COA Stakeholder Surveys / Standards Crosswalk Private Organizations

Transcription

1 COA Stakeholder Surveys / Standards Crosswalk Private Organizations The questionnaires that organizations distribute to their stakeholders during the accreditation process are an important source of evidence that peer reviewers use when assessing and rating an organization's implementation of the standards. Stakeholder responses to the questionnaires are used in conjunction with the narratives, self-study documents, on-site documents, and the on-site activities listed in the Tables of Evidence for each of the standards sections. This crosswalk gives organizations specific information about which standards are related to the questions on each of the stakeholder questionnaires. This provides organizations with an understanding of the full range of evidence that contributes to the ratings they receive during the site visit. Governance Questionnaire 1 As a member of the governing body (GB), we effectively conduct/participate in longterm planning. 2 As the GB, we effectively develop & approve policies. GOV As the GB, we establish resource development targets and goals. GOV 6.05 GOV 6.02, GOV We regularly review fiscal/financial reports. FIN 1, GOV We approve the organization's annual budget. FIN 1, FIN As the GB, we review and formally accept the annual audit. FIN 1, FIN 2.02, FIN As a member of the GB, I review and provide input regarding the organization's quality improvement activities/ initiatives. 8 As a member of the GB, we receive information on the organization's program outcomes and outcomes for persons served. 9 The organization's GB and the CEO/Executive Director have an effective working relationship. PQI 1.01, PQI 5.03, PQI 5.04 PQI 5.03 GOV 6.07, PQI At least annually as members of GB, we assess areas of risk to the organization. GOV 6.08, RPM We receive quarterly reports of immediate and ongoing risk within the organization. RPM The organization collaborates with the community to advocate for issues of mutual concern. 13 I received an orientation as to my GB responsibilities. GOV The organization's GB is representative of the community it serves. GOV 2.02, GOV 2.03

2 15 To your knowledge, within the last four years, have any of the following occurred? a. Allegations or findings of professional misconduct, b. Financial malfeasance, c. failure to comply with laws and regulations governing equal opportunity and workforce administration, d. investigations by regulatory or other monitoring bodies which have identified significant problems at the organization. a. ETH 2, ETH 5 b. FIN c. HR 5.01, HR 1.01, HR d. COA Self-Report Personnel Questionnaire 1 My job responsibilities are clearly outlined in my job description. HR I received an orientation within the first three months of beginning work with the organization. TS I have an up-to-date copy of or can access the personnel handbook. HR I am aware of the organization's grievance procedures and know how to make a complaint. 5 I am notified when positions that I may be qualified for become available within the organization. HR 4.05 HR I can access my personnel record. HR I receive annual performance evaluations. HR I receive regular supervision. TS At least annually, employee satisfaction is assessed by the organization. HR The organization implements changes based on the feedback received from personnel. HR 4.04, PQI I participate in quality improvement activities within the organization. PQI 3.02, POI I receive information on program outcomes that is useful to me in working with persons served. PQI I have participated in on-the-job activities that enhance my knowledge and skills. TS 1.02, TS Case records of persons that I serve are readily available or accessible to me. RPM 5.01, RPM 5.02, RPM I participate with others at my organization in quarterly review of my clients' progress toward achieving their goals. 16 I am aware of the organization's policies regarding: 1. Harassment 2. Discrimination prohibition 3. Prohibition of corporal and degrading punishment of consumers 4. Confidentiality Service Section Service Planning and Monitoring Standards 1. HR HR Select Service Section Service Philosophy Standards 4. ETH 5.01, CR 2, RPM 6

3 Advisory Board Questionnaire 1 The organization's advisory board (AB) is sufficiently active in carrying out its assigned responsibilities on behalf of the organization. GOV The role of the organization's AB is well defined. GOV As a member of the AB, we receive information (management and/or quality improvement reports) that supports our designated role/ purpose on behalf of the organization. GOV The work of the organization's AB extends the capability of the organization. GOV 2 5 Upon joining the organization's AB, I received an orientation that addressed AB membership responsibilities/roles. 6 AB members have unique knowledge and skills which complement the knowledge and skills of the organization. 7 The AB's recommendations to the organization contribute to organizational effectiveness. 8 As a member of the AB, I feel my participation contributes to quality of care and/or organizational capacity improvements. GOV 2.04 GOV 2.04 PQI 5.03 PQI The organization's reputation with the community is favorable. GOV 6 10 The organization collaborates with the community regarding issues of mutual concern. 11 The organization's AB is representative of the community it serves and/or the needs of persons served. 12 To your knowledge, within the last four years, have any of the following occurred? a. Allegations or findings of professional misconduct, b. Financial malfeasance, c. failure to comply with laws and regulations governing equal opportunity and workforce administration, d. investigations by regulatory or other monitoring bodies which have identified significant problems at the organization. a. ETH 2, ETH 5 b. FIN c. HR 5.01, HR 1.01, HR d. COA Self-Report

4 Community Questionnaire 1 The organization's facilities are clean and well maintained. ASE 1.01, ASE 4 2 The organization's services are accessible to persons with disabilities. ASE 2 3 The organization's services are conveniently located and accessible to public transportation. ASE The organization does not discriminate in the provision of its services. ETH 5.03, CR Information about the organization's services and eligibility criteria are made available to the community. GOV The organization provides culturally sensitive services. TS 2.05, HR 6.02(f) 7 The organization respects the confidentiality of the persons it serves. ETH 1.05, CR 2, ETH 6, RPM 6, PQI 5 (note) 8 The organization is known for its integrity and ethical practices. ETH, GOV 6 9 The organization conducts a public education program to make its presence known to the community. 10 The organization works with other community organizations to advocate on behalf of the people it serves. GOV The organization promptly screens applicants and persons referred for its services. Service Section Screening 12 Waiting periods for services are reasonable. Service Section Screening 13 Fees are reasonable and fair. CR The organization is fiscally responsible. CR 1.08, FIN 15 The organization's reputation with the community is favorable. GOV 6 16 Personnel are qualified and competent in the performance of their jobs. HR 3, Service Section Personnel Sections 17 The organization is in compliance with all applicable laws and regulations. GOV 6.08, RPM 1

