January 1, 2010
Organization
Mission
Legal Sanction
Regulatory Compliance
Governing Body
Ethical Conduct
Administration
Administrative Authority
Accountability
Policies and Procedures
Personnel
Personnel Practices
Personnel Records
Staff Qualifications
Non-Discrimination
Staff Development
Training of Service Professionals
Services
Definition of People Served
Diversity & Nondiscrimination
Confidentiality
Client/Student Records
Research
Complaints and Appeals
Individualized Educational Plan
Individualized Service Planning
Instructional Planning
Curriculum
Instructional Methods
Educational Support Services
Education Diagnostic/Evaluation Services
Medication
Behavioral and Affective Practices
Emergency Services
Transition to Other Environments
Admission and Exit Procedures
Community
Community Identification
Community Education
Community Planning
Health and Safety
Regulations
Procedures
Physical Plant Safety
Staff Facilities
Financial Management
Financial Resources
Budget
Management of Funds
Control and Audit
Cost Allocations
Insurance Coverage
Evaluation
Goals and Objectives
Program Evaluation
Data Collection
Administrative Studies
Dissemination
Standards for Special Education within Residential Settings
NOTE: Text in italicized type provides guidance to the Site Reviewers in possible sources of evidence for the organization’s compliance with the standard(s) preceding it. It does not list compliance requirements. Other evidence of compliance may be offered by the organization.
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., that 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, 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.
23. – 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 seeks legal counsel, as needed, in defining any policies that are governed by statute and regulation.
Review appropriate document, interview legal counsel, and appropriate staff.
____39. The organization's policies are clearly differentiated from the procedures employed to implement them.
Review policy/procedures.
____40. 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.
____41. 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
Organizations may use a variety of terms (e.g., teacher, instructor, trainer, aide, etc.) to identify personnel responsible for the education and care of its clients/students. For the sake of simplicity the word instructor is used throughout the standards to denote these individuals, recognizing that for particular organizations other terms may be used. There are standards for which alternate terms are deliberately used in order to identify role-specific functions or expectations.
Personnel Practices
____42. The organization has a manual of procedures to guide it in all matters relating to employment policy.
____43. The manual of personnel policies is reviewed at specific intervals and formally adopted by the organization's governing body.
____44. 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.
42. – 44.
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.
____45. The organization has a written job description for each position, including that of chief executive.
Review written job descriptions and list of positions.
____46. 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.
____47. The organization's policies regarding compensation and working conditions promote the employment and retention of qualified staff and encourage high productivity and quality of its services.
Review policy and procedures.
____48. 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
____49. The organization maintains a system of personnel records that includes an annual performance evaluation for each employee.
____50. 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.
____51. 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.
Review personnel files and verify.
____52. 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.
____53. Personnel records are secured against loss, destruction, and/or unauthorized access.
Identify location of personnel files and manner in which security is guaranteed.
____54. 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
____55. 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.
____56. The organization’s hiring practices include screening for criminal record checks, protective services/child abuse checks, and drug abuse, where required or allowed by presiding jurisdictions.
____57. Employment interviews address the organization’s policies and practices related to staff-to-student/client boundaries, including those related to physical contact and communications.
____58. Professional staff members 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.
____59. 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.
____60. Staff members 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
____61. 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.
____62. The organization complies with all applicable federal and state anti-discrimination laws.
Review policy/procedure. Review examples of advertising in diverse publications.
Staff Development
____63. 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.
____64. Staff development is an ongoing, integral, and identifiable part of the organization's program of services.
____65. The organization offers orientation and in-service training for new staff with respect to organization objectives, resources, policies, and services.
____66. Staff development emphasizes awareness, sensitivity, and appreciation of the culture and perspective of each client/student served by the organization.
____67. 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.)
64. – 67.
Review policy and procedure regarding staff training, staff training curriculum, schedule of training sessions, and personnel files; interview staff.
Training of Service Professionals
____68. 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
____69. The education program serves a defined client/student population consistent with its mission and specifies clearly its conditions of eligibility for services.
____70. The education program has a policy that states what the exceptions to confidentiality are and requires that those limits be shared with clients/students and their legal guardians, as appropriate, at the time of enrollment.
Review policy, procedure, and mission statement regarding population to be served.
Nondiscrimination
____71. The education program has a policy of nonbiased admissions practices and evidence of consistent application of that policy.
Review policy/procedure and documentation that demonstrates that demographic characteristics of the client/student population and/or referral base (e.g., race, ethnicity, etc.) that are representative of the demographic characteristics of the larger community served.
Confidentiality
____72. The education program 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.
____73. With signed releases the education program communicates with other organizations involved in the client’s/student’s treatment and/or education to maximize the coordination of services provided to him/her.
____74. The education program has in place policies and procedures that govern the release of information about clients/students necessary to protect their privacy.
____75. The education program’s policies on confidentiality describe clearly the organization’s responsibility for disclosure when a client/student is endangered or may be harmful to others.
72. – 75.
Review policy/procedure regarding confidentiality of client/student records. Interview parents, clients/students, staff.
____76. The education program’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.
____77. The use of audio and/or visual recording methods for any 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
____78. The education program maintains a record for each client/student enrolled for care or services.
____79. Records exist for each client/student that are clear, concise, legible, and chronologically complete from entrance to exit and that:
· Document evaluations that identify the specific needs of the client/student;
· Reflect client/student strengths and needed program components;
· Specify the comprehensive program plan (case plan, Individual Education Program, transition plan) devised to meet identified needs;
· Clearly state goals and objectives;
· Document the review and modification of the program plan, goals and objectives in consideration of the client’s/student’s progress;
· Document each time the record or parts of it are shared with others; and
· Summarize upon exit the client’s/student’s skills and areas of need with relevant program recommendations.
Review client/student file(s).
____80. The education program 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 amendment to the record to correct inaccurate information.
Review policy/procedure regarding access to client/student records by client/student, guardian, and parents. Review access log to records.
____81. Except where otherwise dictated by state regulation or law, a complete record is maintained at the facility for each client/student for three years after discharge.
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
Research means a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge. Activities that meet the definition constitute research for purposes of these standards, whether or not they are conducted or supported under a program that is considered research for other purposes. For example, some demonstration and service programs may include research activities. (definition from Code of Federal Regulations - Department of Health & Human Services)
____82. The education program has written policy/procedures that govern its conducting and reporting of research and conform to all specified federal regulations.
Review policies and procedures. If organization does not conduct research, confirm that this is stated in policy/procedure.
____83. 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.
____84. The education program protects client/student privacy,
assuring confidentiality in conducting/reporting its research and
evaluation, and it releases client/student identifying information only with
proper releases.
82. – 84.
Review policies, procedure, other documents regarding research practices; interview appropriate staff, Board members, licensing/accreditation organization representative. If organization does not conduct research, confirm that this is stated in policy/procedure.
Complaints and Appeals
____85. The education program has policy/procedures that provide applicants and clients/students/legal guardians the opportunity and means to file complaints or appeals when decisions concerning them, or services provided to them, are considered unsatisfactory.
