2023 Edition

Residential Treatment Services Definition

Purpose

Residential Treatment Services enable individuals to improve functioning and well-being, increase productive and pro-social behavior, and return to a stable living arrangement in the community.

Definition

Residential Treatment Services (RTX) provide intensive, structured, and individualized treatment and support as part of a time-limited, interdisciplinary, trauma-informed, and therapeutic 24-hour-a-day intervention. While many individuals can be served in less restrictive community-based settings and will not require an intervention as intensive as residential treatment, services may be needed: (1) when less restrictive programs are unable to address an individual's risks and needs, or (2) as follow-up to a more intensive residential intervention. The level of intensity and restrictiveness for residential treatment programs is greater than for other group care settings due to treatment needs, but services aim to move individuals toward independence or a stable, less intensive level of care. 


Short-Term Diagnostic Centers provide comprehensive assessments, observation, and monitoring in a highly structured setting and make recommendations for additional services that will address identified needs.


Crisis Stabilization Units provide assessment and stabilization services for individuals in acute psychiatric crisis. Individuals are offered services in a safe, structured environment under trained professional care to return to their previous level of functioning.


Withdrawal management programs provide medication management and monitoring, clinical counseling, and other necessary support and referral services to help individuals safely withdraw from the substance(s) on which they are dependent. Services include but are not limited to: individual assessment and service planning, medical and non-medical withdrawal management, counseling and education, therapeutic interventions, and linkages with ongoing substance use treatment including medication-assisted treatment when applicable. Programs are available 24 hours a day, seven days per week and are staffed by an interdisciplinary team of qualified professionals.  Withdrawal management without transition to ongoing medication-assisted treatment is not recommended for individuals with opioid use disorder.

Examples: Individuals in need of services may include, but are not limited to:

  1. children, adolescents, or adults with behavioral health disorders severe enough to prevent them from functioning well in their community, but not so severe as to warrant hospitalization;
  2.  adolescents or adults involved with the justice system;
  3.  individuals who are pregnant or parenting;
  4.  children or adolescents who have been victims of human trafficking;
  5.  individuals needing highly structured, intensive treatment for substance use disorders;
  6.  individuals needing specialized and intensive settings for the purposes of clinical assessment; and
  7.  individuals needing psychiatric stabilization.

Note: Organizations that only operate a Crisis Stabilization Unit will complete RTX 1, RTX 2, RTX 3, RTX 4, RTX 5, RTX 6, RTX 8, RTX 9, RTX 10, RTX 13, RTX 16, RTX 17, RTX 18, and RTX 20 and have the option to take NAs on practice standards where noted. Organizations will also complete RTX 14 and RTX 15 if applicable.


Organizations that only operate a Short-Term Diagnostic Center will complete RTX 1, RTX 2, RTX 3, RTX 4, RTX 5, RTX 6, RTX 8, RTX 9, RTX 10, RTX 11, RTX 16, RTX 17, RTX 18, and RTX 20 and have the option to take NAs on practice standards where noted. Organizations will also complete RTX 14 and RTX 15 if applicable.


Organizations that only operate a withdrawal management program will complete RTX 1, RTX 2, RTX 3, RTX 4, RTX 5, RTX 6, RTX 8, RTX 9, RTX 10, RTX 15, RTX 16, RTX 17, RTX 18, and RTX 20 and have the option to take NAs on practice standards where noted. Organizations will also complete RTX 14 if applicable.


Note: Residential Treatment Services are distinct from Group Living Services (GLS), which provide community-based care and are less restrictive. When residents are ready to leave residential treatment, they may be stepped down to a group living program or a less restrictive setting.


Organizations that provide adventure-based programming will also complete the Experiential Education Supplement (EES).


Note: Though the term trafficking is used throughout this section, there are additional terms that may be utilized, including sex trafficking, commercial sexual exploitation of children (CSEC), domestic minor sex trafficking, and minor prostitution. The term victim is commonly used when referring to individuals who have been trafficked to emphasize that they have been coerced and exploited, though the term survivor may also be used.


Note: Please see RTX Reference List for the research that informed the development of these standards.


Note: For information about changes made in the 2020 Edition, please see the RTX Crosswalk.


2023 Edition

Residential Treatment Services (RTX) 1: Person-Centered Logic Model

The organization implements a program logic model that describes how resources and program activities will support the achievement of positive outcomes.

Note: Please see the Logic Model Template for additional guidance on this standard. 

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.

Logic models have been implemented for all programs and the organization has identified at least two outcomes for all its programs.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  

  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one desired outcome has been identified for all of its programs; or
  • All but a few staff have been trained on use of therapeutic interventions and training is scheduled for the rest; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs; or
  • Several staff have not been trained on the use of therapeutic interventions; or
  • There are gaps in monitoring of therapeutic interventions, as required; or
  • There is no process for identifying risks associated with use of therapeutic interventions; or
  • Policy on prohibited interventions does not include at least one of the required elements.
4

Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,

  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs; or
  • There is no written policy or procedures for the use of therapeutic interventions; or 
  • Procedures are clearly inadequate or not being used; or
  • Documentation on therapeutic interventions is routinely incomplete and/or missing; or
  • There is evidence that persons served have been harmed by inappropriate or unmonitored use of therapeutic interventions.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • See program description completed during intake
  • Program logic model that includes a list of outcomes being measured
  • Procedures for the use of therapeutic interventions
  • Policy for prohibited interventions
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel

 

RTX 1.01

A program logic model, or equivalent framework, identifies:
  1. needs the program will address;
  2. available human, financial, organizational, and community resources (i.e. inputs);
  3. program activities intended to bring about desired results;
  4. program outputs (i.e. the size and scope of services delivered);
  5. desired outcomes (i.e. the changes you expect to see in service recipients); and
  6. expected long-term impact on the organization, community, and/or system.

