CA-PRG Standard. Generated 12/04/2022. ©2022 Council on Accreditation.
2022 Edition

Program Administration Introduction

Purpose

Service delivery practices guide the administration of safe, effective programs that respect personal dignity and self-determination.

Introduction

COA’s Program Administration (CA-PRG) standards promote the development of safe, effective, and respectful programs through the implementation of practices for maintaining complete, organized, and confidential case records; establishing safe, uniform practices for prescribing, dispensing, storing, and administering medication; effectively harnessing technology-based service delivery to better meet the needs of service recipients; and providing services that promote integration and self-determination for individuals with intellectual and developmental disabilities.
Note: Please see the CA-PRG Reference List for the research that informed the development of these standards.

Note: Program Administration is a new section in the 2020 Edition that includes content previously contained in other sections. Please see the RPM Crosswalk, the CR Crosswalk, and the TS Crosswalk for more information. 
 
2022 Edition

Program Administration (CA-PRG) 1: Case Records

Case records contain sufficient, accurate information to:
  1. identify the individual or family being served;
  2. support decisions about interventions or services; and
  3. document the delivery of services.
NA The organization provides only Early Childhood Education (ECE) and/or Out-of-School Time Services (OST).
 
NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.
Related Standards:
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the PRG 1 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the PRG 1 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the PRG 1 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the PRG 1 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case record content and maintenance procedures
  • Mock case record, table of contents, or case record outline for each service
  • Review case records
  • Interviews may include:
    1. Program directors
    2. Relevant Personnel

 
Fundamental Practice

CA-PRG 1.01

The organization maintains a case record for each individual or family.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 1.02

Case records contain information necessary to provide services including:
  1. demographic and contact information;
  2. the reason for requesting or being referred for services;
  3. up-to-date assessments;
  4. the service plan including mutually developed goals and objectives;
  5. copies of all signed consent forms;
  6. a description of services provided directly or by referral;
  7. routine documentation of ongoing services;
  8. documentation of routine supervisory review;
  9. discharge or aftercare plan;
  10. recommendations for ongoing and/or future service needs and assignment of aftercare or follow-up responsibility, if needed; and
  11. a closing summary entered within 30 days of termination of service.
Related Standards:

Interpretation

This standard describes the basic elements to be included in individual case records. COA recognizes that in some cases not all listed information is obtainable for an individual or family. In these cases, an explanation should be placed in the case record. Additionally, the listed information may not be routinely available due to the nature of the service, e.g., a low demand shelter or drop-in center.
 

Interpretation

Regarding element (h),"documentation of routine supervisory review" refers to the quarterly review of individual cases that is found in the Service Planning and Monitoring sections of most Service Standards. This review is unrelated to Supervision between the supervisor and personnel addressed in CA-TS 3.

Interpretation

Case records and signatures can be paper, electronic, or a combination of paper and electronic.

EAP

Interpretation

In Employee Assistance Programs, case records contain appropriate information to demonstrate the status of the case and whether it is open or closed.
 

FEC

Interpretation

 
Elements (h) and (i) are not applicable to credit counselling organizations.
 
DV

Interpretation

 
When domestic violence services are provided, documentation in case records should be limited to essential information. Personnel should be conscious of the language they choose, avoid unnecessary detail, and refrain from editorializing or recording opinions.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • In all but a few cases, the organization complies with the standard; or
  • One of the elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases, the organization does not comply with the standard; or
  • Two of the required elements are not fully addressed; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Three or more of the required elements are not fully addressed, or
  • Two or more elements are not addressed at all.

 
Fundamental Practice

CA-PRG 1.03

The case record contains essential medical and legal information including, as applicable:
  1. orders for and results of psychological, medical, toxicological, diagnostic, or other evaluations;
  2. documentation of all prescribed and over-the-counter medications including copies of all written orders for medications or special treatment procedures, when applicable;
  3. special treatment procedures, allergies, or adverse treatment responses; and
  4. court reports, documents of guardianship or legal custody, birth or marriage certificates, and any legal, regulatory, and/or contractual directives related to the service being provided.
NA The organization does not obtain legal or medical information.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • With a few exceptions records contain necessary and required information.
3
Practice requires significant improvement; e.g.,
  • Procedures require significant strengthening; or
  • Many records do not have the necessary or required information; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Two or more elements are not addressed at all.

