1522 K Street, NW, Suite 1032

Washington, DC 20005

Phone: 202.408.3338

Fax: 202.408.3340

Email: napsec@aol.com

Specific Program/Service Standards

·        Special Education – Day Programs – Standards for Accreditation

·        Special Education – Residential Programs

·        Educational Support Services

·        Education Diagnostic/Evaluation Services

Standards listed in Bold are Core Standards and must be met in full compliance.

In addition, at a minimum, 80% of the non-bold Standards must be met to be eligible for accreditation.

Standards for Accreditation

ORGANIZATION

The organization is structured and governed for the purpose of providing educational and related services to individuals with special needs.

Mission

____1.    The organization defines its mission and purpose and establishes a program of educational and related services for its attainment.

Review copy of Board authorized mission statement and minutes of Board meeting at which the mission statement was authorized.

____2.     The organization maintains a current and readily available statement of its mission and purpose and description of its program(s) and services.

Review written program description, noting date of publication.

____3.     The organization provides an up-to-date description of its program(s) and services to the community it serves.

Review brochures, newspaper articles, etc., which demonstrate that information is made available to the community being served.

Legal Sanction

____4.    The organization is a duly organized corporation or is otherwise authorized by law to offer a program of special education and related services.

____5.    The organization is incorporated in the state in which it conducts its operations, or is authorized by the state's statutory authority for education, where such exists, to provide special education and support services for children, youth, adults and/or families.

4 - 5

Review articles of incorporation or other legal document(s) that identify the organization and state its purpose (licenses, certifications, etc.).

Regulatory Compliance

____6.     The organization is in compliance with applicable federal, state, and local requirements for its program of services.

Review legal documents, if any, which stipulate terms under which the organization operates.

____7.    An individual(s) is identified as having the responsibility for ensuring compliance to all laws and regulations applicable to all operations of the facility.

Review job description that identifies person responsible. Review letter of appointment or Board minutes authorizing appointment of person responsible.

____8.    The organization possesses copies of current regulations that govern any of its programs or services. If the facility transports individuals for any purpose, copies of those applicable regulations/policies are available.

Review copies of statutes, regulations, policies, etc., which identify operating requirements.

____9.    The organization possesses documentary evidence of its operating authority, including charter, by-laws and all required licenses, certifications, or approvals as evidenced by the availability or display of these items.

Review licenses, certificates, letters of authorization, noting date(s).

Governing Body (advisory body/proprietor)

____10.    The organization has a governing body responsible for establishing its policies and determining its leadership.

Review document that identifies governing body and which is in accordance with legal requirements operating the organization.

____11.    The governing body organizes itself in a manner that enables it to provide continuous organization governance.

Review written document, which identifies manner in which the governing body delegates authority (organizational chart) - responsibility, including a listing of the chain of command.

 ____12.    The governing body ensures that the organization is funded, housed, staffed, and equipped in a manner appropriate to its program of services and population served.

Review operating plan, strategic plan, financial plan/budget or other appropriate documents (annual reports, audited statement).

____13.     The governing body ensures that the organization complies with all applicable laws and regulations governing its services and employment of staff.

Review policy regarding manner in which the organization insures compliance with applicable legal requirements.

____14.     The governing body delegates responsibility for the administration of the organization to a chief executive, whom it holds accountable for the organization's performance.

Review job descriptions of chief executive; letter of appointment, Board minutes.

____15.     The governing body annually evaluates the performance of the chief executive.

Review performance evaluation documents; Board minutes, etc.

____16.     The members of the governing body receive orientation on the organization's goals, objectives, programs, and methods of operation.

Review orientation documents, interview Board member(s) to verify that they have participated in an orientation program.

____17.     Minutes of all meetings of the governing body and its committees are maintained in the organization’s permanent records.

Review policy on formulation, distribution, maintenance of Board meeting minutes; review files where Board meeting minutes are maintained.

Ethical Conduct

____18.     The organization has a written code (or codes) of ethics for the operation of its programs and services.

Review policy regarding ethical conduct; Review licensing-accreditation survey reports; interview representatives from licensing and accreditation agencies.

____19.    The organization’s governing body, voluntary board, staff and consultants are not favored in applying for or receiving the services of the organization.

Review conflict of interest policy.

____20.     The organization neither receives nor provides  payment (or other consideration) from or to another provider of services for the referral of any applicant or client/student to or from such provider of services. (Note: This prohibition does not preclude one organization from contracting with and compensating another for the provision of services.)