Examples: Please see the W.K. Kellogg Foundation Logic Model Development Guide and Social Current’s PQI Tool Kit for more information on developing and using program logic models.


Examples: Information that may be used to inform the development of the program logic model includes, but is not limited to: 

  1. characteristics of the service population; 
  2. needs assessments and periodic reassessments;
  3. risks assessments conducted for specific interventions; and
  4. the best available evidence of service effectiveness.

 

RTX 1.02

The logic model identifies desired outcomes in at least two of the following areas:

  1. change in clinical status;
  2. change in functional status;
  3. health, welfare, and safety;
  4. permanency of life situation;
  5. quality of life;
  6. achievement of individual service goals; and
  7. other outcomes as appropriate to the program or service population.

Interpretation: Outcomes data should be disaggregated to identify patterns of disparity or inequity that can be masked by aggregate data reporting. See PQI 5.02 for more information on disaggregating data to track and monitor identified outcomes. 

Examples: Although some organizations providing residential treatment focus primarily on outcomes measured at the time of discharge, others emphasize the importance of tracking the longer-term outcomes that reveal whether the gains achieved during treatment are maintained over time. For example, some residential treatment programs measure outcomes at six months, one year, or even three to five years after discharge. Domains to consider can include but are not limited to: (1) living situation; (2) social and community connections; (3) engagement in school and/or work; and (4) physical and behavioral health.


 
Fundamental Practice

RTX 1.03

The organization:

  1. ensures staff are trained on therapeutic interventions prior to working with the service population;
  2. monitors the use and effectiveness of therapeutic interventions;
  3. identifies potential risks associated with therapeutic interventions and takes appropriate steps to minimize risk when necessary; and
  4. discontinues an intervention immediately if it produces adverse side effects or is deemed unacceptable according to prevailing professional standards.


Note: Therapeutic Interventions do not include restrictive behavior management techniques, which are addressed in Behavior Support and Management (BSM). Please see the glossary definition for Therapeutic Interventions for additional guidance on this standard.


 
Fundamental Practice

RTX 1.04

Organization policy prohibits:

  1. corporal punishment by personnel and by parenting individuals, as applicable;
  2. the use of aversive stimuli and/or therapies;
  3. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain;
  4. the use of demeaning, shaming, degrading or bullying language or activities;
  5. forced physical exercise to eliminate behaviors;
  6. unnecessarily punitive restrictions, including restricting family contact, celebrations, or prescribed treatment interventions as a disciplinary action; 
  7. unwarranted use of invasive procedures or activities as a disciplinary action;
  8. punitive work assignments;
  9. punishment by peers; and
  10. group punishment or discipline for individual behavior.


2023 Edition

Residential Treatment Services (RTX) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of individuals and their families.

Interpretation: Competency can be demonstrated through education, training, or experience, including lived experience when applicable. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  

  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up to date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3

Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,

  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
Self-Study Evidence Site Visit Evidence On-Site Activities
  • List of program personnel that includes:
    • Title
    • Name
    • Employee, volunteer, or independent contractor
    • Degree or other qualifications
    • Time in current position
  • See organizational chart submitted during application
  • Procedures or other documentation specific to peer/family partners, if applicable
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
No Site Visit Evidence
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files

 

RTX 2.01

Direct care workers have: 

  1. a bachelor’s degree or demonstrated competence with appropriate and ongoing supervision and training; 
  2. the personal characteristics and experience to collaborate with and provide appropriate support to persons served, gain their respect, guide their development, and participate in their overall treatment program;
  3. the ability to engage and support the families of persons served;
  4. the ability to support constructive family contact and involvement in community activities;
  5. the temperament to work with, and care for, children, youth, adults, or families with special needs, as appropriate; and
  6. the ability to work effectively with the treatment team and other internal and external stakeholders.


Examples: Direct care workers can include, for example: (1) residential counselors; (2) adult care workers; (3) youth care workers; and (4) childcare workers. Their responsibilities typically include general supervision of persons served, daily support and activities, and crisis prevention and management.


Examples: Regarding element (a), ways to demonstrate competence can include, but are not limited to, specialized training available through state or national certification programs or previous experience working in residential treatment.

Note: When personnel with lived experience are specifically hired to provide peer or family support, they will be covered by RTX 2.06 instead of this standard. 


 

RTX 2.02

Supervisors are qualified by: 

  1. an advanced degree in social work or a comparable human service field and two years of relevant experience; or
  2. a bachelor’s degree in social work or a comparable human service field and four or more years of relevant experience.