 
Fundamental Practice

CA-PRG 1.04

Case record entries are made by authorized personnel only, and are:
  1. specific, factual, relevant, and legible;
  2. kept up to date from intake through case closing;
  3. completed, signed, and dated by the person who provided the service; and
  4. signed and dated by supervisors, where appropriate.
Examples: When selecting an electronic record keeping system, the organization may consider, among other things, whether or not the system has the capacity to:
  1. verify the individual’s identity and ensure that each electronic signature is unique to the individual; and
  2. ensure that the signature will remain tied or connected to the content being signed for as long as the record is maintained.
 
Examples of ways to verify the authenticity of digital signatures when using electronic records include, but are not limited to: a digitalized signature via tablet or two identifying components such as a user identification code (ID) and password/personal identification number (PIN).
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • In a substantial percentage of cases reviewed, the organization complies with the standard; or
  • One of the elements is not fully addressed. 
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases, the organization does not comply with the standard; or
  • Two of the required elements are not fully addressed; or 
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Three or more of the required elements are not fully addressed; or 
  • Two or more elements are not addressed at all. 

 
Fundamental Practice

CA-PRG 1.05

Progress notes comply with legal, regulatory and/or contractual requirements and are entered:
  1. at least quarterly; or
  2. monthly for individuals receiving protective services, out-of-home care, day treatment, or frequent or intensive counseling or treatment.
Related Standards:
FEC

Interpretation

For credit counselling organizations providing DMPs, disbursement records can suffice as evidence of progress made.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record content and maintenance procedures need strengthening; or
  • Progress notes in most case records are up to date and reflect the progress of the client; or
  • One of the elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • In a significant percentage of cases progress notes have not been kept up to date; or
  • In a significant percentage of cases progress notes are lacking in content and do not reflect the progress of the client; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 1.06

At case closing, case records are reviewed and unsummarized notes, personal observations, and impressions are expunged unless otherwise required by law, regulations, and/or contracts.
NA The organization only provides Financial Education and Counselling (CA-FEC) services.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Most case records are reviewed prior to closure and unnecessary information is removed.
3
Practice requires significant improvement; e.g.,
  • Many closed records contain worker notes and/or unnecessary material.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 1.07

Unless otherwise mandated by law, the organization maintains case records as follows:
  1. for at least seven years after case closing for adults;
  2. until the age of majority or seven years after case closing, whichever is longer, for minors; and
  3. disposes of case records in a manner that protects privacy and confidentiality in the event of the organization's dissolution.
Related Standards:
FEC

Interpretation

Credit counselling organizations are required to maintain case records for a minimum of one year unless otherwise mandated by law.
Examples: Proper disposal of paper and electronic records can include, but is not limited to, shredding paper records, clearing electronic files when computers are replaced or reassigned, and destroying electronic media such as flash drives.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements needs strengthening; or
  • With few exceptions procedures are understood by staff and are being used.
3
Practice requires significant improvement; e.g.,
  • One of the elements has not been addressed at all; or
  • Procedures are not well-understood or used appropriately.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Program Administration (CA-PRG) 2: Access to Case Records

Access to case records is appropriately limited.
NA The organization provides only Early Childhood Education (CA-ECE) and/or Out-of-School Time Services (CA-OST).

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.
Related Standards:
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-PRG 2 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the CA-PRG 2 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the CA-PRG 2 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 2 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Case record access policies
  • Case record access procedures
No On-Site Evidence
  • Interviews may include:
    1. Information systems manager
    2. Program directors
    3. Relevant personnel
  • Observe case record room/files and information systems accessibility observation

 
Fundamental Practice

CA-PRG 2.01

Access to confidential case records is limited to:
  1. the service recipient or, as appropriate, a parent or legal guardian;
  2. personnel authorized to access specific information on a “need-to-know” basis;
  3. former service recipients;
  4. individuals requesting records of deceased service recipients; and
  5. auditors, contractors, and licensing or accrediting personnel consistent with the organization’s confidentiality policy.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 2.02

