  1. identify the consumer;
  2. support decisions about interventions or services; and
  3. document the delivery of services.

Interpretation: In addition to supporting the delivery of services, case records are an important risk management tool. Well-maintained records can help shield the organization from allegations of misconduct and negligence, while poorly-maintained records and improper documentation are a known liability.

Independent contractors who provide direct services to organization clients, maintain records for those clients in accord with RPM 7.

Note: See DV 17 for further guidance about the information to be included in case records for Domestic Violence Services (DV).

Note: Please see Case Records Checklist - Private, Public for additional assistance with this standard.

Note: If the organization operates a program that qualifies for an NA but also provides other types of services, the standards should be implemented in all programs aside from those that qualify for the NA.

NA The organization provides only Community Change Initiatives (CCI), Early Childhood Education (ECE), Social Advocacy (SOC), and/or Youth Development (YD) Services.

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.

NA The network management entity does not provide screening, assessment, service authorizations, or other services for specific clients.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the RPM 7 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the RPM 7 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the RPM 7 Practice standards; and/or
  • At least one of the Fundamental Practice Standards received a 3 or 4 rating.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the RPM 7 Practice standards; and/or
  • At least two of the Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Record content and maintenance procedures
    • Policy on clients adding statements to their case records
    • Mock case record, table of contents, or outline for each service section
    • Review case records
    • Interview:
      1. Personnel
      2. Supervisors
      3. Program directors
      4. Persons served
    • Network interview:
      1. Managing entity screening, assessment, and authorization staff, if these services are provided
      2. Providers who request authorizations from the managing entities
    • Network interview:
      1. Provider personnel
      2. Provider supervisors
      3. Provider program directors

  • RPM 7.01

    The organization maintains a case record for each person or family.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement.
    3
    Practice requires significant improvement.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all in a majority of cases.

  • FP
    RPM 7.02

    Case records comply with all legal requirements and contain information necessary to provide services, including:

    1. demographic and contact information;
    2. the reason for requesting or being referred for services;
    3. up-to-date assessments;
    4. the service plan, including mutually developed goals and objectives;
    5. copies of all signed consent forms;
    6. a description of services provided directly or by referral;
    7. routine documentation of ongoing services;
    8. documentation of routine supervisory review;
    9. discharge or aftercare plan;
    10. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
    11. a closing summary entered within 30 days of termination of service.

    Update:

    • Added Interpretation - 02/15/18

    Interpretation: RPM 7.02 describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for a person or family. In these cases, an explanation should be placed in the case record. The listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center.

    Interpretation: Regarding element (h),"documentation of routine supervisory review" refers to the quarterly review of individual cases that is found in the Service Planning and Monitoring sections of most Service Standards , e.g. AD 4.07.  This review is unrelated to Supervision between the supervisor and personnel addressed in TS 3.?

    Interpretation: Case records and signatures can be paper, electronic, or a combination of paper and electronic. When using electronic (or digital) signatures, organizations should take appropriate measures to verify the individual’s identity and ensure that each electronic signature is unique to the individual.

    Electronic signatures (by both personnel and service recipients) can include, for example, a digitalized signature via tablet or two identifying components such as a user identification code (ID) and password/personal identification number (PIN). Procedures or protocols for electronic signatures should be included in the organization’s record content and maintenance procedures.

    Organizations that rely upon electronic signatures should ensure their electronic systems have the functionality to maintain and update the signature-to-content association of all files over time. Such precautions ensure non-repudiation, uphold the integrity of electronic documents in-spite of staffing changes or system updates, and protect the organization when files undergo third-party review or audit.


    Interpretation: To most effectively collect information on trends and outcomes, consistent terminology and structured data should be used within the electronic records system.

    Interpretation: In EAPs case records contain appropriate information to demonstrate the status of the case and whether it is open or closed. 

    Note: Elements (h) and (i) are not applicable to credit counseling organizations.

    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., 
    • Record content and maintenance procedures need strengthening; or
    • In a substantial percentage of cases reviewed, the organization complies with the standard; or
    • One of the elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • In a significant percentage of cases, the organization does not comply with the standard; or
    • Two of the required elements are not fully addressed; or
    • One element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Three or more of the required elements are not fully addressed, or
    • Two or more elements are not addressed at all.