 
Fundamental Practice

RTX 2.03

A physician or other qualified medical practitioner familiar with the needs of the service population assumes 24-hour on-call medical oversight to ensure that individuals’ health needs are identified and promptly addressed.

Interpretation: The physician can provide services as an employee, contractor, or through another formal arrangement. There may be more than one physician fulfilling the role.


Interpretation: COA Accreditation recognizes that geographic placement and resources can pose barriers to standard implementation. If the organization is unable to arrange 24-hour on-call medical oversight, it can receive a rating of 2 if it can ensure program personnel are prepared to recognize and respond to illness and injury. The organization must demonstrate that procedures outline, and personnel are trained on: (1) how to recognize medical needs, and (2) how to access medical care in the community.

NA All individuals have private primary care providers.


 
Fundamental Practice

RTX 2.04

A licensed psychiatrist with experience appropriate to the level and intensity of service and the population served is responsible for:
  1. developing guidelines for participation in services;
  2. providing psychiatric services, as applicable; and
  3. providing full-time coverage on an on-call basis 24 hours a day, seven days a week.

Interpretation: The psychiatrist can provide services as an employee, contractor, or through another formal arrangement. There may be more than one psychiatrist fulfilling the duties outlined. Programs whose primary service is residential substance use treatment are not required to implement element (c), and may implement element (b) through a formal referral arrangement on an as-needed basis.


Interpretation: In situations where a psychiatrist is not available to assume psychiatric responsibility for persons served, the organization can receive a rating of 2 if they have an advanced practice registered nurse (APRN) supervised by a physician.


 

RTX 2.05

Qualified professionals and specialists are available to provide services and support depending on the program model, population served, and specialized care needs.

Interpretation: Qualified professionals and specialists can provide services as employees, contractors, or through another formal arrangement.

Examples: Qualified professionals and specialists may be needed to provide supports and services related to, for example: 

  1. mental health;
  2. substance use;
  3. crisis intervention;
  4. medicine and dentistry;
  5. psychological services, such as testing and evaluation;
  6. prenatal and postnatal care, and the developmental needs of children;
  7. prenatal and postpartum depression, including screenings and care;
  8. nursing;
  9. education and vocational skill development;
  10. physical and developmental disabilities;
  11. speech, occupational, and physical therapy;
  12. recreation and expressive therapy;
  13. nutrition; and/or
  14. religion and spirituality.



Examples: Examples of populations with specialized care needs include, but are not limited to:

  1. older adults;
  2. children and youth with pervasive developmental disorders;
  3. children and youth who engage in fire setting;
  4.  individuals who exhibit sexually reactive behavior;
  5. victims of physical, psychological, or sexual abuse;
  6. LGBTQ+ population, especially those with needs related to gender identity or transition;
  7. individuals with eating disorders; and
  8.  individuals who have trouble communicating or being understood without special assistance.

 

RTX 2.06

When peer or family partners with lived experience provide support to individuals or their families, the organization: 

  1. clearly defines their roles and responsibilities;
  2. includes peer or family partners as equal partners on the interdisciplinary treatment team;
  3. helps other program personnel understand the position and its purpose at the program;
  4. establishes guidelines for recruitment and selection;
  5. ensures peer or family partners are trained to perform their roles and responsibilities; 
  6. provides ongoing support and supervision to address any issues that occur, including to help peer or family partners manage personal triggers that may arise on the job; and 
  7. facilitates opportunities for peer or family partners to connect and consult with others performing similar roles.


Interpretation: When peer or family partners are employed by another agency, and that agency is responsible for implementing elements (d), (e), (f), and (g), the organization should provide evidence documenting that arrangement (e.g., a contract).

NA The organization does not hire or contract with peer or family partners.

Examples: Peer and family partners can play an important role in welcoming, engaging, empowering, supporting, and advocating for individuals and families. When they are viewed and included as full partners who have input into program decisions, peer and family partners can help organizations ensure their culture and practices prioritize the experience and involvement of persons served and their families. 


Organizations may also use other terms to describe peer/family partners, such as peer support specialists, youth advocates, family advocates, family mentors, and/or family liaisons. 



 
Fundamental Practice

RTX 2.07

There is at least one person on duty at each program site any time the program is in operation that has received first aid and age-appropriate CPR training in the previous two years that included an in-person, hands-on CPR skills assessment conducted by a certified CPR instructor.


 

RTX 2.08

All direct service personnel are trained on, or demonstrate competency in: 

  1. the principles and practices of person-centered care;
  2. implementing a range of practices that promote a supportive and noncoercive environment and prevent the need for restrictive interventions;
  3. assessing needs in crisis situations;
  4. understanding needs related to age, gender identity, race, substance use and mental health disorders, developmental disabilities, and/or other needs typically presented by the service population;
  5. skills and strategies for engaging, partnering with, and supporting family members;
  6. understanding the definitions of human trafficking (both labor and sex trafficking) and sexual exploitation, and identifying potential victims; and
  7. procedures for responding to individuals who run away.



 

RTX 2.09

Employee workloads support the achievement of positive outcomes for individuals and families and are regularly reviewed.