5 Supervisors / Managers Questionnaire 1 The organization has an effective quality improvement program PQI 2 I participate in the organization's quality improvement activities. 3 The organization regularly examines its internal access and service delivery processes. TS 3.08, PQI 1.03, PQI 3.02, PQI 5.02, PQI 5.03 PQI 3.03, PQI The organization conducts quarterly reviews of accidents, incidents, and grievances. RPM 2.02, RPM Outcome data is used to improve services for consumers. PQI I am aware of the organization's conflict of interest policy. ETH 2 7 The organization does not discriminate in hiring/promoting. HR I receive an annual performance evaluation. HR The organization is prepared to respond to natural disasters and other emergencies. ASE 7 10 The finances of the program in which I work are managed by the organization with integrity and according to sound business practices. 11 The organization's services are well coordinated. General information regarding service provision 12 The organization facilitates timely and easy access for consumers. Service Section Screening 13 Access to emergency and crisis intervention services is available for consumers. Applicable to select services FIN 7 14 I have time to conduct supervision with my staff. TS The organization monitors its relationship with contractors who provide services to consumers. 16 The organization's governing body and the CEO/Executive Director have an effective working partnership. HR 6.04 GOV 6.07, GOV I am aware of the organization's confidentiality policy and procedures. ASE 1.05, CR 2, ETH 6.04, TS 2.02, RPM 6.01

6 Consumer Questionnaire 1 I was given written information about my rights and responsibilities as a consumer/client. 2 The people who work at the organization treat me with respect and courtesy. CR 1 3 The staff is respectful of my confidentiality and privacy. TS 2.02, CR 2, ASE 1.05, ETH 6 4 I know where to go at the organization or whom to speak to if I have a complaint. CR 1.01, CR2 5 The organization asks me about my ideas on how to improve its services. PQI 3.02, PQI The organization is easy for me to get to. ASE The organization's services are available at times that are good for me. ASE The organization's building and offices are clean. ASE 1.01, ASE 4 9 I feel safe while at the organization and on its property. ASE 6 10 I help plan my services and set my goals. Service Section Service Planning and Monitoring Standards 11 I was able to receive services from the organization without too much waiting time. Service Section Screening 12 I would recommend the organization to my family and friends. General information regarding service provision 13 If I needed help or services again I would come back to the organization. General information regarding service provision 14 Overall, I am satisfied with the services that I am receiving. PQI 4.02 CR1

7 Contractee Questionnaire 1 My responsibilities within the organization and as a contracted provider are clear and established in writing. 2 There is an effective mechanism for resolving conflicts between the organization and contracted service providers, including conflicts of interest. 3 As a contracted provider, I receive information about the organization's performance (outcomes and consumer satisfaction). 4 The organization has an effective quality improvement process. PQI HR 3.01 ETH 2 PQI I participate in the organization's quality improvement activities PQI 3.02, PQI Outcome data is used to improve service delivery. PQI The organization's services are well coordinated. General information regarding service provision 8 The organization facilitates timely and easy access for consumers. Service Section Screening 9 Access to emergency and crisis intervention services for consumers is available 24/7. Applicable to select services 10 The organization maintains good working relations with its contracted service providers. 11 The organization works in partnership with the community to improve services and advocates on behalf of consumers. 12 The organization adequately addresses liability issues regarding its contracted service providers. General information regarding contractee/ organization relationship HR The organization has informed me of its confidentiality policy and procedures. CR 2, ETH 6, RPM 6, ASE The organization monitors and evaluates the quality of the services I provide. HR 6.04

8 Foster Parent Questionnaire 1 I participate in service planning for my foster child. CR1.07, FC 3 2 The organization provided me with specific information about the child prior to placement in my home. 3 The organization responds proactively to challenges and conflicts associated with the placement. 4 I am given adequate notice when I am to receive a child and when a child is to be removed. 5 My foster child maintains relationships with family members, friends and their community through visits and/ or activities. 6 The organization ensures my foster child receives needed services identified in the service plan, such as: counseling, support, and education services. 7 My foster child has opportunities to participate in ethnic, cultural, and/or religious activities consistent with his/her cultural o native traditions. 8 My foster child receives needed medical, dental, developmental and mental health services. FC 6.06 FC 6.06 FC 6.06 FC 7 FC 9 CR 1.05(c), FC 3.03(c), FC 9.05 FC 10 9 I received information about my foster child's healthcare needs. FC I have access to a caseworker whenever I need information and assistance. FC I have a private visit with the caseworker at least once a month. C Foster parents are involved in the organization's foster parent recruitment and retention efforts. 13 The training I received from the organization has effectively prepared me to be a foster parent. FC I have been informed of my rights and responsibilities as a foster parent. FC I have access to services to prevent/reduce stress, such as childcare, respite care, counseling, peer support, or recreational activities. 16 The organization provided or helped me develop a plan for responding to emergencies such as accidents, run away behavior, serious illness, fire, and natural disasters. FC 16.03, FC 16.04, FC 16.05, BSM 3 FC FC The organization assesses the safety of my home. FC 17