____21.    The organization has a mechanism for reviewing and approving directed referral of its applicants, clients/students or their families to any private practice in which its staff or consultants may be engaged. Such approval is based on the best interests of the applicant, client/student or family, who is notified in advance of the relationship between the practitioner and organization.

18. – 21.

Review policy on referral practices, interview referring organization representative.

____22.     The organization maintains a record of the ownership of all its properties and of all financial transactions it enters into with respect to such properties.

Review list of facilities, title(s) or other documents, which verify ownership.

____23.     In the case of a non-profit organization board members, staff and consultants have no direct or indirect financial interest in the assets, leases, business transactions, or professional services of the organization.

____24.     Where a conflict of interest might exist for board members, staff and consultants, there is prior written disclosure, and such persons exempt themselves from voting or otherwise influencing results for personal gain, and there is a policy in effect for such purposes.

22. – 24. 

Review conflict of interest policy, verify Board awareness (signed document); interview licensing/accreditation organization representative.

ADMINISTRATION

The organization is directed and managed in accordance with formally established policies and procedures.

Administrative Authority

____25.      With the governing body and, where the organization is so constituted, with the assistance of its advisory body, the chief executive plans and coordinates the development of policies and procedures governing the organization's program of services.

Review documents, interview Board member or chief executive to verify policy-making procedures.

____26.     The chief executive plans with the organization's governing body, coordinates its work, assists its members and committees in the performance of their duties, and ensures that it is kept informed on matters affecting the organization's finances, operation, and services.

Review Board minutes and policy regarding working relationship between the chief executive and the governing body.

____27.     The chief executive is authorized to employ and discharge staff and to otherwise administer the organization’s personnel policies.

Review chief executive job description.

____28.     The chief executive assumes no outside duties that interfere with his/her responsibility for administration of the organization.

Interview Board members, staff members, and/or other persons about knowledge of chief executive activities. Review CEO’s job description.

____29.     The chief executive has the credentials and experience to ensure effective utilization of the organization's personnel and financial resources and to ensure coordination of its program of services.

Review resume and personnel file, interview chief executive.

 ____30.    The chief executive’s responsibilities include oversight of the development, coordination and administration of the organization's program of services.

Review chief executive job description and Board policy.

____31.     When delegating these responsibilities, the chief executive delegates them to staff members who are qualified by position and by professional education and experience to assume them.

Review organizational chart, interview to validate; review job description and personnel files.

Accountability

____32.    Clear lines of accountability and authority exist at all levels of the organization's organizational, administration, and service structures.

____33.      The organization has an organizational chart that is kept current and clearly delineates lines of accountability and authority. The organization updates changes to the organizational chart as they occur.

____34.     The organizational chart is made known to all staff.

Review organizational chart, noting date of last publication; interview chief executive and staff to verify accuracy--compliance.

____35.     Clear lines of communication exist among staff at the same, as well as different, levels of administration or service.

32. – 35.

Review organization chart; review job descriptions; interview appropriate staff member(s); review personnel files.

____36.    Procedures are available for staff and clients/students to alert the organization's administration and governing body to changing community conditions or other matters of concern to the organization.

Review written procedures, interview staff and client/students. Review staff meeting notes.

Policies and Procedures

____37.     The policies and procedures of the organization are formulated and maintained in a way that promotes effective administration.

Review written document regarding formulating polices and procedures, including minutes of governing body meetings.

____38.       The organization's policies are clearly differentiated from the procedures employed to implement them.

Review policy/procedures.

____39.     Policies and procedures are readily available, in written form, for the guidance of the governing body, organization staff, cooperating agencies, and other interested groups or individuals, as appropriate.

Review policy and procedures; interview staff to verify their knowledge of location and accessibility.

____40.       In non-profit organizations policies are approved by the governing body.

Review minutes showing governing body approval of the organization’s policies and procedures.

PERSONNEL

Personnel Practices

____41.     The organization has a manual of procedures to guide it in all matters relating to employment policy.

____42.       The manual of personnel policies is reviewed at specific intervals and formally adopted by the organization's governing body.

____43.      All staff members are given a copy of the personnel policies and required to sign a form indicating that they have read and agree to comply with these policies.

41. – 43

Review written policy(ies) relating to employment practices and manual of procedures, noting authorization dates and sources of authorization. Establish that employee signatures, whether on a dedicated form or other document, confirm their receipt and agreement to comply with all personnel policies.