Interpretation: The size of case managers’ caseloads may vary depending on the organization’s approach to service delivery but should generally not exceed 12 individuals/families.

Examples: Factors that may be considered when determining workloads include, but are not limited to: 

  1. the qualifications, competencies, and experience of personnel, including the level of supervision needed;
  2. characteristics of the population the program is designed to serve;
  3. case complexity, including the special needs and circumstances of individuals and families;
  4. case status, including progress toward achievement of desired outcomes;
  5. the work and time required to accomplish assigned tasks and job responsibilities; and
  6. service volume.

 

RTX 2.10

The organization promotes stability and service continuity by:

  1. assigning a case manager, clinician, or other worker at intake or early in the contact; and
  2. minimizing the number of case managers, clinicians, or other workers assigned to the individual and family over the course of their contact with the organization.


Examples: Organizations can strive to promote stability and service continuity by, for example: (1) arranging for staff to transition with individuals as they depart the program, rather than having an entirely different set of staff assist with the move to the community; (2) assigning the same staff to work with both persons served and their families, rather than assigning different staff to work with different members of the same family; (3) addressing factors that may contribute to personnel turnover (e.g., ensuring workloads are reasonable and providing appropriate training, supervision, and support); and (4) establishing transition procedures for internal turnover (e.g. limiting reassignment of cases due to promotions or other role changes). 


 

RTX 2.11

The organization prevents and counters the development of secondary traumatic stress by:

  1. helping personnel understand how they can be impacted by stress, distress, and trauma;
  2. helping personnel develop the skills and behaviors needed to manage and cope with work-related stressors;
  3. encouraging respectful collaboration and support among co-workers;
  4. examining how the organization’s culture and policies contribute to or prevent the development of secondary traumatic stress; 
  5. providing reflective supervision; and
  6. informing personnel about treatment services, as needed.


Examples: Regarding element (b), organizations can help personnel develop the skills and behaviors that will enable them to: (1) engage in positive thinking; (2) increase their self-awareness; (3) know their limits and needs; (4) practice self-compassion; (5) establish healthy boundaries; (6) effectively communicate about unrealistic and unspoken expectations; (7) monitor and regulate their emotions and behaviors; (8) identify and manage emotional triggers; (9) have difficult conversations with co-workers and supervisors; (10) practice brain-aware activities to stay regulated; and (11) take time for self-care.


Regarding element (d), areas to consider include, but are not limited to: (1) supervision; (2) caseload assignment; (3) scheduling; (4) trainings; (5) crisis response; (6) psychological safety; and (7) healthy and realistic staff expectations and boundaries. 


2023 Edition

Residential Treatment Services (RTX) 3: Admission

Individuals who require and will benefit from the residential intervention are accepted into the program. 

Interpretation: Level of family involvement in admission may vary based on the population served, program model/design, and the expressed wishes of individuals. See RTX 6 for more information on expectations for family involvement.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • In a few rare instances, urgent needs were not prioritized; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 




4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Eligibility criteria
  • Screening, admission, and intake procedures
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 3.01

The organization establishes eligibility criteria that: 

  1. define the population the program is equipped to serve, including age, developmental stage, and range of needs addressed; and
  2. specify any exclusion criteria. 



 

RTX 3.02

The organization encourages the appropriate use of residential interventions by informing individuals, their families, and referral sources about: 

  1. the program’s eligibility criteria;
  2. what service options and levels of care will be available and when;
  3. the scope of services and supports provided, including any special areas of expertise;
  4. the goals of the residential intervention, including information on the effectiveness of treatment, when available; 
  5. opportunities for family and community involvement;  
  6. the importance of connecting individuals to programs that address their risks and needs in the least restrictive environment necessary; and
  7. the importance of placing individuals in residential treatment programs close to their families and home communities, to the extent possible.


Examples: Advocating for the availability of needed community services that can provide an alternative to residential treatment, as addressed in GOV 3, can also help to encourage appropriate placements. 


 

RTX 3.03

The organization promptly screens prospective service recipients to:

  1. determine whether they meet the program's eligibility criteria;
  2. evaluate whether the services and supports offered match their needs; and
  3. provide placement on a waiting list or recommendation for appropriate resources when individuals cannot be served or cannot be served promptly.

Interpretation: When individuals are referred by a public agency, element (c) may not be applicable. Instead, the organization may be required to notify the referral source if an individual cannot be served or cannot be served promptly. When organizations provide services under contract with a “no reject, no eject” provision, the interdisciplinary team should carefully review admission decisions to ensure the organization is prepared to address any special needs or services the individual may require.

NA Another organization is responsible for screening, as defined in a contract.


 
Fundamental Practice

RTX 3.04

Prompt, responsive intake practices:

  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations; and
  3. support timely initiation of services.



 

RTX 3.05

The organization helps admitted individuals and their families prepare for admission by:

  1. ensuring they are welcomed and engaged throughout the admission process;
  2. providing the information and support they need to integrate into the program; and 
  3. providing the opportunity for a pre-admission visit, whenever possible. 


NA The organization only operates a crisis stabilization unit. 

Examples: Peer and family partners can play an important role in welcoming individuals and families and helping them integrate into the program.