____86. The education program acts within its policies and procedures on all complaints, documents complaints, appeals, and their resolution, and notifies client/student/legal guardian of any outcomes that are related to client’s/student’s education or treatment.
85. – 86.
Review written policy, procedures; interview appropriate staff, board member, and licensing/accreditation representative.
Individualized Education Program
____87. Each special education client/student has an individualized education program.
____88. The individualized education program includes:
· A statement of the individual's present levels of educational performance;
· A statement of annual goals, including short-term instructional objectives;
· 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;
· The projected dates for initiation of services and the anticipated duration of the services;
· Appropriate objective criteria and evaluation procedures and schedules for determining whether the short-term instructional objectives are being achieved;
· A transition plan, where appropriate; and
· A family service plan, where appropriate.
____89. Objectives specified in the individualized education program maximize the individual’s potential.
____90. All individualized education programs are reviewed and updated on at least an annual basis or more frequently as required by law or regulation.
____91. The education program has written policies and procedures for involving parents or guardians in the development and review of individualized education programs in compliance with state and federal requirements.
87. – 91.
Review policy/procedures regarding development of individualized education plan, IEPs, and minutes of IEP meetings.
Individualized Service Planning
____ 92. The education program plans, provides, and evaluates educational and related services on an individualized basis and is responsive to all regulatory agencies.
____93. Each service within a program is clearly defined in writing.
____94. There are clearly defined policies and procedures for referring a client/student, including eligibility criteria, for each service component of the program.
92. – 94.
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.
Instructional Planning
____95. The education program ensures systematic, effective instructional planning to include at minimum:
· Written daily, weekly, monthly, or unit based instructional plans in each curriculum area;
· Regular, documented supervision of instructors by school administrator or designee;
· Submission, review, and approval of written instructional plans by school administrator or designee; and
· Substantive observation and formal classroom observations are conducted and feedback is provided for each instructor at least two times per academic year by school administrator or designee
____96. Instructors maintain day-to-day records of client/student progress in each curriculum area (e.g., anecdotal notes, charts, worksheets, etc.).
____97. Instructional objectives are reviewed at least quarterly and updated based on clients’/students’ progress and instructional planning is adapted accordingly.
____98. Task analysis is used to identify the appropriate level and sequence of instruction.
95. – 98.
Review policy/procedures regarding instructional planning and lesson – unit plans, interview appropriate staff.
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.
Transition programs, postsecondary and lifelong adult service models offer direct instruction/training in each area of student/client need moving that student/client to the adult environments of personal living spaces, community and social venues and work/training sites. The goal and intent of all instruction and skills application is to provide knowledge and support skills necessary for student/client success in life. This success is geared toward an individual’s optimal levels of performance and will necessarily require the development and access of appropriate accommodations for that individual.
____99. The education program has a written, comprehensive curriculum that addresses all of the program’s specific areas of instruction or training, as well as mastery goals, objectives, and limits of assessment (minimal standards) in each course of instruction at each grade or developmental level taught including personal, social, behavioral, and career independence where appropriate.
____100. The curriculum addresses the specific abilities and educational needs of each client/student and promotes individual achievement and independence.
Review program description--education program and curriculum document(s)
____101. The curriculum used in the educational program is consistent with the program's philosophy and goals.
____102. The education program can provide evidence of unbiased, nondiscriminatory curricula.
Review appropriate documents verifying such affiliation and review curriculum that applies.
____103. The instructional activities are consistent with learning goals and objectives and the needs of the population(s) being served.
Review curriculum document(s), interview appropriate member(s) of staff and governing body.
____104. Provisions are made for modifying materials and instruction to meet the needs of individual clients/students.
____105. The curriculum and instruction are modified as necessary to remain congruent with needs defined by the formal individual client/student plan (e.g., IEP, IFSP, Individual Service Plan, Individual Treatment Plan, etc.).
____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:
· Readiness skills: pre-reading, pre-mathematics, pre-writing;
· Basic skills in language, reading, writing, spelling, and mathematics;
· Perceptual skills/fine motor development: auditory, visual, tactile;
· Science and social studies;
· Communication skills (receptive and expressive language development and/or augmentative communication devices);
· Social/interpersonal skills;
· Pre-vocational and vocational skills;
· Technology skills;
· Self-help and independent living skills;
· Positive attitudes toward self and others;
· Problem solving skills;
· Productive work and study habits; and
· Health and physical development (including gross motor development).
____107. The curriculum includes instructional activities designed to facilitate positive interaction among all clients/students in the school and encourage clients/students to accept and understand the abilities, needs, and feelings of their peers.
104. – 107.
Review curriculum document(s), interview appropriate member(s) of staff and governing body, and observe classroom instruction.
____108. In programs that enroll high school students, standards-based curriculum options exist within the program to provide the opportunity for those students to accrue credits toward graduation, where appropriate.
____109. The program’s curriculum and teaching methods facilitate client/student transition to the public school system or to other appropriate educational programs, where indicated by client/student needs.
Review curriculum document(s).
Transition/Postsecondary Services/Programs must also meet Standards 110 to 113.
____110. The curriculum provides for a theory/research-based comprehensive program of instruction/training/support designed to address the specific abilities and lifelong learning needs of each client/student to promote optimal individual achievement.
____111. The curriculum includes instructional experiences and activities designed to facilitate chronologically age appropriate activities in appropriate, natural environments.
____112. The curriculum is designed to address attitudes, knowledge, and skills related to all areas of life management and performance as well as personal enrichment. The curriculum addresses but is not limited to the following areas appropriate to the individual clients/students served:
· Personal living skills/needs;
· Community inclusion including transportation and participation;
· Health and physical wellness needs;
· Sexuality issues and needs;
· Personal management and organization skills/needs;
· Time management skills/needs;
· Social/interpersonal skills/needs;
· Problem solving and self-determination skills/needs;
· Personal enrichment activities and skills (e.g., music, art, hobbies);
· Pre-vocational and vocational skills/needs;
· Job search/placement skills/needs; and
· Job development and maintenance skills/needs.
____113. The curriculum includes experiences and activities designed to facilitate self-awareness of abilities, feelings and needs, accommodations, modifications and strategies to perform tasks of work and daily living.
Review curriculum document(s).
Instructional Methods
____114. Throughout the client’s/student’s educational experience there is a consistent and positive emphasis on achievement, and the expectation of achievement is shared with clients/students, as appropriate.
Review instructor lesson plans; interview clients/students, instructional and administrative staff; observe classroom instruction
____115. When evaluating client/student progress, standards are individualized to promote client/student achievement.
Review policy/procedures for assessment; interview clients/students, instructional and administrative staff.
____116. In addition to formal testing, assessment methods include informal evaluations, criterion-referenced testing, observations, review of the client /student history, conferences, and where indicated, testing for specific disabilities or developmental delay.