Service recipients may review and, when desired, add a statement to their files in accordance with applicable laws and regulations, and:
  1. reviews are conducted in the presence of professional personnel on the organization’s premises;
  2. reviews are carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record;
  3. any personnel responses to service recipient additions are added with the service recipient’s knowledge; and
  4. the service recipient is given the opportunity to review and comment on personnel responses.
Examples: Organizations using electronic record keeping systems can provide safe access to case records by, for example, creating a separate user portal or printing the case record.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 2.03

If the organization determines that serious harm would likely ensue if an individual were to review their case record, and applicable law, regulations and/or contracts provides no guidance on case record access, then:
  1. senior management reviews, approves in writing, and enters into the case record the reasons for refusal; and
  2. procedures permit a qualified professional to review records on behalf of service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Record access policy or procedure needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Record access policy or procedure needs significant strengthening; or
  • In a few instances the organization does not comply with the standard.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Program Administration (CA-PRG) 3: Medication Control and Administration

The organization ensures safe, uniform medication control and administration.

Interpretation

 This standard does not apply to foster care and kinship care homes. See CA-FKC 19.04.
NA The organization does not prescribe, dispense, administer, or store medication.
Related Standards:

Note: When an organization’s medication management activities are limited to administering naloxone in the event of an opioid overdose, the NA at CA-PRG 3 applies. See CA-ASE 6.03 for more information on training and procedures related to treating opioid overdose. 

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-PRG 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-PRG 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-PRG 3 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 3 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Medication management procedures
  • Resumes and job descriptions from relevant job categories
  • Documentation tracking staff completion of medication management training
  • Medication logs
  • Aggregate reports of psychotropic medication use in children and youth for the past six months
  • Interviews may include:
    1. Relevant personnel
  • Review case records
  • Facility observation

 
Fundamental Practice

CA-PRG 3.01

Personnel directly involved in medication control and administration are qualified by license or training in accordance with applicable legal, regulatory, and/or contractual requirements.

Interpretation

 Physicians who prescribe and dispense approved buprenorphine products for opioid addiction are appropriately credentialed by the Drug Enforcement Agency (DEA) and provide treatment in accordance with DEA policy.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • With few exceptions, staff possess the required qualifications.
3
Practice requires significant improvement; e.g.,
  • A significant number of staff do not possess the required qualifications, and as a result the integrity of the service may be compromised.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.02

When medication is initially prescribed, the prescribing clinician provides education to service recipients about the medication including:
  1. medication name;
  2. dose;
  3. reason for use;
  4. how to administer;
  5. desired effects; and
  6. potential side effects.

Interpretation

Written, detailed information regarding specific medications may be provided by the pharmacy responsible for filling a prescription.
NA The organization does not prescribe medication.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard. Written information along with documented verbal consultation is provided for each and every client.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation needs improvement.
3
Practice requires significant improvement; e.g.,
  • Information is not consistently provided to persons served; or
  • Documentation needs significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.03

When individuals are receiving prescription medication:
  1. qualified personnel obtain and/or update information about the medications the individual is taking at each visit; and
  2. the prescribing clinician compares current medications the individual is taking at each visit, including vitamins or other non-prescription medications, with new or changed medication orders to identify possible adverse interaction of medications.
NA The organization does not prescribe or administer medication.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The required assessments do not happen at each visit; however, reviews are conducted regularly and when new medications are prescribed.
3
Practice requires significant improvement; e.g.,
  • One of the elements is not consistently addressed as required; or
  • Assessments are not regularly conducted.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.04

Procedures for the proper administration and storage of medication address:

  1. locked, supervised storage with access limited to authorized personnel and in accordance with law, regulation, and manufacturer's instruction;
  2. maintaining medication in original packaging and labeling with the name of the service recipient, medication name, dosage, prescribing physician name, and number or code identifying the written order;
  3. appropriate disposal of expired or unused medication, syringes, medical waste, or medication prescribed to former service recipients;
  4. maintaining a record of who received medications, what medications were dispensed or administered, and when and by whom medications were dispensed or administered;
  5. administration of over-the-counter medications; and
  6. safe dispensing or administering of sample medications, in accordance with applicable legal, regulatory, and/or contractual requirements.