 

RTX 3.06

The organization describes: 

  1. personal items individuals may bring with them, consistent with a safe, therapeutic setting;
  2. items that are discouraged or prohibited; and
  3. any safety procedures the program follows, or consequences that can result, when prohibited items are brought to the program site.


Interpretation: Given the rise in information and communication technologies, organizations must specify in their admission materials what electronic devices are permitted and prohibited.

2023 Edition

Residential Treatment Services (RTX) 4: Assessment

The organization’s assessment practices ensure prompt and responsive access to appropriate services and supports.

Interpretation: When the organization is working with an American Indian or Alaska Native family, tribal representatives or other tribal community members must be involved in the assessment process, as determined by the tribe and the family.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Services are frequently not initiated in a timely manner; or
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; or
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Assessment and reassessment procedures
  • Copy of assessment tool(s)
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 4.01

Individuals participate in an individualized, trauma-informed, culturally and linguistically responsive assessment that is: 

  1. completed within established timeframes; 
  2. conducted by clinical personnel, including a licensed psychiatrist, psychologist, or other qualified mental health professional, as appropriate to the program model and population served;
  3. conducted in a standardized manner using an age-appropriate, evidence-based, and validated assessment tool; 
  4. focused on information pertinent for meeting service requests and objectives;
  5. relationship-focused, allowing time to build rapport, answer questions, and acknowledge concerns; and
  6. supplemented with information and input provided by the referral source, collaborating providers, family members, and/or others involved with the individual and family, when appropriate.



 
Fundamental Practice

RTX 4.02

The comprehensive assessment addresses: 

  1. individual and family strengths, risks, protective factors, and resilience;
  2. behavioral and physical health needs and goals;
  3. trauma exposure and related symptoms, including a trauma screen and, when appropriate, a trauma assessment;
  4. an evaluation for risk of suicide, self-injury, neglect, exploitation, and violence towards others;
  5. community and social support, resources, and helping networks;
  6. cultural identity and related practices and traditions;
  7. educational and vocational accomplishments, needs, and goals;
  8. social skills, recreational activities, hobbies, and special interests;
  9. sexual orientation and gender identity;
  10. factors that can impact group living success;
  11. additional tests and assessments when indicated; and
  12. a summary of symptoms and diagnoses.


Interpretation: The Assessment Matrix - Private, Public, Canadian determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.


Interpretation: Due to the nature of withdrawal management programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process.


Interpretation: Element (j) may not be applicable for crisis stabilization units and short-term diagnostic centers.


Interpretation: Vulnerable populations, such as people who are lesbian, gay, bisexual, transgender, and questioning (LGBTQ+), are at high risk of violence and harassment while in residential care. The organization should consider these factors to ensure all people are safe and welcomed. When exploring gender identity and sexual orientation personnel should use inclusive language and ask open-ended questions that prompt discussion, help establish rapport, and allow for self-disclosure of gender identity, pronouns, and sexual orientation. Information shared should be used to inform service planning, when appropriate, and should only be included in written plans when explicit consent is given. Names and pronouns identified by the person should always be used.


Interpretation: Personnel that conduct assessments should be aware of the indicators of a potential trafficking victim, including, but not limited to: evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in a confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents. Several tools are available to help identify a potential victim of trafficking and determine the next steps toward an appropriate course of treatment. Examples of these tools include, but are not limited to, the Rapid Screening Tool for Child Trafficking and the Comprehensive Screening and Safety Tool for Child Trafficking.

Examples: Organizations serving young children can tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history.


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



 
Fundamental Practice

RTX 4.03

When an individual’s assessment indicates a substance use disorder, the organization records a thorough alcohol and drug use history, including an evaluation of the effects of alcohol and other drug use on the individual’s family, and provides: 

  1. an appropriate level of service and withdrawal management, as necessary; or
  2. connection to appropriate services when the program does not serve individuals with substance use disorders.




 

RTX 4.04

To facilitate successful social and community reintegration following residential care, the assessment:

  1. includes attention to the services, supports, and resources currently available in the individual’s home community; and
  2. determines whether the services, supports, and resources the individual may need following residential treatment are available or lacking. 


Interpretation: The organization can collaborate with relevant partners in the home community to obtain this information. 

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.


 

RTX 4.05

Reassessments are conducted as needed, including at specific milestones in the treatment process. 

Note: For more information regarding individuals that return after an episode of running away, refer to RTX 10.01 and RTX 18.03

2023 Edition

Residential Treatment Services (RTX) 5: Service Planning and Monitoring

Individuals and families participate in the development and ongoing review of comprehensive service plans that are the basis for delivery of appropriate services and supports.

Interpretation: Level of family involvement in the service planning process may vary based on the population served, program model/design, and the expressed wishes of individuals. See RTX 6 for more information on expectations for family involvement.


Interpretation: When the organization is working with American Indian and Alaska Native children and families, tribal or local Indian representatives must be included in the service planning process and culturally relevant resources available through or recommended by the tribe or local Indian organizations should be considered when developing the service plan.  