Review policy/procedures for assessment; observe classroom instruction; and interview clients/students, instructional and administrative staff.
____117. Clients/students are assessed at least two times per year to evaluate progress or more frequently as dictated by local, state, or federal requirements. Those clients/students who are not making the expected progress receive further evaluation that may lead to alternative instructional approaches or therapeutic intervention. If modifications are made, there is documentation of them in the client/student record.
Review policy/procedures for assessment (actual evaluation tool in client’s/student’s record); interview clients/students, instructional and administrative staff.
____118. Instructors prepare clients/students for each lesson by explaining the objectives and expectations of the lesson in simple, direct language. Instructors in preschool settings prepare students for each activity or concept by utilizing precise language and modeling techniques.
____119. Except where the clients’/students’ needs dictate otherwise, when mastery of prerequisite knowledge or skills is demonstrated, clients/students move to the next level of developmentally- or instructionally-sequenced goals and learning material.
118. – 119.
Review instructor lesson plans; interview clients/students, instructional and administrative staff; observe classroom instruction.
____120. Instruction is clear and focused. Instructors:
· Provide an overview of the lesson;
· Use clear written and verbal directions;
· Repeat key points and directions;
· Check client/student understanding; and
· Use precise language and modeling techniques.
Review instructor lesson plans; observe classroom instruction.
____121. Instructors provide frequent and planned reviews of key ideas and skills throughout the year to assess and strengthen client/student retention.
Review program description/education program; interview clients/students, instructional and administrative staff; observe classroom instruction.
____122. Instructors match teaching and testing activities to the learning objectives in order to promote optimal achievement.
____123. Instructors provide for individual differences by adapting instructional methods, assignments, and tests to different learning styles and paces.
122. – 123.
Review instructor lesson plans; interview clients/students, instructional
and administrative staff; observe classroom instruction.
____124. Modifications are made within the instructional process when either the content of the lesson or method of instruction is inappropriate for the learner.
____125. Learning activities include opportunities to use all modalities (visual, auditory, tactile, and kinesthetic), as appropriate to the population being served.
____126. The amount of time-on-task that is spent in instructional activities is appropriate to the population being served and in keeping with state regulations where such exist.
Confirm that the organization has undergone a rational process for determining the amount of time-on-task for its population(s) and provides that amount in practice.
____127. Instructional groups are formed in educational settings to maximize instruction and learning, as appropriate to the population served.
124. – 127.
Review instructor lesson plans; observe classroom instruction. Ask how are instructional groupings completed?
____128. Intensive and individualized remedial instruction is provided for those clients/students who need these services, including individual instruction, as needed.
Review instructor lesson plans; interview clients/students, teaching and administrative staff; observe classroom instruction.
____129. In the instructional/learning activity, the instructor demonstrates good questioning techniques.
Observe classroom instruction.
____130. Instructors utilize technology and audio-visual materials effectively with clients/students, including hands-on instructional materials where developmentally appropriate.
____131. Instructors utilize a variety of instructional materials in the educational setting.
130. – 131.
Review instructor lesson plans; observe classroom instruction, availability of technology resources.
____132. There are clear and efficient classroom routines (e.g., clients/students are required to bring the materials they need to class, instructors have assignments and materials ready for clients/students, and classes start quickly and purposefully) and smooth transitions, as appropriate to the developmental level of the population being served.
Interview clients/students, instructional and administrative staff; observe classroom instruction.
____133. Homework is assigned to support and reinforce classroom learning, as well as developmental skills and goals, as appropriate to the population served, and corrected assignments are returned to students in a timely manner.
Review instructor lesson plans; observe classroom instruction.
Educational Support Services
Rationale and Definition
Educational support services include a diversity of specialists traditionally called instructional consultants, learning disability instructor consultants, school psychologists, social workers, speech therapists, physical therapists, occupational therapists, curriculum specialists, child study team experts, and physicians (esp. pediatricians, psychiatrists, and/or pediatric neurologists). The list is not designed to be exhaustive but to illustrate the range of specialists who are available and at times required to support special education services.
These standards are designed to ensure that an organization seeking accreditation that provides such services administers them in a coordinated manner, verifies training, expertise, certification and licensing of experts and holds them accountable for delivery of support services in a manner consistent with organization mission, philosophy, policies and procedures.
____134. The organization has taken reasonable steps to make sure that each specialist in a support services role has:
· At least two objective and favorable references prior to performing assigned duties,
· A current certificate and/or license,
· Regular continuing education and in-service training to stay current with developments/changes in their fields or specialty, and
· A clear job description or contract specifying his/her role at the organization and including interdisciplinary cooperation.
Review credentials of each specialist to verify that the program has obtained:
1. Two objective and favorable references.
2. Verification that the specialist meets all local/state, and/or national standards for certification/licensing.
3. A currently valid license.
4. A record of continuing education activities.
5. Review job description(s) of each specialist.
____135. All specialists employ well-validated procedures for delivering support services and communicate their recommendations clearly (i.e., free of jargon that confuses other staff not trained in their own specialty), orally and in writing to all staff working with clients/students.
Interview specialists(s) to determine procedures used for delivery of support services and appropriate program staff; review reports written by specialist(s) including memos to staff; evaluation reports, etc.
____136. Where clinical services under the IEP or individual service plan are given to clients/students, documented progress notes are kept and shared, as appropriate, with other staff working with the client/student.
Interview specialist(s) to verify generation of progress notes and sharing of information with appropriate school staff, interview appropriate school staff, review client/student education and other record(s).
____137. Support service personnel are given an orientation to organization policies and procedures and are held accountable for complying with them.
Review in-service/orientation program provided to specialists, document(s) verifying that specialist(s) have participated in in-service/orientation program, and performance evaluation of specialist(s).
____138. Clearly articulated lines of authority exist for support service personnel.
Review organizational chart that includes educational specialists.
____139. Support service personnel are evaluated at least annually on standards consistent with organization needs and objectives.
Review performance evaluation of specialist(s).
____140. For contractual support service personnel and consultants, there exists a written contract clearly specifying the beginning and ending of the contract relationship and stipulating terms and conditions. The contract is reviewed annually.
Review written contract/agreement(s) to verify that it contains:
1. Specific time frames for beginning and ending the contract - agreement,
2. Terms and conditions of employment, and
3. Terms for being reviewed at least annually.
____141. Support services exist to augment special education programs and do not interfere or otherwise compete with the organization goals and objectives.
Review program description/educational program and schedule of appointments for special education services; interview specialist(s) and appropriate program staff.
____142. Support services are clearly described to the consumers who receive them and to their families.
____143. 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 client’s/student’s educational/clinical services at least twice a year.
Interview appropriate family members(s), review documents (IEP – transition plans) that communicate information regarding special education services. Review written inter-organization agreements between agencies utilizing common support services personnel.
____144. All support service personnel comply with their disciplines’ code(s) of ethics, where such exists, and comply with the organization’s code of ethics.
Interview specialist(s), review written code(s) of ethics if applicable.
