Standards for Canadian organizations

2020 Edition

Residential Treatment Services (CA-RTX) 4: Intake and Assessment

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

Currently viewing: RESIDENTIAL TREATMENT SERVICES (CA-RTX)

VIEW THE STANDARDS

Purpose

Residential Treatment Services provide individualized therapeutic interventions and a range of services, including education for residents to increase productive and pro-social behaviour, improve functioning and well-being, and return to a stable living arrangement in the community.
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 and reassessment procedures
  • Copy of assessment tool(s)
  • Community resource and referral list
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Residents
  • Review case records

 

CA-RTX 4.01

Residents are screened to determine whether they meet the program’s eligibility criteria, and are informed about:
  1. how well the their request matches the organization's services;
  2. what service options and levels of care will be available and when;
  3. the effectiveness of treatment, when available; and
  4. opportunities for active family participation and support, and involvement in community activities.

Interpretation

Screenings will vary based on the program’s target population and services offered, and can include information to identify any of the following: trauma history, substance use conditions, mental illness, and/or individual’s risk of harm to self or others.

Interpretation

When organizations provide services under contract with a “no reject” provision the interdisciplinary team should carefully review admission decisions to ensure the organization is prepared to address any special needs or services the resident may require.
NA Another organization is responsible for screening, as defined in a contract.

 
Fundamental Practice

CA-RTX 4.02

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.

 

CA-RTX 4.03

Residents participate in a comprehensive, individualized, trauma-informed, strengths-based, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes; and
  2. focused on information pertinent for meeting service requests and objectives.

Interpretation

Standardized and evidence-based assessment tools should be used to support structured and consistent decision-making.

 
Fundamental Practice

CA-RTX 4.04

The assessment is conducted by clinical personnel, including a licensed psychiatrist, psychologist, or other qualified mental health professional, as appropriate to the program model and population served, and addresses:
  1. behavioural and physical health;
  2. a trauma screen and, when appropriate, a trauma assessment;
  3. an evaluation of suicide risk, self-injury, neglect, exploitation, and violence towards others;
  4. family strengths, risks, and protective factors;
  5. community and social support, resources, and helping networks;
  6. environmental, religious or spiritual, and cultural factors;
  7. educational and vocational accomplishments;
  8. social skills, recreational activities, hobbies, strengths and special interests;
  9. factors related to successful group living;
  10. additional tests and assessments needed; and
  11. a summary of symptoms and diagnoses.

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.

Interpretation

Due to the short-term nature and focus of detoxification treatment programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process.

Interpretation

Vulnerable populations, such as youth that are lesbian, gay, bisexual, transgender, and questioning (LGBTQ), are at high risk of violence and harassment while in residential placement. The organization should consider these factors to ensure these youth are safe and welcomed by staff.

Interpretation

Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to:
  1. evidence of mental, physical, or sexual abuse;
  2. physical exhaustion;
  3. working long hours;
  4. living with employer or many people in confined area;
  5. unclear family relationships;
  6. heightened sense of fear or distrust of authority;
  7. presence of older significant other or pimp;
  8. loyalty or positive feelings towards an abuser;
  9. inability or fear of making eye contact;
  10. chronic running away or homelessness;
  11. possession of excess amounts of cash or hotel keys; and
  12. inability to provide a local address or information about parents.

Several tools are available to help identify a potential victim of trafficking and determine next steps toward an appropriate course of treatment. Examples of these tools include, but are not limited to, the Rapid Screening Tool for Child Trafficking and the Comprehensive Screening and Safety Tool for Child Trafficking.
Examples: Organizations serving young children can tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behaviour, and/or a thorough health and developmental history.

Examples: Factors that can impact group living success can include:
  1. possible reciprocal individual and group effects;
  2. the individual’s ability to adjust to a group;
  3. safety issues;
  4. previous placements; and
  5. trauma history.

 
Fundamental Practice

CA-RTX 4.05

When a resident’s assessment indicates a substance use condition, the organization records a thorough alcohol and drug use history, including an evaluation of the effects of alcohol and other drug use on the resident’s family and:
  1. provides an appropriate level of service and detoxification, as necessary; or
  2. connects the resident and/or family members to appropriate services when the program does not serve individuals with substance use conditions.

 

CA-RTX 4.06

Reassessments are conducted as needed, including at specific milestones in the treatment process, including:
  1. after significant treatment progress;
  2. after a lack of significant treatment progress;
  3. after new symptoms are identified;
  4. when significant behavioural changes are observed;
  5. when there are changes to a family situation or parental status;
  6. when significant environmental changes occur; or
  7. when a resident returns following an episode of running away.
Note: For more information regarding residents that return after an episode of running away, refer to CA-RTX 10.01 and CA-RTX 18.03.