Standards for Canadian organizations

2020 Edition

Psychiatric Rehabilitation Services (CA-PSR) 4: Intake and Assessment

The organization’s intake and assessment practices ensure that persons served receive prompt and responsive access to appropriate services.
2020 Edition

Currently viewing: PSYCHIATRIC REHABILITATION SERVICES (CA-PSR)

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Purpose

Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency. 
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
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; 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
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
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.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Screening and intake procedures
  • Assessment procedures
  • Copy of assessment tool(s)
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

CA-PSR 4.01

The organization defines in writing: 
  1. eligibility criteria;
  2. scope of services and supports, special areas of expertise and range of behavioural/emotional concerns addressed;
  3. opportunities for active family participation and support; and
  4. opportunities for active participation in community activities.

CA-PSR 4.02

Individuals are screened and informed about:
  1. how well the individual’s request matches the organization's services; and
  2. what services will be available and when.
NA Another organization is responsible for screening, as defined in a contract.

Fundamental Practice

CA-PSR 4.03

Prompt, responsive intake practices:
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations;
  3. support timely initiation of services; and
  4. provide placement on a waiting list or referral to appropriate resources when individuals cannot be served or cannot be served promptly.

Interpretation

Vulnerable populations, such as individuals that are lesbian, gay, bisexual, transgender, and questioning (LGBTQ), are at high risk of violence and harassment. The organization should ensure these individuals are safe, welcomed by staff, and are treated with respect. For example, providing intake forms that allow individuals to self-identify their gender as well as their first name and preferred pronouns can support that effort.
Examples: Organizations can respond to identified suicide risk by connecting the individual to more intensive services; facilitating the development of a safety and/or crisis plan; or contacting emergency responders, 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilisation, or 24-hour crisis hotlines, as appropriate.

CA-PSR 4.04

Persons served participate in an individualized, culturally, and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. updated as needed based on the needs of persons served; and
  3. focused on information pertinent for meeting service requests and objectives.

CA-PSR 4.05

Individuals are assessed:
  1. for a history and presence of serious and persistent mental illness and substance use or other health conditions;
  2. for life skills and available resources;
  3. for traumatic experiences and trauma-related symptomatology;
  4. for past or present connection to the criminal justice system;
  5. for medical history, including past medications and community support; and
  6. to determine if they can benefit from services that promote the ability to live and function in the environment of their choice.

Interpretation

The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.