Education Diagnostic/Evaluation Services
Rationale and Definition
These standards deal with the use of properly validated, replicated, and current (not outdated) assessment instruments that are administered by persons properly trained, proficient, and certified to administer and conduct diagnostic services. Additionally, these services are to be used to identify strengths in an individual and seek solutions to problems rather than merely to label individuals and/or limit their potential for success.
____145. All educational assessments and related diagnostic evaluations are performed by individuals appropriately educated, trained, and certified (where required) to administer such procedures.
Review program description, list of diagnostic/assessment instruments utilized by the organization, list of individual(s) administering diagnostic/assessment instruments utilized by the organization, and credentials/personnel file of individual(s) administering diagnostic/assessment instruments; interview individuals(s) administering diagnostic/assessment instruments.
____146. All assessments are performed for a valid reason and used to help clients/students make greater gains in their programs, not to limit potential.
Review written protocols regarding referral for diagnostic/assessment services.
____147. All diagnostic instruments used by the organization meet professionally accepted standards of validation and replication and are utilized only in a manner and for purposes consistent with their design. Only evaluation instruments appropriate to the individual's needs, age, and background and to the assessment questions are utilized.
Review list of diagnostic/assessment instruments utilized by the organization, written protocols regarding referral for diagnostic/assessment services, and written protocols regarding administering diagnostic/assessment instruments; interview person(s) administering diagnostic/assessment instruments.
____148. Individuals are evaluated only after appropriate consent has been obtained from the required party(ies).
Review written protocols regarding administering diagnostic /assessment instrument(s).
____149. All assessment data are carefully recorded using professional standards, and a report is made by a competent professional who interprets the scores so other team members can clearly understand what they mean. The report is filed in the client’s/student’s permanent record.
150. All evaluation and diagnostic instruments are selected, administered, and interpreted with sensitivity to language and cultural differences.
Review written protocols regarding administration diagnostic /assessment instrument(s) and written report(s) based on utilization of diagnostic/assessment instrument(s).
____151. All assessments specify the nature of the problem(s) being evaluated and identify strengths as well as difficulties.
Review written report(s) based on utilization of diagnostic/assessment instrument(s).
____152. Whenever difficulties or disabilities are identified, an attempt is made by the evaluator to describe methods for their remediation, compensation, and management so other personnel can implement such procedures.
Review written report(s) based on utilization of diagnostic/assessment instrument(s), interview school personnel responsible for implementing recommendations generated by the diagnostic/assessment process.
____153. Evaluations and diagnostic assessments specify a plan of action for the client/student, when appropriate.
Review written report(s) based on utilization of diagnostic/assessment instrument(s).
____154. Evaluations and diagnostic assessments attempt to integrate a client’s/student’s total needs rather than be confined in an isolated manner that prevents multi-disciplinary understanding and cooperation.
Review written report(s) based on utilization of diagnostic/assessment instrument(s).
____155. Whenever possible, evaluations and diagnostic assessments prescribe methods for accurate data collection and future monitoring of the client’s/student’s progress or regression so that decisions can be made objectively and in the best interests of the client/student.
Review written report(s) based on utilization of diagnostic/assessment instrument(s), interview personnel responsible for implementing recommendations generated by the diagnostic/assessment process.
____156. Whenever possible, assessments and diagnostic evaluations are explained to the individual, his/her support staff and family members, guardians, and significant others in a manner that encourages clear communication, collaboration, and verification of results.
Review written report(s) based on utilization of diagnostic/assessment instrument(s); interview person(s) administering diagnostic/assessment instrument(s) and, as appropriate, program staff and family member(s).
____157. The educational evaluations and/or diagnostic services are evaluated periodically (at least every three years) by competent peer reviewers to assure their appropriateness to the organization’s mission and purpose.
Review program evaluation procedures and written reports and/or evaluations of diagnostic and/or assessment services.
____158. There is a clear process for case-management or overall client/student case coordination of all diagnostic services to assure a good general understanding of all specific areas evaluated and to avoid unnecessary duplication of assessment.
Review program description and interview, as appropriate, staff and family member(s) and program evaluation procedures and written reports/evaluations of diagnostic/assessment services.
Medication
____159. Programs that administer medication do so only with written policies and procedures that are compliant with all applicable jurisdictions.
Review policy/procedure on medication administration.
____160. The program administers medications only with a prescription or order provided by an individual qualified by the state to order or prescribe medications.
Review orders and/or prescriptions and credentials of personnel issuing orders and/or prescriptions.
____161. Medications are administered only by individuals qualified by the state to administer medications. Programs that allow client/students to self-administer medications have policies and procedures that describe in detail self-administration and that consider the client’s/student’s ability and training when supervising the administration of medication.
Review policy/procedure on medication administration and credentials of personnel administering medications. In programs that allow client/student self-administration review relevant client/student assessments and training documentation.
___162. Programs that administer medication maintain and follow written protocols to insure that prescription medications are taken only by clients/students for whom they are ordered/prescribed and only in accordance with the order/prescription.
Review policy/procedure on medication administration; interview personnel responsible for ordering and personnel responsible for administering medication.
____163. Programs that administer medication store all medications in locked storage accessible only to those qualified by the state and organization to administer medication. Medication security facilities and procedures are compliant with all applicable jurisdictions.
Review policy/procedure on medication storage; interview personnel responsible for medication administration; inspect storage facilities.
____164. Programs that administer medication dispose of discontinued, out-of-date, and unused medications and containers following procedures that are compliant with applicable jurisdictions.
Review policy/procedure on medication disposal; interview personnel responsible oversight of medication administration.
____165. Programs that administer medication maintain accurate, timely records of all medications administered. All medication errors and adverse drug reactions are reported to the prescribing practitioner and state authorities where applicable.
Review policy/procedure on medication administration and medication administration records.
____166. Programs that administer medications have access to medical personnel available to consult regarding medication administration, as needed.
Review policy/procedure on medication disposal; interview personnel responsible oversight of medication administration.
Behavioral and Affective Practices
____167. The instructor/service provider exhibits professional authority while demonstrating self-confidence as an instructional model.
Interview clients/students, instructional and administrative staff; observe classroom instruction.
____168. The instructor provides an effective structure within the educational setting while maintaining the ability to react spontaneously to unexpected occurrences.
Review instructor lesson plans; observe classroom instruction.
____169. The instructor/service provider maintains a routine while exhibiting the ability to react spontaneously to unexpected occurrences.
____170. The instructor exercises appropriate visual monitoring and verbal cues to maintain order within the classroom.
Observe classroom instruction.
____171. The behavior supports system employed within the program complies with all applicable federal and state statutes, regulations, and other requirements.
____172. The behavior supports system employed within the program is consistent with the philosophy and the goals of the program, allows for flexibility in response to individual client/student needs, and is readily apparent and consistently implemented by all staff.
Review behavior management documents, including philosophy; interview clients/students, instructional and administrative staff.