Interpretation

Storage of medication in a secure, central location with access by authorized personnel only is an effective risk management measure and best practice. However, COA recognizes that some programs, such as shelters and safe homes, allow service recipients to store medications in a safe, lockable personal space (e.g., individual lock boxes or private use lockers). In these instances, organizations can demonstrate implementation of the standard by providing protocols, procedures or other documents that demonstrate that they have acknowledged the potential risks of this method and subsequently taken appropriate measures to minimize those risks.
 
Organizations also need to clearly communicate that service recipients are personally responsible for administering and storing their own medications. Intake processes should stipulate what service recipients are allowed to store in their secure, personal space and assign responsibility of the space to the client to support this approach to storing medication.
 

Interpretation

Elements (d), (e), (f), and (g) do not apply to organizations that only store medication.
NA The organization does not dispense, administer, or store medication.
Note: Please see the Facility Observation Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • There are minor problems with storage or labeling but safety has not been compromised; or
  • Documentation needs minor improvement; or
  • Procedures need strengthening.
3
Practice requires significant improvement; e.g.,
  • There are problems with storage or labelling that raise concerns about safety; or
  • Documentation is inconsistent, or some documentation is missing or incomplete; or
  • Procedures need significant strengthening. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.05

Immediately prior to administration, qualified personnel review with the individual the medication to be administered and its purpose, and verify:
  1. the identity of the individual and the medication ordered;
  2. that the medication to be administered matches the medication order; and
  3. the integrity of the medication through visual inspection.
NA The organization does not administer medication.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures are consistently followed with minor exceptions; or
  • Documentation needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Procedures are not consistently followed; or
  • Documentation needs significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.06

Following administration of medication, personnel observe and assess the effects of medication on the individual and consult with pharmacists/medical professionals, as necessary.
NA The organization does not administer medication.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation of observed effects needs minor improvement; or
  • Procedures need strengthening.
3
Practice requires significant improvement; e.g.,
  • Documentation of observed effects is inconsistent, or some documentation is missing or incomplete; or
  • Procedures need significant strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 3.07

The organization tracks the use of psychotropic medications in children and youth at the individual and program level and:
  1. engages prescribers and other partnering providers in corrective action when concerns are noted; and
  2. advocates for increased availability and use of non-pharmacological interventions.
NA The organization does not prescribe or administer psychotropic medication for children and youth.
Examples: Measures to prevent inappropriate or unnecessary use of psychotropic medications can include:
  1. ensuring prescribing providers are familiar with child and adolescent trauma symptoms; and
  2. establishing a team- or peer-based prescribing model.
Note: See CA-PRG 1.03 for more information on tracking pharmacological interventions at the individual case level.

Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation and/or monitoring of corrective actions could be strengthened.
3
Practice requires significant improvement; e.g.,
  • The organization tracks psychotropic medication use but findings and recommendations are not being used; or
  • Procedures need significant strengthening. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Program Administration (CA-PRG) 4: Technology-based Service Delivery

When engaging service recipients in technology-based service delivery, services are based on the needs of the service population and are provided by appropriately trained and licensed personnel.
NA The organization does not engage service recipients in technology-based service delivery.
Examples: Examples of different technologies that may be used include, but are not limited to: telephones/mobile phones, computers, tablets, videoconferencing, interactive messaging systems, or any other tool that allows personnel to see, hear, and/or interact with service recipients from a remote location and provide services at a distance.

Terms that are often used to refer to the delivery of services via technologies include, but are not limited to: telehealth, teleservices, telepractice, telemental health, telepsychiatry, mHealth, online therapy, distance counseling, internet- or web-based interventions, telephonic services, and digital services.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-PRG 4 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-PRG 4 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-PRG 4 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 4 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • List of services being provided via technology
  • Technology-based services policies
  • Technology-based services procedures
  • Criteria for assessing the appropriateness of technology-based services for individuals
  • Table of contents of training curricula
  • Information provided to service recipients to help them make an informed choice
  • Training curricula
  • Documentation tracking staff completion of required training
  • Documentation of licensure
  • Interviews may include:
    1. Program directors
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Demonstration of technologies, if appropriate
  • Review personnel records