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some persons served is clearly inappropriate; or
  • Service planning is often done without the full participation of persons served; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Service planning and monitoring procedures
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 5.01

To support timely initiation of services:

  1. an initial service plan is developed within one week of admission; 
  2. a comprehensive service plan is developed within 30 days of admission; and 
  3. the process for service planning is expedited when crisis or urgent need is identified.


NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Note: Service planning timeframes for crisis stabilization units are addressed in RTX 13.03.


 

RTX 5.02

Service plans are developed: 

  1. with the individuals served;
  2. with families, guardians, and/or legal advocates;
  3. with the involvement of supportive people chosen in collaboration with individuals and families; and
  4. in collaboration with other involved service providers and systems. 


Examples: Supportive people chosen in collaboration with individuals and families can include, for example: (1) extended family; (2) friends; and (3) community members (e.g., coaches and representatives from cultural or faith-based institutions). Other service providers and systems can include those involved with the individual and family both during and before the residential intervention, for example: (1) health care providers; (2) behavioral health providers; (3) teachers or other school personnel; and (4) representatives from the public agency that referred the individual for services. This team can be involved not only in planning and monitoring services at the program, but also in providing support and follow-up over time, including in planning for transition from the program.


 

RTX 5.03

A comprehensive, individualized, and assessment-based service plan includes: 

  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. a plan for family contact and participation, when appropriate;
  3. services and supports to be provided, and by whom, including the specific treatment modalities to be used;
  4. the estimated length of treatments and stay;
  5. criteria for discharge; and
  6. documentation of the individual’s and/or legal guardian’s participation in service planning.


Interpretation: Safety concerns for victims of human trafficking often do not end when they are admitted to residential settings. When an individual is a victim of human trafficking the organization should work with them to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services; maintaining the residence’s location in confidence or restricting access to the program site; and linking efficiently to law enforcement, if needed. Psychological safety should also be prioritized as the emotional effects of trauma – mistrust, anxiety, and depression – can be persistent and overwhelming for victims.


 

RTX 5.04

To ensure the organization is prepared to prevent, de-escalate, and manage crises, service plans for individuals with emotional or behavioral challenges identify: 

  1. strategies to promote ongoing self-care and support self-regulation;
  2. triggers that may lead to distress or dysregulation; 
  3. warning signs that the individual is experiencing distress or dysregulation; and 
  4. techniques to help the individual remain calm and/or re-gain control when experiencing distress or dysregulation. 


Note: See BSM 2.03 for additional expectations regarding the behavior support and management plans that should be developed when organizational policy does not prohibit restrictive behavior management interventions. 


 

RTX 5.05

An interdisciplinary treatment team works in active partnership with individuals and families to ensure that all aspects of the individual’s life, including services, supports, and daily living experiences, are integrated and coordinated to support goal achievement.

Interpretation: The service plan should specify how the services, supports, and opportunities addressed throughout the RTX Standards will be coordinated and integrated to address needs and promote the achievement of desired outcomes. For example, participation in movement and arts activities such as running or singing can help to calm the brain, support healing, and increase an individual’s capacity to self-regulate and master new skills. Similarly, if individuals practice the skills they learn in therapy both in daily life at the program and while engaging with family and the community, they may be better prepared to utilize those skills in a real-life setting after discharge. 

Examples: The organization can encourage effective coordination and integration by including both clinical and direct care workers, as well as peer and family partners, on the interdisciplinary treatment team.

Note: When some service components are delivered by outside providers, implementation of this standard will overlap with RTX 5.06.


 

RTX 5.06

Working in active partnership with individuals and families, the organization collaborates with other relevant organizations and agencies to: 

  1. arrange for the delivery of needed services the organization does not provide;
  2. promote a coordinated approach to service delivery;
  3. ensure that individuals and families receive appropriate advocacy support; 
  4. mediate barriers to services within the service delivery system;
  5. identify and develop opportunities for community involvement during residential treatment; and
  6. promote continuity of care and access to all needed services and supports following discharge from the program.


Interpretation: Some standards elements may not be applicable for crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.

Examples: Relevant organizations and agencies can include, for example: (1) representatives of the public agency that refers individuals for service; (2) other professionals providing services to individuals while they are in the organization’s care (e.g., schools, speech/language therapists, medical professionals, and legal counsel); (3) other organizations in the surrounding community (e.g., parks and recreation services, libraries, cultural institutions, local businesses, and faith-based institutions); and (4) organizations in the individual’s home community, including both those serving the individual’s family, and those that will provide primary support to the individual following discharge.


 

RTX 5.07

The interdisciplinary treatment team partners with individuals and families to review their cases at least quarterly to: 

  1. assess service plan implementation; 
  2. review progress toward achieving service goals and desired outcomes, as well as factors contributing to or impeding that progress; and
  3. determine the continuing appropriateness of the agreed upon service goals, and the continuing need for residential treatment. 


Interpretation: Case reviews may occur more frequently based on individual needs and/or anticipated length of stay. Quarterly reviews may not be appropriate in shorter term programs when services are only provided for a few months. In these cases, reviews should be conducted more frequently to confirm progress and the continued appropriateness of the service plan.