____173. The standards for acceptable behavior and the consequences of misbehavior are written, taught, and reviewed with the clients/students in detail at the start of the program, and administered effectively throughout the year as appropriate to the population served.
____174. Rules and behavior expectations are appropriate to the population served and stated within a positive framework.
167. – 174.
Review behavior management documents, including philosophy; interview clients/students, instructional and administrative staff; observe classroom instruction.
____175. Individual plans are based on a comprehensive ecological/functional behavior analysis of the student/client across all domains and program environments in which that individual must function.
____176. Client/student behaviors are evaluated in terms of the function they may serve for the client/student. Attempts are made to systematically teach appropriate alternatives.
175. – 176.
Review behavior management documents, including philosophy and individual client/student behavior plans.
____177. There is a known and observable hierarchy of interventions utilized in the program.
____178. Programs utilize the least restrictive/least invasive behavioral interventions sufficient to achieve the student’s safety, behavioral, and instructional goals.
____179. Highly restrictive/invasive interventions are utilized only under the following conditions:
· Informed consent of the parent/guardian;
· Full compliance with all applicable laws and regulations;
· Evidence of the intervention’s efficacy in addressing the target behavior(s);
· A risk-benefit assessment that favors the intervention over other less restrictive/invasive interventions;
· Comprehensive documentation of every incident of the intervention’s application; and
· A schedule of regular reviews of the effectiveness of the intervention and possible modifications to the plan for its use.
____180. The staff uses principles of applied behavioral analysis effectively with clients/students, as appropriate to the population served. This includes:
· Use of effective reinforcers;
· Awareness of the cognitive level and frustration level of a client/student when developing interventions;
· Continually moving the client/student to a higher level of performance where greater independence and less external control are needed; and
· Use of data to assess the effectiveness of an intervention and make necessary modifications.
Review instructor lesson plans; interview clients/students, instructional and administrative staff; observe classroom instruction.
____181. The instructor demonstrates skill in minimizing behavior problems by:
· Attending to the physical environment;
· Attending to the schedule of the clients/students;
· Developing routines and setting clear expectations and limits;
· Developing a climate of respect, encouragement, and warmth;
· Developing a sense of group cohesiveness among the clients/students in a class; and
· Re-grouping for instruction and restructuring content, sequence, method and/or materials as appropriate.
____182. The instructor provides clients/students with frequent, consistent, and meaningful praise and encouragement for both learning performance and behavior.
____183. The instructor displays emotion in a meaningful and genuine manner as a way of providing feedback to the clients/students.
182. – 183.
Observe classroom instruction; interview clients/students, instructional and administrative staff.
____184. The staff is able to utilize a variety of psycho-educational interventions, such as "management of surface behavior" and/or "life-space interviewing."
Observe classroom instruction; interview clients/students, instructional and administrative staff; review behavior management documents, including philosophy, and individual client/student behavior plans.
____185. The instructor responds to behavioral outbursts in a calm, controlled, and consistent manner while reestablishing order in the classroom, calling on additional resources, as necessary.
____186. The instructor nurtures students/clients and exhibits a mature and positive model.
185. – 186.
Observe classroom instruction; interview clients/students, instructional and administrative staff.
____187. The support of colleagues is available to staff when trying to analyze, plan, and implement behavioral supports or other interventions.
188. Instructors are aware of the range of available behavior support options and use them effectively.
____189. Staff members collaborate to analyze and plan behavioral interventions. Staff members are aware of the program model and include the student/client input in the problem-solving process, as appropriate.
____190. Behavior plans and practices are directed toward generalization and maintenance of new skills in natural environments.
Interview clients/students, instructional and administrative staff; review behavior management documents, including philosophy, and individual client/student behavior plans.
____191. Programs that utilize restraint and seclusion have guidelines for their use that are written and practiced by staff, and are consistent with all applicable federal and state statutes, regulations, and other requirements.
____192. Programs that utilize restraint and seclusion require all staff to undergo approved training prior to initiating these interventions.
190.–192.
Observe classroom instruction; interview clients/students, instructional and administrative staff; review behavior management documents, including philosophy, and individual client/student behavior plans, review training log of staff.
____193. Personnel required to receive behavior management training, including restraint and seclusion training, are tested for competency prior to employing such strategies.
Review Training log of staff in personnel files, review testing instrument utilized for competency training.
____194. Personnel authorized to use behavior management techniques, including restraint and seclusion, receive a refresher course, or at least annually.
Review training log of staff in personnel file; interview appropriate staff members.
____195. Programs using restraint and seclusion inform parents/guardians and clients/students prior to admission and parent/guardians sign a release giving permission for use of restraint and seclusion that could be used.
Review admissions release from relative for restraint and seclusion permission.
____196. There is appropriate documentation in the client’s/student’s record (e.g., critical incident report, restraint report, etc.) clearly stating what restraint and seclusion was used and why.
Review client/student files.
____197. Staff members utilize cooperative activities to develop a sense of group cohesiveness among clients/students.
Observe classroom instruction; interview clients/students, instructional and administrative staff.
____198. Students/clients are taught and practice a problem-solving model that provides for self-evaluation and appropriate collaboration with others.
____199. Generalization and maintenance of new skills in behavior, socialization, and affective areas are facilitated by providing opportunities for positive practice in a variety of situations both within and outside of the organization, as appropriate.
198. – 199.
Observe classroom instruction;
interview clients/students, instructional and administrative staff;
review behavior management documents, including philosophy, and individual
client/student behavior plans.
Emergency Services
____200. Safeguards and written procedures for responding to client/student medical and psychiatric emergencies exist and are made known to all staff responsible for the oversight of clients/students.
____201. These procedures minimally:
· Require that parents/guardians be notified of the emergency as soon as possible;
· Identify safety protocols for insuring client/student safety;
· Describe access to and utilization of available emergency resources (e.g., local fire and police, community hospital emergency department, on-call medical personnel).
· Specify notifications to others responsible for the client’s/student’s safety (e.g., bus driver, after-school program staff); and
· Require comprehensive documentation of the medical or psychiatric emergency to minimally include known precipitants, description of the emergency, attempts to resolve the emergency and their effectiveness, any sequelae to the event; and all notifications.
____202. Policies and procedures for responding to medical and psychiatric emergencies are followed.
Transition to Other Environments
____203. The education program has a policy of promoting transition to the most appropriate functional environment.
____204. The possibility of transition to a more appropriate functional environment is evaluated at least annually, as evidenced by a notation of a supervisory meeting or progress report, if appropriate to the population being served.
203. – 204.
Review policy/procedures regarding criteria for clients/students and documents, interview staff and family of current & discharged clients/students.
Admission and Exit Procedures
Rationale
Admission-Exit procedures refer to the process by which clients/students are admitted into, and discharged from, the program. The existence of the procedures helps to assure that appropriate clients/students are admitted into the program and provides both the expectation and criteria for clients/students leaving the program. The admission procedures help to define the parameters of the services provided and reflect the philosophy of the program. The exit procedures also help
to clarify expectations for client/student, family, and staff while providing useful information for program evaluation.