 

CA-PRG 4.01

The organization develops policies and procedures to guide technology-based service delivery that address:
  1. privacy and security measures specific to the service delivery model;
  2. the use of acceptable technologies, including personnel-owned devices if applicable; and
  3. collecting, storing, tracking, and transmitting information gathered electronically.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • All elements of the standard are addressed, but some aspects of the policies/procedures need further development; or
  • With few exceptions, policies and procedures are understood by staff and are being implemented appropriately.
3
Practice requires significant improvement; e.g.,
  • Two of the elements are not fully addressed; or
  • One of the elements is not addressed all; or
  • Policies and procedures are not well-understood and/or implemented appropriately.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 4.02

For each individual, the organization:
  1. assesses the appropriateness of technology-based service delivery based on established criteria and suitability factors;
  2. monitors whether or not the service delivery model is effective; and
  3. arranges for services to be delivered in-person when necessary.
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The standard is met in practice, but procedures need minor clarification; or
  • In a few instances documentation in the client’s case record was not found.
3
Practice requires significant improvement; e.g.,
  • Procedures need significant strengthening; or
  • Procedures are not well-understood or used appropriately by personnel; or
  • In a significant number of instances documentation in the client’s case record was not found.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 4.03

Prior to engaging in technology-based service delivery, service recipients receive information needed to make an informed decision about engaging in the service including:
  1. the service provider’s physical location, contact information, and credentials;
  2. alternate methods of service delivery, including access to other service providers, in the event of a technological failure;
  3. privacy and confidentiality limitations associated with electronic communication;
  4. instructions on how to access services and use the technologies;
  5. risks and benefits associated with the service delivery model;
  6. emergency response procedures including verifying the person's current location for the purposes of emergency management;
  7. how personal information and data will be documented, stored, protected, and used; and
  8. under what conditions a referral for face-to-face services may be made.
Related Standards:
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The standard is met in practice, but procedures need minor clarification; or
  • In a few instances, required information was not provided to service recipients; or
  • In a few instances, documentation in the client’s case record was not found.
3
Practice requires significant improvement; e.g.,
  • Procedures need significant strengthening; or
  • In a significant number of instances, the information was not provided to service recipients; or
  • In a significant number of instances documentation in the client’s case record was not found. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 4.04

Personnel are trained on, or demonstrate competency in:
  1. use of equipment and software as appropriate to their position and the services provided;
  2. privacy and confidentiality issues specific to the service delivery model;
  3. recognizing and responding to emergency or crisis situations from a remote location; and
  4. engaging and building rapport with service recipients when communicating electronically.
Examples: Examples of equipment and software training topics include, but are not limited to:
  1. set up;
  2. features;
  3. maintenance;
  4. safety and security measures; and
  5. responding to technical matters (e.g., maintenance issues and troubleshooting) directly or by contacting the appropriate parties for assistance.
Examples: Regarding element (c), in the event of a medical emergency, personnel would need to know how and when to contact local emergency responders and/or service recipients’ emergency contacts.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel have not been trained, but are scheduled to be trained.
3
Practice requires significant improvement; e.g.,
  • The curriculum related to two of the elements is not fully developed or lacks depth; or
  • Training does not address one of the elements at all; or
  • A significant number of staff have not been trained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 4.05

Personnel only provide technology-based services to service recipients located in provinces and territories where they are appropriately licensed, if required.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • While staff are appropriately licensed, legal requirements have not been recently reviewed; or
  • Procedures for documenting licensure need minor improvement.
3
Practice requires significant improvement; e.g.,
  • Documentation of staff licensure is missing or incomplete.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization is aware of compliance problems and is not working to remediate deficiencies; or
  • Staff report providing services to service recipients in provinces or territories where they are not appropriately licensed.
 
2022 Edition

Program Administration (CA-PRG) 5: Services for Persons with Intellectual and Developmental Disabilities

Children, youth, and adults with intellectual and developmental disabilities receive services that help them achieve full integration and inclusion, make choices, exert control over their lives, and fully participate in, and contribute to, their communities.