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Examples: Timeframes for service plan reviews may be adjusted depending upon needs and the intensity of services provided. For example, service plans may be reviewed more frequently when serving young children or individuals with specialized care needs, or when individuals experience changes in their life situations or psychological conditions. Service plans may also be reviewed more frequently to comply with contractual requirements.

2023 Edition

Residential Treatment Services (RTX) 6: Family Connections and Involvement

The organization works with individuals and families to maintain an optimal level of family involvement, and to prepare the family to support the individual after discharge.  

Interpretation: COA Accreditation recognizes that involving families can be difficult, especially if the program is far from an individual's home community, or if the organization faces funding constraints that make it challenging to work with families. However, organizations should still strive to involve families and implement the practice standards in this core concept to the extent possible, unless family contact is determined to be inappropriate for a particular individual. When the person served is a minor, families should be actively involved to the maximum extent possible unless contraindicated. When organizations serve adults who do not want their families involved, RTX 6.02 to RTX 6.08 may not be implemented for those particular individuals. Program type and length of stay can also impact family involvement. For example, due to the nature of programs that provide withdrawal management or crisis stabilization, engaging family members in the treatment process may not always be possible or appropriate.


If family involvement is limited for any reason (whether due to contraindication, the wishes of the individual, or difficulty engaging a particular family), written justification should be included in the case record.

Note: When the organization provides out-of-home care for children in custody of a public agency, implementation of this standard may overlap with permanency planning as addressed in RTX 7.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or  
  • Documentation is routinely incomplete and/or missing.            
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for facilitating family contact and involvement
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 6.01

The organization helps every individual served to: 

  1. understand separation from family or significant others and grieve the loss of family; and
  2. express the level/type of family connection they wish to have.


Interpretation: When serving adults who do not want family involvement, efforts should be made to help them identify friendship/peer support opportunities. When serving children or youth with limited family involvement, efforts should be made to help them connect with a non-custodial parent and/or other extended family members. As noted in the Glossary, individuals may define their family to include extended family members, significant others, close friends, current or former foster family, adoptive family, and others with an important role in supporting individual or family well-being.


Interpretation: In cases where an individual is a victim of human trafficking or trafficking is suspected, the organization should work with the individual to identify people with whom they wish to maintain a relationship. Traffickers may pose as a significant other or older relative or communicate through another person and utilize visitation to continue the exploitation of the victim. It is also important to be aware that the individual’s parent or caregiver may be the trafficker or complicit in the trafficking. In such cases, determining the appropriate level of involvement should include the input of the child as well as child welfare and law enforcement systems. 



 

RTX 6.02

The organization helps individuals maintain relationships with family members by:

  1. informing individuals and family members of the organization’s procedures regarding family contact; 
  2. facilitating in-person family contact, both at home and at the facility, as often as possible; and
  3. encouraging phone or web-based family contact, as often as possible. 


Interpretation: Unless contraindicated by court-order or compelling reasons to limit contact, individuals should have the opportunity to spend time with family. Frequent contact will be especially important when the organization serves children and youth and should include contact with siblings. Contact at home may not be possible when operating a crisis stabilization unit, short-term diagnostic center, or withdrawal management program. 

Examples: Recognizing the importance of family contact, some programs serving children and youth encourage phone calls at least once a day, and in-person contact at least once a week. Programs may encourage regular contact by, for example: (1) allowing families to call or come to the program anytime; (2) permitting children and youth to spend time at home whenever the family wants; (3) arranging for staff to accompany the child or youth home to provide support and ensure safety, if necessary; and (4) assisting with transportation to and from the facility, as addressed in RTX 6.07. Advocating for children and youth to be placed close to home, as addressed in RTX 3.02, can also help to preserve family connections.


 

RTX 6.03

Families are involved in the care and treatment of the person served, to the extent possible and appropriate. 

Examples: In addition to formal involvement in admission, assessment, service planning, service delivery, and aftercare planning, families can be actively involved in day-to-day issues and decision making. For example, families of children and youth can: (1) provide input regarding what strategies may or may not work with their child; (2) be kept up to date on their child's daily appointments and activities; and (3) participate in activities such as haircuts or clothing purchases.

Note: Expectations regarding family involvement in admission, assessment, service planning, and aftercare planning are addressed in RTX 3, RTX 4, RTX 5, and RTX 19.


 

RTX 6.04

Family members participate in educational and/or therapeutic services that help them develop the skills and strategies needed to:

  1. understand and support the individual in care;
  2. strengthen family relationships;
  3. improve family functioning; and
  4. promote successful reintegration into the family and community following the residential intervention. 


Interpretation: Implementation of this standard may be limited in crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.


Interpretation: When the organization serves victims of sex trafficking, educating parents on sex trafficking is an important component to prevention, identification, and treatment. Information provided either directly or by referral should address how parents can raise their children in an environment free of abuse, neglect, and exploitation, through information on topics such as internet safety, how to respond when a child runs away, and developing healthy relationships. Additionally, information for parents of trafficking victims should emphasize the issue of stigma associated with prostitution to help the family provide a healthy, nonjudgmental home environment, supportive of a successful reintegration.


 

RTX 6.05

The organization helps family members address unmet needs by recommending appropriate resources. 

Examples: Family members may need help obtaining needed community services, developing their informal support networks, and/or connecting with formal peer support resources. 