____205. There is a written statement regarding admission and assessment that includes a checklist of activities to be completed, responsibilities of personnel, time-lines, and procedures to be followed.
____206. When clients/students are admitted to the organization for residential placement, the residential and educational program staff members participate jointly in the intake process.
____207. There is a checklist of necessary records to be obtained for each client/student, reflecting criteria for admission to the organization and for appropriate placement within the program.
____208. Instructionally relevant data, including any diagnostic information from relevant sources and in the case of special education students an IEP, are sought at the start of the admission process.
____209. When instructionally relevant data are unavailable, a reasonable time frame is set for obtaining such data by qualified organization staff.
____210. Before an individual starts the program, relevant academic and social data are presented and discussed with the appropriate staff.
____211. Ongoing assessment outcomes are made available to all appropriate personnel in a timely fashion.
____212. Each client/student referred for admission is assessed using the program's formal intake process and an admission decision is made within one month of referral or sooner where required by law or regulation.
____213. Assessment of a new client/student includes diagnostic testing and/or criterion-referenced testing in all academic subjects and/or environmental assessment, and/or behavioral analysis through individual observation, as appropriate.
____214. There are written criteria for determining client/student exit from the program.
____215. There is a written statement regarding transition planning that includes responsible personnel, timelines for tasks to be initiated and completed, and procedures to be followed.
____216. In preparing for client’s/student’s exit from the program, parents, client/students, and instructional personnel from both the organization and the receiving program, where applicable, are encouraged to participate in transition planning with proper releases of information.
____217. For each client/student discharged for any reason, a discharge statement is placed in his/her master file.
Review discharge summary reports, interview staff and family of discharged client/student(s).
____218. When students transition to other schools, their records are forwarded to the receiving schools in a timely manner.
Review policy/procedures and documents regarding admissions procedures, review client/student records, interview current parents/guardians to verify compliance and policy/procedures.
COMMUNITY
The organization serves a defined community and is guided by the needs and concerns of the community in shaping its program or services.
Community Identification
____219. The organization identifies or otherwise defines the community being offered its program of services.
____220. The organization identifies its community in a manner consistent with its ability to provide services, with the responsibilities it is prepared to assume as required by law, and as indicated by its primary funding sources.
____221. The organization fulfills its responsibility to serve the needs of its community, as per its mission.
219. – 221.
Review policy/procedure regarding how the organization defines its community and determines its methods of interaction with this community.
Community Education
____222. The organization conducts an ongoing program of community education to provide the general public with an understanding of its purpose, function, and place in the community, including its program of services and its service population(s).
____223. The organization focuses on increasing the body of knowledge available to other organizations and professions likely to encounter individuals and families who may have need of its program and services.
222. – 223.
Review policy/procedure; interview representatives of the organization's defined community; review documents (articles, event publications) related to communication with the organization's defined community.
Community Planning
____224. The organization makes efforts to establish relationships with other community agencies and coordinates its programs accordingly.
____225. The organization initiates or participates in efforts to identify the urgent needs of the community and address gaps in the community's services.
____226. The organization’s role and program of services are clearly defined and made known to the community and other agencies.
____227. In shaping its array of services, the organization seeks and is responsive to input from community groups, service agencies, and other relevant sources.
224. – 227.
Review documents (notes, minutes of community/task force meetings), interview representatives of the organization's defined community.
HEALTH AND SAFETY
The organization's policies and procedures reflect attention to the health and safety of clients/students, staff, and visitors.
____228. The organization complies with all local and state safety, fire, and health regulations.
Review policy/procedure regarding compliance regulations and documents
verifying licenses, certificates, etc.
____229. The organization has a policy regarding smoking by
clients/students and staff.
____230. When the organization permits smoking it:
· Allows smoking only by those clients/students permitted by law to smoke;
· Restricts smoking to areas that are environmentally isolated from the general population of the program and are designed to minimize risk of fire (e.g., contain smoke detectors, contain fire suppression equipment, are constructed of combustion-resistant materials, etc.); and
· Provides clients/students with education about the risks of smoking and resources for its cessation.
____231. An individual (or individuals) is identified, as evidenced in a job description or statement of policy, as having the responsibility for assuring that the facility meets, at minimum, state and local standards regarding health and safety of clients/students and staff.
Review job description; interview staff on the job.
____232. Records of all fire safety inspections conducted by the organization, as well as any made available by governmental agencies and insurers, are maintained on file.
Review file documents of inspections.
Procedures
____233.
There
are established written procedures for meeting all potential types of
emergencies that the organization may reasonably be expected to encounter,
including lock-down procedures, and these procedures are made known to all
staff.
____234. Emergency procedures are reviewed at least annually and revised as
needed.
____235. The organization performs drills of its emergency procedures on a
semi-annual basis such that each emergency type is addressed. An actual
emergency that is addressed by the emergency procedures may be utilized as a
drill. Emergency procedures, staff training, and the allocation of resources
related to emergency preparedness and response are informed by analysis of
these drills.
____236. Emergency procedures are designed to meet the needs of the population(s) being served, including those with physical or mental disabilities that may impact their mobility or otherwise alter their response to emergency procedures and directives.
____237. There are established written procedures, for the emergency evacuation from any space in which a client/student might be placed that locks from the outside and cannot be opened from the inside, if applicable. Such procedures are made know to all staff members who work in any such areas.
____238. Emergency exits and evacuation routes and procedures are posted prominently in all areas utilized by students.
236. – 238.
Review procedure and verify dissemination by interview or observation of posted procedures; review logs of emergency drills and staff training; review minutes or other documents to establish that procedures are rationally developed given the population, physical plant, available resources, and findings from previous drills.
Physical Plant Safety
____239. The organization's premises and equipment are structurally sound, well maintained, functionally safe, and well-suited to the needs of its clients/students, staff, and visitors.
____240. The organization's buildings and grounds, offices and other structures conform to applicable zoning, building, and fire codes and regulations.
____241. The organization's plumbing, ventilation, heating, cooling, lighting, food preparation and storage, elevators and other fixtures and equipment conform to applicable health and safety codes and regulations.
____242. The organization conducts a program of regular inspection and preventive maintenance to ensure the soundness and safety of its premises, equipment, and fixtures. Records of all inspections and maintenance activities are maintained by the organization.
239. – 242.
Review policy/procedures regarding physical plant and safety, documents of inspection (Certificate of Occupancy, fire inspection, list of equipment; legal requirements, and list of equipment requiring inspection); and inspection reports (maintenance contracts, repair records). Conduct tours to establish physical plant conditions for compliance.
____243. Specific measures are taken to ensure adequate fire prevention,
fire protection, and accident prevention.
____244. Fire drills are conducted at intervals as required by the presiding jurisdiction and minimally on a quarterly basis during all quarters for which the program is in session. Records of all fire drills are maintained by the organization. Analysis of fire drills informs procedure development, staff and client/student training, and physical plant re-design.