____44.      The organization has a written job description for each position, including that of chief executive.

Review written job descriptions and list of positions.

____45.     The organization's policies specify clearly the conditions under which it employs personnel related to board or staff members serving in a governing, administrative or supervisory capacity and the protection it offers against favoritism or undue influence stemming from such relationships in the administration of its personnel practices.

Review policy, noting authority and date.

____46.     The organization's policies regarding salaries and working conditions promote the employment and retention of qualified staff and encourage high productivity and quality of its services.

Review policy and procedures.

____47.      Grievance procedures are made available to employees of the organization and are described in the manual of personnel policies.

Review policy and procedures regarding grievances. Interview staff to validate - Chief Executive and others as appropriate.

Personnel Records

____48.     The organization maintains a system of personnel records that includes an annual performance evaluation for each employee.

____49.     The personnel record contains the employee's application for employment,  agreed-upon terms of employment, a signed form indicating that the employee has read and agrees to comply with all personnel policies, job classification, job description, health certificate (where required), verification of education, names of persons to contact in case of emergency, written performance evaluations, evidence of current certifications/licensure, where applicable, and other documents required for licensure or approval.

____50.     Annual performance evaluations are conducted jointly with the employee, and the results are reviewed with and signed by the employee before being entered in the personnel record. Opportunity for employee comment is provided.

48. – 50.

Review personnel files and verify.

____51.     Employees are permitted to review the information in their personnel records, and a written procedure exists for requesting review and correction of information.

Review written policy and procedures.

____52.     Personnel records are secured against loss, destruction, and/or unauthorized access.

Identify location of personnel files and manner in which security is guaranteed.

____53.      The organization defines in writing its policies and procedures for controlling access to or receipt, use, and release of information about its employees.

Staff Qualifications

____54.      The organization retains personnel qualified in all respects to staff its program(s) of services.

Review policy and procedures or other documents that state the organization's position regarding the hiring of qualified personnel.

____55.      Professional staff have at least a bachelor's degree from an accredited school, have the experience and competence required in the performance of their duties, are qualified according to the accepted standards of their respective professions or disciplines and meet required state standards.

Review list of professional staff, personnel files, and related documents.

____56.      Administrative and professional staff and consultants abide by their respective codes of ethics and meet all applicable state registration, certification, or licensing requirements.

Interview administrative/professional staff, review policy and procedures regarding ethics.

____57.      Staff who lack professional training or have limited professional experiences are assigned duties and receive in-service training and supervision appropriate to their skills and demonstrated competence.

Review policy and procedure regarding staff training, staff training curriculum, schedule of training sessions; and personnel files; interview staff.

Diversity & Non-Discrimination

____58.     The organization actively recruits and employs qualified personnel and administers its personnel practices without regard to age, sex, sexual orientation/preference, race, ethnicity, nationality, or disability of the individuals under consideration.

Review policy/procedure regarding hiring without regard to age, sex, race, ethnicity, nationality, or physical disability; interview appropriate staff; licensing/accreditation, organization representative.

_____59.     The organization complies with all applicable federal and state anti-discrimination laws.

Review policy/procedure. Review examples of advertising in diverse publications.

Staff Development

____60.      The organization has a staff development program that offers opportunities for staff to improve their knowledge, skill, and ability in order to enhance the organization’s service delivery to clients/students.

Review policy/procedure regarding staff development, interview appropriate staff.

____61.     Staff development is an ongoing, integral, and identifiable part of the organization's program of services.

____62.       The organization offers orientation and in-service training for new staff with respect to organization objectives, resources, policies and services.

____63.        Staff development emphasizes awareness, sensitivity, and appreciation of the culture and perspective of each client/student served by the organization.

 ____64.        Staff development utilizes a variety of training resources, including those available in the surrounding community (e.g., area experts, resources accessible through local colleges and universities, etc.)

60. – 64.

Review policy and procedure regarding staff training, staff training curriculum, schedule of training sessions, and personnel files; interview staff.

Training of Service Professionals

____65.      The organization participates with institutions of higher education (i.e., colleges and universities) in the training of their students, where possible.

Review policy and procedure regarding internships, student teaching, etc., personnel files; documentation of student teaching and internships; interview staff and higher education institutions – as needed. .

SERVICES

Definition of People Served

____66.       The organization serves a defined client/student population and specifies clearly its conditions of eligibility for services.

