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.
read more >>

ORGANIZATION TESTIMONIAL

Family Services of the North Shore

Kathleen Whyte, Manager of Human Resources / Accreditation Coordinator

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency.
read more>>

Purpose

Shelter Services meet the basic needs of individuals and families who are homeless or in transition, support family stabilization or independent living, and facilitate access to services and permanent housing. 

SH 4: Service Planning and Monitoring

Service recipients and their families participate in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support. 

Interpretation: Assessment-based service planning helps service recipients form a plan for attaining the support and skills needed to return to community life, securing and maintaining safe, affordable housing in the community, and connecting to appropriate services and community-based resources. 

Rating Indicators
1
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.
2
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 (HR 6.02) and training (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.
3
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 (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.
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
    • Documentation of case review
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • SH 4.01

    An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient and legal guardian. 

    Interpretation: Service planning is conducted such 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 resident is a minor or an adult under the care of a guardian, the organization should follow applicable state laws and regulations requiring involvement or consent of the resident’s legal guardian.

    When the service recipient is a minor or an adult under the care of a guardian, the organization should follow applicable state laws and regulations requiring involvement or consent of the service recipient’s legal guardian. In situations where a legal guardian is involved in service planning and monitoring, the service recipient should still have the opportunity to participate in the process.


  • SH 4.02

    During service planning the organization explains:

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

  • SH 4.03

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

    1. agreed upon goals, desired outcomes, and timeframes for achieving them;
    2. services and supports to be provided, and by whom; and
    3. the service recipient’s and legal guardian’s signature, as appropriate.

    Interpretation: Strategies for building rapport, establishing trust, and promoting psychological safety are critical when working with victims of trafficking to facilitate the development of realistic goals in an empowering and trauma-informed manner.


  • SH 4.04

    The service plan addresses, as appropriate:

    1. a return to permanent housing;
    2. unmet service and support needs;
    3. possibilities for maintaining and strengthening family relationships; and
    4. the need for support of the service recipient’s informal social network.

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


  • SH 4.05

    The worker, service recipient, and legal guardian regularly review progress toward achievement of agreed upon goals and document revisions to service goals and plans.

    Interpretation: In regards to documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the service recipient, and a legal guardian when the service recipient is a minor, or otherwise documented in a manner that is consistent with the organization’s service planning and monitoring procedures.

    Interpretation: If the organization provides enhanced emergency shelter services, progress toward achieving service goals should be reviewed with the service recipient every two weeks, or more often, depending on the needs of the person or family and/or expected length of stay.
     


  • SH 4.06

    Service plans are reviewed at least biweekly by the worker and a supervisor, or a clinical, service, or peer team, to assess:

    1. service plan implementation;
    2. progress toward achieving service goals and desired outcomes; and
    3. the continuing appropriateness of the agreed upon service goals.

    Interpretation: Significant revisions to the service plan are made with the participation of the service recipient or legal guardian, as appropriate.

    Experienced workers may conduct service plan reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations according to the requirements of the standard.

Copyright © 2018 Council on Accreditation. All Rights Reserved.  Privacy Policy and Terms of Use