Review policy/procedure on fire drills and record of fire drills, interview clients/students and staff to verify knowledge and compliance.
____245. The organization conducts a program of safety education such as fire and accident prevention and first aid for its staff and clients/students, as appropriate to their age and developmental level, to ensure the safety of individuals occupying or using its premises and equipment.
Review training logs.
Staff Facilities
____246. The organization has facilities that comply with the Americans with Disabilities Act or has a plan to bring its facilities into ADA compliance, as appropriate, unless it is grand-parented under the Act.
____247. The organization maintains a work environment for its staff that is conducive to effective performance.
____248. Private offices or rooms are available to staff to engage in interviewing or counseling clients/students and families.
246. – 248.
Review policy/procedure: provision of appropriate work environment, interview staff; observe rooms/areas for offices, private space, lounges, and conference areas - note barriers.
FINANCIAL MANAGEMENT
Financial Resources
____249. The organization obtains funding sufficient to operate its program of services at a level consistent with these provisions.
Review financial planning policy/procedures and current year operating budget.
____250. The organization actively seeks a broad basis of financial support by considering a variety of funding sources or has a plan in place for alternative funding sources to ensure sustainability.
Interview appropriate staff or governing body representative regarding income sources for operating plan.
Budget
____251. The organization prepares a budget annually for allocating its funds.
Review current year financial plan/budget or board/committee minutes, which should reflect that the priorities are board approved.
____252. The budget is based on an assessment of the organization's program priorities and reflects a realistic appraisal of funding anticipated during the program year and of all costs of operating the organization's program of services.
Review current year financial plan/budget.
____253. The budget is approved by the governing body as the financial plan for managing the organization's receipts and disbursements during the program year, and this approval is documented in the governing body’s meeting minutes.
Review policies/procedures regarding approval process for operating plan/budget and minutes of governing body meeting at which time the operating plan was approved.
Management of Funds
____254. The organization receives, disburses, and accounts for its funds in accordance with sound financial practices.
____255. The organization develops and follows procedures that meet generally accepted principles of sound financial management.
____256. The organization has a bookkeeping and accounting system that tracks all movements of its funds.
254. – 256.
Review audit/policy/procedures regarding financial management, interview appropriate staff and member of governing body.
Control and Audit
____257. The organization demonstrates fiscal accountability through regular reporting of its finances to the governing body and otherwise, as required by regulation, and through an annual independent audit.
Review audited statement from prior fiscal year.
____258. Revenues and disbursements are summarized at regular specified intervals, but not less than quarterly, compared with the approved budget and reported in writing to the governing body.
Review policy/procedures regarding financial planning and financial report(s), interview appropriate staff.
____259. An annual financial statement is prepared by a certified public accountant, approved by the governing body, or if a public organization, by the appropriate governmental body and made available for public inspection.
____260. If the certified public accountant’s audit results in a management letter, the management letter is approved by the governing body, or, if a public organization, by the appropriate governmental body.
Review annual financial statement and management letter prepared by a certified public accountant, interview member of governing body.
Cost Allocations
____261. The organization maintains procedures for analyzing the costs of the services it provides.
____262. The procedures, at a minimum, produce cost analyses that reflect the comprehensive cost of providing services.
____263. Cost analyses are made at designated intervals to monitor trends and reflect current practices.
261. – 263.
Review financial management policies and procedures and financial reports.
Insurance Coverage
____264. The organization maintains insurance as protection for its governing body, staff, clients/students, funds, and properties.
____265. The organization carries adequate fire, theft, liability, and workers' compensation insurance, and meets regulatory requirements.
____266. Provision is made for indemnifying board members, trustees, officers, employees, and volunteers of the organization against liability incurred while acting properly in behalf of the organization, and meets regulatory requirements.
____267. All persons delegated the authority to sign checks or manage funds are bonded at the organization's expense. And procedures are in place to insure adequate checks and balances for risk management.
____268. The organization’s insurance program is appraised annually to assure adequate coverage.
Review insurance policy and support documents; interview appropriate staff and member of governing body.
EVALUATION
The organization holds itself accountable for the services it provides and continually evaluates its performance.
Goals and Objectives
____269. The organization sets goals and objectives for its program of services that are consistent with the needs of its clients/students and its commitment to the community.
Review program description and policy/procedures regarding the development of program goals and objectives.
____270. Written goals and objectives are established for the 1) quality of the services available to clients/students and 2) benefits or outcomes to be achieved by clients/students who use them.
____271. Objectives are measurable and directly related to goals.
____272. Organization goals and objectives guide program examination, the setting of priorities, and program planning.
____273. Communication with parents/guardians about the new placement is initiated at least once during the first year following exit.
____274. There is a systematic procedure for follow-up of discharged clients/students. Data collected from discharge follow-ups is utilized in program evaluations.
270. – 274.
Review written document that contains information regarding the goals and objectives that have been developed; review documentation of data collection and utilization in program evaluation.
____275. The governing body and administrative staff re-examine, at designated intervals, the organization's goals and objectives and the allocation of necessary resources.
Review policy/procedures regarding goals and objectives, interview appropriate staff. Review Strategic Planning documents.
Program Evaluation
____276. The organization conducts, in accordance with a written plan, an ongoing evaluation of its program of services, minimally attempting to evaluate the outcomes of the services it provides, and the organization participates in a state or national outcomes study.
Review policy/procedures regarding program evaluation, as well as reports of specific program evaluation findings in areas relevant to service outcomes (e.g., percentage of clients/students returning to mainstream education, percentage of former students attending school at one year post discharge, percentage of students who advance by one academic year per calendar year, percentage of clients/students who live independent of family home, percentage of clients/students who establish employment in their community, percentage of clients/students utilizing community services, etc.).
Note: The routine measurement of outcomes is a critical process in evaluating the quality of services and identifying opportunities for improvement in it. Ideally, such an evaluation process should compare the organization’s current performance against its own goals and past performance, as well as against regional and national benchmarks, where such exist. While there may be a variety of large-scale outcomes databases against which to compare, one such database is available through NAPSEC’s outcome study. It is also important to consider internal data pools comparing current client/student outcomes to former client/student outcomes.
The NAPSEC outcomes forms and directions are available to the organization electronically as an example and potential tool for meeting the outcomes requirement.
____277. The organization’s program of services is regularly evaluated by the board and administrative staff to determine the need for the organization's services and its ability to meet its own and the community's expectations with respect to outcomes.
Review program evaluation reports and feedback received from member(s) of the governing body.
____278. The organization utilizes internal expertise and consultation with external resources appropriate to its needs in evaluating its program of services, methods of service provision, and the quality of its services.
Review policy/procedures regarding program evaluation, interview appropriate staff.
Data Collection
____279. The organization defines and systematically obtains the information it needs to evaluate its program of services.
Review policy/procedures regarding program evaluation and program evaluation report(s), interview appropriate staff.