  • FP
    RPM 7.03

    The case record contains essential legal and medical information, including, as applicable:

    1. orders for and results of psychological, medical, toxicological, diagnostic, or other evaluations;
    2. documentation of all prescribed and over-the-counter medications including copies of all written orders for medications, when applicable; 
    3. special treatment procedures, allergies, or adverse treatment responses; and
    4. court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal directives related to the service being provided.

    NA The organization does not obtain legal or medical information.

    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., 
    • Record content and maintenance procedures need strengthening; or
    • Most records contain necessary and required information; or
    • In a substantial percentage of cases reviewed, the organization complies with the standard; or
    • One of the elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • Procedures require significant strengthening; or
    • Many records do not have the necessary or required information and the organization has not made significant efforts to obtain the information; or
    • In a significant percentage of cases, the organization does not comply with the standard; or
    • Two of the required elements are not fully addressed; or
    • One element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Three or more of the required elements are not fully addressed; or
    • Two or more elements are not addressed at all.

  • RPM 7.04

    Case record entries are made by authorized personnel only, and are:

    1. specific, factual, relevant, and legible;
    2. kept up to date from intake through case closing;
    3. completed, signed, and dated by the person who provided the service; and
    4. signed and dated by supervisors, where appropriate.

    Note: Please refer to the interpretation at RPM 7.02 for guidance on electronic signatures. 

    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., 
    • Record content and maintenance procedures need strengthening; or
    • In a substantial percentage of cases reviewed, the organization complies with the standard; or
    • One of the elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • In a significant percentage of cases, the organization does not comply with the standard; or
    • Two of the required elements are not fully addressed; or
    • One element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Three or more of the required elements are not fully addressed; or
    • Two or more elements are not addressed at all.

  • RPM 7.05

    Progress notes comply with legal requirements and are entered:

    1. at least quarterly; or
    2. monthly, or as required by law or regulation for individuals receiving protective services, out-of-home care, day treatment, or frequent or intensive counseling or treatment.

    Interpretation: For credit counseling organizations providing DMPs, disbursement records can suffice as evidence of progress made.

    Note: Medicaid requires that every encounter be documented on the date the service was provided in a progress note that include: the client’s name, date services were rendered, identification of services delivered, location of the services, client response to services provided, next steps in the treatment process, and start and end time of services.  Organizations should review their state Medicaid plans for other important documentation requirements.

    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., 
    • Record content and maintenance procedures need strengthening; or
    • Progress notes in most case records are up to date and reflect the progress of the client; or
    • In a substantial percentage of cases reviewed, the organization complies with the standard; or
    • One of the elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • In a significant percentage of cases, the organization does not comply with the standard; or
    • Progress notes have not been kept up to date or they are lacking in content and do not reflect the progress of the client; or
    • One element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • RPM 7.06

    Service recipients may add a statement to their case records, and:

    1. any response by personnel is added with the service recipient’s knowledge; and
    2. the service recipient is given the opportunity to review and comment on such additions.

    Note: See RPM 8.02 for additional information on access to case records.

    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., 
    • Policy or procedures need strengthening; or
    • With few exceptions clients acknowledge receipt of information about the policy and procedures.
    3
    Practice requires significant improvement; e.g.,
    • Policy or procedures need significant strengthening; or
    • In numerous instances there is no documentation that clients received information about the policy and procedures.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Service recipients do not receive a copy of this policy or are unaware that this policy exists.

  • RPM 7.07

    At case closing, case records are reviewed and unsummarized notes, personal observations, and impressions are expunged.

    NA The organization only provides Financial Education and Counseling services.

    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., 
    • Record content and maintenance procedures need strengthening; or
    • Most case records are reviewed prior to closure and unnecessary information is removed; or
    • In a substantial percentage of cases reviewed, the organization complies with the standard.
    3
    Practice requires significant improvement; e.g.,
    • Many closed records contain worker notes and/or unnecessary material; or
    • In a significant percentage of cases, the organization does not comply with the standard; or
    • Two of the required elements are not fully addressed.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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