Review policy, procedure, and mission statement regarding population to be served.

Nondiscrimination

____67.      The organization has a policy on nondiscrimination in admissions and documented evidence of the populations it serves.

Review policy/procedure or other document regarding population served.

____68.       The organization can provide evidence of unbiased, nondiscriminatory curricula.

Review appropriate documents verifying such affiliation and review curriculum that applies.

Confidentiality

____69.       The organization seeks legal counsel in defining its policies with respect to laws and regulations governing the confidentiality of records.

Review appropriate document, interview legal counsel, and appropriate staff.

____70.       The organization conforms to all applicable federal and state requirements governing the collection, maintenance, and dissemination of client/student information, including the Family Education Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act (HIPAA), where applicable.

Review policy/procedure on confidentiality of client/student records and signed consent forms, interview client/student/guardian to verify.

____71.        Communication with other organizations involved in the client’s/student’s treatment and/or education is conducted with proper releases and carried out frequently enough and in such a manner as to maximize the coordination of services provided to him/her.

____72.     When the client/student is endangered or may be harmful to others, the organization determines its responsibility for disclosure to appropriate parties as required for protection of the client/student or the community.

70. – 72

Review policy/procedure regarding confidentiality of client/student records. Interview parents, students, staff.

____73.     The organization's recording and record-keeping practices and storage facilities have procedural and physical safeguards to prevent unauthorized access to information.

Review policy/procedure regarding confidentiality of client/student and observe location of records.

____74.     The organization has a policy that establishes procedures to allow the clients/students, or where applicable the client’s/student’s guardian, to review the client’s/student’s records and request correction of inaccurate information except where prohibited by law.

Review policy/procedure regarding access to client/student records by client/student, guardian, and parents. Review access log to records.

 ____75.         The use of audio and/or visual recording methods for diagnostic, therapeutic, or training purposes occurs only with full knowledge of the purposes by the client/student or legal guardian and his/her approval.

Review policy/procedure; review signed authorization and policy regarding access to client/student records by client/student, guardian, and parents.

Client/Student Records

____76.       The organization maintains a record for each client/student enrolled for care or services.

____77.         Records exist for each client/student that are chronologically complete from entrance to exit and that  document an evaluation that identifies the specific needs of the client/student,

1.      Specify the comprehensive program plan (case plan, individual education plan, transition plan) devised to meet identified needs,

 

2.      Clearly state goals and objectives,

3.      Report client/student progress toward the goals and objectives,

4.      Document the review and modification of the program plan, goals and objectives in consideration of the client’s/student’s progress, and

5.      Summarize upon exit the client’s/student’s skills and areas of need with relevant program recommendations.

76. – 77

Review client/student file(s).

____78.       The confidentiality of client/student records is protected by written policies and procedures that govern receipt, access, use, duplication, release, and dissemination of their contents. These policies and procedures conform to all applicable federal and state requirements, including FERPA and HIPAA, where applicable.

Review written policy and procedures regarding confidentiality of client/student records.

____79.        Client/student records are clear, concise, and reflect client/student strengths and needed program components.

____80.       A complete record is maintained at the facility for each client/student for three years after discharge, or longer if required by state and/or local law.

Review list of every client/student (if it is available) and discharged client/student files to verify; review list of discharged clients/students and client/student records to verify compliance of 3 years requirement.

Research

____81.       The organization has written policy/procedures that govern its use of research. (need def. of research)

Review policies and procedures. If organization does not conduct research, confirm that this is stated in policy/procedure.

____82.       The organization exhibits due regard for client/student privacy in conducting and reporting research.

Research means a systematic investigation, including research development, testing and evaluation, designed to develop or contribute to generalizable knowledge. Activities which meet this definition constitute research for purposes of this policy, whether or not they are conducted or supported under a program which is considered research for other purposes. For example, some demonstration and service programs may include research activities.

____83.       The organization assures that client/student identity and privacy are protected throughout all phases of the research.

____84.           Participation in research is completely voluntary, as evidenced by informed consent forms signed by the client/student and in the case of minors the parent/guardian. Informed consent must include a statement of the potential risks and benefits of participation, and the assurance that refusal to participate will have no negative implications for the client/student.

82. – 84.

Review policies, procedure, other documents regarding research practices; interview appropriate staff, Board members, licensing/accreditation organization representative.

Complaints and Appeals

____85.        The organization provides clients/students the opportunity and means to file complaints or appeals when decisions concerning them, or services provided to them, are considered unsatisfactory.