Interpretation

Throughout these standards the term "person" is defined to include children, youth, and adults with intellectual and developmental disabilities. In instances where the person cannot make his or her own decisions, sign documents, or is otherwise limited in his/her ability to provide informed consent, the term, "person" may be understood to also include an advocate or legal guardian, as in "...the person, his/her advocate, or legal guardian."
NA The organization does not provide any programs or services to persons with intellectual and developmental disabilities.

NA The organization is implementing the standards for Intellectual and Developmental Disabilities Services (CA-IDDS).
Note: Please see the Case Record Checklist for additional guidance on this standard.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-PRG 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-PRG 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-PRG 5 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 5 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • See service planning procedures with the service planning and monitoring evidence of each applicable service section
  • Procedures for use of interventions that limit movement, diminish sensory experience, limit personal freedom, or cause personal discomfort
  • Procedures for helping persons access and use assistive technology
  • Procedures for providing or making referrals for family support services
  • Training curricula and/or educational materials provided to support families
  • Training curricula and/or educational materials provided to service recipients regarding sexuality and relationships
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records

 
Fundamental Practice

CA-PRG 5.01

The organization works in partnership with the person, and his or her team according to the wishes of the person, to develop and implement a service plan that promotes self-determination and enables the fullest and most independent life possible in the community.
Examples: Individuals that may be members of the person’s team include, but are not limited to: the person's family, friends and other natural supports, circle of support, support/service broker, and service coordinator.

Service planning topics for persons with intellectual and developmental disabilities can include, but are not limited to:
  1. health and safety issues;
  2. degree of supervision needed;
  3. independent living, social, and daily living skills;
  4. dietary needs;
  5. leisure and vocational interests and aptitudes and the need for greater social inclusion;
  6. screening and treatment for co-occurring psychiatric disorders or substance use conditions;
  7. the need for assistive technology, auxiliary aids, and other special accommodations;
  8. positive behaviour support planning;
  9. medication needs;
  10. issues related to adaptive, behaviour, and cognitive functioning including concrete and abstract reasoning;
  11. specialized supports such as physical, speech, and occupational therapy;
  12. ancillary services;
  13. end of life planning; and
  14. the need for hospice or palliative care.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Practice meets the intent of the standard but procedures need strengthening.
3
Practice requires significant improvement; e.g.,
  • Procedures need significant strengthening; or
  • The standard has not been met in a few cases.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 5.02

Interventions that limit physical movement, diminish sensory experience, restrict personal freedoms, or cause personal discomfort are implemented only when:
  1. the organization can document its reasons for believing that the intervention will be beneficial to the person served;
  2. the person has been fully informed about the risks and benefits of the intervention and has consented to it;
  3. the intervention is prescribed by a qualified medical practitioner or recommended by an interdisciplinary team, and specific parameters for use of the intervention, such as time limits and clear criteria for when the intervention should be applied, have been established;
  4. the organization periodically reviews the continued need for and effectiveness of the treatment or intervention; and
  5. the intervention is not used as a substitute for appropriate staffing patterns, for the convenience of personnel, or as punishment.
Related Standards:
NA The organization does not use interventions that limit physical movement, diminish sensory experience, restrict personal freedoms, or cause personal discomfort.
Examples: Examples of such treatments and interventions include, but are not limited to: splints or poseys to prevent self-injury; use of visual or auditory screens to reduce stimulation; and use of distasteful substances, textures, or activities as a consequence for behaviour.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures, that include well delineated treatments and interventions, guide practices, but one of the elements needs strengthening; or
  • Documentation related to use of interventions needs minor improvement.
3
Practice requires significant improvement; e.g.,
  • Procedures need strengthening for two of the elements; and/or
  • Documentation needs significant improvement. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • In a few instances one of the standard's elements was not implemented; or
  • Use of interventions is not documented.

 
Fundamental Practice

CA-PRG 5.03

The organization provides assistive technology, or helps the person gain access to assistive resources, as needed, and the person is:
  1. involved in the selection of specific technologies;
  2. afforded the opportunity to try the device prior to purchase or assignment; and
  3. trained on the use of specific assistive devices being provided.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Two of the elements need strengthening; or
  • One of the elements is not addressed; or
  • Assistive technology is sometimes not available.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Assistive technology is generally not available.