____280. Information is obtained that at a minimum describes:
· Clients/students served, services provided, services needed but not provided, and outcomes achieved;
· Applicants not accepted for services, the services requested, the reasons for non-acceptance and referrals or other dispositions made;
· Clients/students who discontinue services and their reasons for discontinuation; and
· Client/student/parent satisfaction, suggestions and input for developing and analyzing services and outcomes
Review policy/procedures regarding program evaluation and documents containing data collected for program evaluation, interview appropriate staff.
____281. All information needed for evaluation is maintained in retrievable form as part of the organization's record-keeping system(s).
Review documents containing data collected regarding program evaluation.
Administrative Studies
____282. The organization annually reviews its administrative policies and procedures to ensure effective use of available resources.
Review policy/procedures regarding program evaluation and administrative staff performance evaluations, interview appropriate staff and member(s) of governing body. Review meeting minutes, operations, and administrative manual.
____ 283. Work assignments, workload distributions, staff performance, personnel practices, and other internal administrative practices are appraised annually.
Review policy/procedures regarding program evaluation and administrative staff performance evaluations, interview member(s) of governing body.
____284. Appraisal is made of the organization's referral sources and its collaborative arrangements with other agencies.
Review policy/procedures regarding program evaluation, evaluation reports on referral sources, and collaborative arrangements with other agencies.
____285. Changes are made where indicated by the findings of the administrative reviews.
Review policy/procedures regarding program evaluation and administrative studies, including recommendations for programmatic changes; interview appropriate staff and member(s) of governing body.
Dissemination
____286. The results of the organization's evaluation and administrative studies are made available to its board, staff members, and other constituents when appropriate.
____287. The organization disseminates through publication, workshops, or other means, its findings and experiences
____288. The organization participates in community, state, or national reporting systems wherever appropriate, without violating the confidentiality of the client/student or family
286. – 288.
Review policy/procedures regarding program evaluation, published reports, and list of agencies that received copies of the reports.
For an organization to achieve accreditation in this category, it must also meet the Standards for Accreditation.
Rationale
By their nature, residential programs are ecological entities where diverse groups of employees are required to work together toward common goals. Instructors, clinical staff, child-care workers, recreation specialists, etc., all have responsibility for an individual for a period of time.
The necessity for staff collaboration and cooperation is clear. Staff relationship refers to the climate, policies, and practices evident in the organization's operations that enhance a spirit of collaboration and cooperation among all parties.
____289. The various professional disciplines represented within the program function in a mutually supportive manner offering help to those who appear in need of assistance (e.g., during behavioral crisis, in program planning, etc.) and demonstrate appreciation of each other's contributions.
Review program description/educational and residential programs, interview client/student, instructional and administrative staff.
____290. The various professional disciplines represented within the program work collaboratively on behalf of the clients/students, each contributing the expertise of his/her discipline.
Interview clients/students, instructional and administrative staff. Review notes from interdisciplinary meetings.
____291. Frequent formal and informal discussions among staff members center around the nature and needs of particular clients/students being served in the program.
Review program description/educational and residential programs and documents containing information shared to and from the day program and residential setting; interview clients/students, instructional and administrative staff and review team notes.
____292. Staff cohesiveness is recognized as a program goal that has the potential for impacting positively on the services afforded clients/students.
Review program description/educational and residential programs, staff training curriculum, and documents verifying joint participation of the day program and residential staff in activities; interview clients/students, instructional and administrative staff.
____293. Staff members display openness toward innovation, training, and emerging best practices.
____294. There is a sense of pride in accomplishment that permeates the staff and helps them to accept with confidence the challenges of working with clients/students.
293. – 294.
Interview clients/students, instructional and administrative staff. Review Team notes.
____295. Staff members carry out their daily duties in such a way as to demonstrate optimism and the belief in their own potential to change the academic and behavioral functioning of the clients/students.
Observe clients’/students’ transition to and from the day program and residential settings; review client/student activity schedules and documents that verify activities participated in jointly by the day program and residential staff; interview clients/students, instructional and administrative staff.
____296. Members of the staff work effectively together to accomplish specific program objectives.
Review documents (e.g., ad hoc and standing committee minutes, policy/procedure) that verify activities participated in jointly by the day program and residential staff; interview appropriate administrative staff, instructional staff, clients/students.
____297. The staff have available to them support mechanisms that help to impact positively on staff morale.
Interview clients/students, instructional and administrative staff.
____298. Program goals are communicated in writing interdepartmentally, throughout the organization, at least annually.
Review program description/educational and residential programs, documents which contain information shared between the day program and residential setting and those documents which verify activities participated in jointly by the day program and residential staff; interview clients/students, instructional and administrative staff.
____299. Planning for each client/student is developed interdepartmentally.
Observe clients’/students' transition to and from the day program and residential setting; review documents that verify activities participated in jointly by the day program and residential staff; interview appropriate clients/students, administrative, and instructional staff.
____300. The educational program staff, clinical staff, and residential staff meet at a minimum three times annually to review their respective individual clients’/students’ treatment plans for compatibility and coherency.
Review program description/educational and residential programs, documents that contain information shared between the day program and residential setting, staff training curriculum, and documents that verify activities participated in jointly by the day program and residential staff; interview appropriate administrative staff; instructional staff, clients/students.
____301. Daily communication in either verbal or written form occurs between the educational program staff and residential staff regarding client/student performance.
Review documents that contain information shared between the day program and residential setting. Observe clients’/students’ transition to and from the day program and residential setting.
____302. When homework is completed outside of school, it is an integral part of a client’s/student’s residential program, and residential staff provide adequate time and support to clients/students in the completion of their assignments.
Review program description/residential program; interview appropriate clients/students, administrative and instructional staff.
____303. Staff from the education program and staff from the other programs with whom they interface demonstrate knowledge of and support for each other’s programs.
Review documents that contain information shared between the day program and residential setting; interview appropriate clients/students, administrative and instructional staff.
____304. Intra-organization staff communication is frequent enough and carried out in such a manner as to build trust, cooperation, and mutual support for the goals and objectives of individual clients/students.
Review documents that contain information shared between the day program and residential setting and documents that verify activities participated in jointly by the day program and residential staff, observe clients’/students’ transition to and from the day program and residential setting.
____305. The educational curriculum addresses the needs of clients/students outside of school hours.
Review program description/educational and residential programs, documents that contain information shared between the day program and residential setting, and documents verifying joint participation of the day program and residential staff in activities; interview clients/students, instructional and administrative staff.
____306. Opportunities for community involvement occur frequently and are a part of the client’s/student’s formal program.
Review program description/educational and residential programs, client/student activity schedules, interview appropriate clients/students, administrative and instructional staff.
____307. Life-skills training is formally implemented in the residential program (e.g., responsibility, empathy, self-care, environmental care, domestic care, etc.).
Review program description/residential program and client/student activity schedules, interview clients/students, instructional and administrative staff.
____308. Responses to unacceptable behavior are clearly communicated and consistently followed.
Review program description/educational and residential programs, documents that contain information shared between the day program and residential setting.