____86.       The organization acts promptly on any complaint and notifies the client/student/legal guardian in writing of any outcomes of its actions that are related to his/her education or treatment.

____87.       The organization documents all complaints and appeals, including their resolution.

85. – 87.

Review written policy, procedures; interview appropriate staff, board member, and licensing/accreditation representative.

Individualized Service Planning

The organization plans and provides educational and related services on an individualized and accountable basis.

____88.       Each service within a program is clearly defined.

____89.      All separate services of a program, as identified in the application form, are listed in written form.

____90.       Criteria for entry into each service are available in written form.

____91.     There are clearly defined procedures for referring a client/student into each service component of the program.

88. – 91.

Review policy/procedure regarding development of plan for education and related services, meeting minutes, etc., to verify procedures, list of services provided, documents defining sources, and document identifying criteria for involvement in services.

Individualized Educational Plan

____92.       Each special education client/student has an individualized education plan.

____93.       The individualized education plan includes:

1.      A statement of the individual's present levels of educational performance;

2.      A statement of annual goals, including short-term instructional objectives;

3.      A statement of the specific special education and related services to be provided to the client/student and the extent to which the individual will be able to participate in regular educational programs;

4.      The projected dates for initiation of services and the anticipated duration of the services;

5.      Appropriate objective criteria and evaluation procedures and schedules for determining             whether the short-term instructional objectives are being achieved; and

6.      A transition plan, where appropriate.

____94.      Objectives specified in the individualized education plan maximize the individual’s potential.

____95.       All individualized education plans are reviewed and updated on at least an annual basis.

____96.       The organization has written procedures for involving parents or guardians in the development and review of individualized education plans.

92. – 96.

Review policy/procedures regarding development of individualized education plan, IEPs, and minutes of IEP meetings.

Instructional Planning

____97.       The organization has policies that ensure systematic instructional planning (e.g., regular supervision of instructors, monthly submission to educational leadership of instructional plans, classroom observation, etc.).

____98.       Any instructor is able to exhibit day-to-day records, which can be in the form of anecdotal notes, charts, worksheets, or other data, describing client/student progress in each curriculum area.

____99.       Each client’s/student’s short-term instructional objectives are reviewed at least quarterly and updated based on the client’s/student’s progress.

 ____100.     A written schedule or plan of review is in evidence indicating review of each client’s/student’s progress with the team responsible for the child’s educational/clinical services at least twice a year.

97. – 100. 

Review policy/procedures regarding instructional planning and lesson – unit plans, interview appropriate staff. Review notes from planning meeting for 100 – 101.

Curriculum

Curriculum may be viewed as the framework of an educational program. It ultimately determines what clients/students will learn in the way of skills and competencies. While subject matter, methods, and techniques may vary according to a number of different factors, the delivery of curriculum requires balancing the demands of traditional subject matter and methods with the unique needs of the individual learner.

For early childhood programs, the goal of instruction is to build a foundation for lifelong learning, achievement and assisting each child to reach her/his full potential. Instruction is embedded in the design of learning centers /environments, materials, as well as daily routines and transitions.

Language and literacy development in early childhood builds the foundation for learning across content areas.

Family members play a critical role in supporting the growth and development of their children. In preschool programs, families are partners in the planning and implementation of their child’s program.

____ 101.    The organization has clear curricula that include subject matter and, where appropriate to the population served, behavior intervention practices.

____102.    The curriculum provides for a comprehensive and develop-mentally sequential program of instruction designed to address the specific abilities and educational needs of each client/student and to promote individual achievement.

Review program description--education program and curriculum document(s)

____103.    The curriculum used in the educational program is consistent with the program's philosophy and goals.

 ____104.    The curriculum provides for consistency between the learning goals/objectives and instructional activities.

103. – 104. 

Review curriculum document(s), interview appropriate member(s) of staff and governing body.

____105.    Provisions are made for modifying materials and instruction to meet the needs of individual clients/students.

____106.    The curriculum is designed to assist each client/student to develop relevant attitudes, knowledge, and skills appropriate to his/her individual interests, abilities, and needs. The curriculum addresses the following areas, as appropriate to the population served:

Ø     basic skills in language, reading, writing, spelling, and mathematics;

Ø     science and social studies;

Ø     communication skills;

Ø     social/interpersonal skills;

Ø     pre-vocational and vocational skills;