 

CA-PRG 5.04

The organization supports persons with intellectual and developmental disabilities to establish meaningful social relationships, build and maintain natural support systems, exercise their rights and responsibilities, and participate in the life of their community by:
  1. helping them identify and pursue the types of social roles and relationships they wish to pursue;
  2. providing opportunities for social and physical interaction with people, other than service providers and other service recipients; and
  3. helping them achieve an optimal level of community involvement and participation.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 5.05

Family support services and information are available to:
  1. strengthen the family's ability to provide care;
  2. prevent unwanted and inappropriate out-of-home placements;
  3. help resolve conflicts between the person and his/her family, advocate, or others involved in establishing and implementing the person's plan; and
  4. help maintain family unity.
Examples: Informational topics that may assist caregivers include, but are not limited to: early childhood development, behaviour, home economics, work-life balance, and nutrition.
 
Examples of community support services include, but are not limited to: behavioural support, case management, counseling, early intervention services, financial assistance, in-home support, public entitlements, respite services, and support groups.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedure or documentation related to one of the elements needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Procedure or documentation related to two of the elements needs strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 5.06

Persons with intellectual and developmental disabilities receive support and education regarding sexuality and relationships that has been tailored to their assessed needs, capacity, and learning style including:
  1. sexual health and development;
  2. family planning;
  3. prevention of STDs and HIV/AIDS; and
  4. sexual abuse and exploitation including giving and receiving sexual consent.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedure or documentation for support or education related to one of the elements needs strengthening.
3
Practice requires significant improvement; e.g.,
  • Procedure or documentation for support or education related to two of the elements needs strengthening.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Program Administration (CA-PRG) 6: Personnel Training for Intellectual and Developmental Disabilities Services

Personnel who provide direct services to people with intellectual and developmental disabilities are trained and able to provide services, supports, and other forms of direct assistance.
NA The organization does not provide any programs or services to persons with intellectual and developmental disabilities.

NA The organization is implementing the standards for Intellectual and Developmental Disabilities Services (CA-IDDS).
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-PRG 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-PRG 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-PRG 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-PRG 6 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Table of contents of training curricula
  • Training curricula
  • Documentation tracking staff completion of required training
  • Interviews may include:
    1. Relevant personnel

 

CA-PRG 6.01

Direct service personnel are trained on, or demonstrate competency in:
  1. communication techniques;
  2. de-escalation techniques for individuals with intellectual and developmental disabilities; and
  3. implementing the principles of self-determination and inclusion.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel have not been trained.
3
Practice requires significant improvement; e.g.,
  • The curriculum related to two of the elements is not fully developed or lacks depth; or
  • Training does not address one of the elements at all; or
  • A significant number of staff have not been trained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-PRG 6.02

Direct service personnel are trained on, or demonstrate competency in, the following topics as appropriate to the service and needs of persons served:
  1. assisted dining techniques and good nutrition;
  2. lifting and transfer techniques;
  3. safe transportation techniques;
  4. health related supports;
  5. use of assistive technology; and
  6. teaching ADLs.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel have not been trained.
3
Practice requires significant improvement; e.g.,
  • The curriculum related to two of the elements is not fully developed or lacks depth; or
  • Training does not address one of the elements at all; or
  • A significant number of staff have not been trained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-PRG 6.03

Direct service personnel are trained and evaluated on the restrictive interventions identified in the treatment plan prior to working with the individual and annually thereafter including:
  1. the parameters under which interventions may be used;
  2. the proper and safe use of chosen interventions; and
  3. the potential for re-traumatization.
NA The organization does not permit the use of restrictive interventions as part of behaviour management.
Examples: Restrictive interventions are those that limit physical movement, diminish sensory experience, restrict personal freedoms, or cause personal discomfort.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures, that include well delineated treatments and interventions, guide practices that are basically appropriate to the intent and elements of the standard, but one of the elements needs strengthening; or
  • Documentation related to use of interventions needs minor improvement.
3
Practice requires significant improvement; e.g.,
  • Procedures need strengthening for two of the elements; and/or
  • Documentation needs significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • In a few instances one of the standard's elements was not implemented; or
  • Use of interventions is not documented.
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