Note: When another entity (e.g., a public agency) is responsible for providing this support to families, the organization may request an NA if it provides documentation of this arrangement.


 

RTX 6.06

When the individual in treatment and/or others in the family have experienced trauma, the organization helps family members: 

  1. understand how trauma may impact current functioning; 
  2. identify, anticipate, and manage responses to trauma reminders; and 
  3. appropriately support recovery.


NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Note: See RTX 9.03 for more information regarding the services that should be provided to individuals in treatment who have experienced trauma. When other family members have experienced trauma, they may need to be recommended trauma resources as per RTX 6.05.


 

RTX 6.07

The organization minimizes barriers to family involvement by: 

  1. providing written information regarding the family’s role in services;
  2. including family members in scheduling decisions;
  3. allowing participation by phone or video conference;
  4. assisting with arranging transportation, accommodations, and childcare, as needed and to the extent possible; and
  5. providing or arranging services for family members in the family’s home and community, as needed and to the extent possible.



 

RTX 6.08

The organization provides family members with opportunities to be meaningfully engaged in program planning and decision making.

Examples: Organizations may involve current and former family members by, for example: (1) soliciting feedback through surveys or focus groups; (2) providing opportunities for family members to provide feedback on program operations over the course of treatment; (3) establishing family advisory councils; (4) including family members on ongoing committees; (5) inviting family members to serve on the governing body; and (6) hiring family members to serve as Family Partners. Engaging family members in this manner can be beneficial to both family members themselves and the organization.

2023 Edition

Residential Treatment Services (RTX) 7: Child Permanency

The organization participates in or facilitates permanency planning to promote physical, emotional, and legal permanence for children.
Interpretation: When the organization is not responsible for facilitating permanency planning, it should document all participation in the process and any efforts to connect children to positive relationships with significant adults.

In addition, organizations should demonstrate their role in supporting timely permanency planning through regular case record documentation and official reports provided to the local child welfare agency or the court which comment on children’s and/or families’ progress towards permanency goal(s).


Interpretation: The permanency planning process for American Indian and Alaska Native children and families must always involve tribal representatives and service providers to ensure compliance with the Indian Child Welfare Act’s placement preferences and support culturally responsive planning that recognizes and incorporates tribal definitions of permanency and tribal perspectives of the best interests of the child into the permanency plan. To facilitate full participation, the organization must ensure that the tribe or local Indian organization receives timely notification of court or administrative case reviews, and is informed of any changes made to the permanency plan.

NA The organization does not provide out-of-home care for children in custody of a public agency.


NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Note: Permanency planning often occurs in conjunction with service planning.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for permanency planning
  • Procedures for finding and engaging kin
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 7.01

Permanency planning:

  1. occurs with families and the team of people that support them, including out-of-home care providers, service providers, and extended family members or other supportive individuals identified by the family, as appropriate;
  2. is scheduled at times when appropriate parties can attend; and
  3. is child-driven, with children actively involved in every stage of the process as appropriate to their age and developmental level.


Examples: Child-driven permanency planning can include, but is not limited to, involving children in: (1) conversations about what permanency means to them; (2) the discovery of extended family and other significant adults; and (3) the formation of a permanency team that will support their desired outcomes and have an ongoing role in their lives.


 

RTX 7.02

The organization collaborates with children, parents, and the local child welfare agency to identify, notify, and engage relatives and other close, supportive adults that can be resources or supports for placement and permanency for children of all ages, regardless of whether they currently wish to be adopted.

Examples: Procedures for identification of kin may include: (1) engaging children and family members in identification; (2) conducting a thorough review of the case record; (3) using technological resources for family-finding; (4) providing notification in family members’ preferred languages; and (5) providing notifications in multiple forms, including written form.


 

RTX 7.03

Concurrent planning is documented and includes: 

  1. early, preliminary, and reasoned assessment of the potential for reunification, the best interests of the child, and the need for an alternative plan;
  2. full disclosure to involved parties of all permanency options, including expectations, implications, available supports, and legal timelines;
  3. joining a resource family that is prepared to develop a life-long relationship with the child; and
  4. counseling parents about relinquishment and alternative permanency options if needed.


Interpretation: The age of a child should not limit the consideration of all permanency options.

 

RTX 7.04

Permanency plans document:
  1. permanency goals;
  2. why goals are in the best interest of children and their well-being;
  3. why other permanency options are not appropriate; and
  4. how service plans and identified interventions support permanency and child well-being.

 

RTX 7.05

Case records document efforts made to support parents toward reunification, including: 

  1. involvement in assessment, service planning, and service selection;
  2. access to needed services and supports, including both formal and informal community resources;
  3. ongoing, constructive, and progressive contact with their children; and
  4. reduction of barriers to contact and involvement in the child’s care.


Interpretation: When the organization is working with American Indian and Alaska Native children and families, the Indian Child Welfare Act requires active efforts be provided to prevent family breakup. Active efforts require affirmative, thorough, timely, and culturally responsive engagement with families to satisfy the case plan by accessing resources and services and partnering with the tribe. Early consultation with the child’s tribe is critical to ensuring that a full range of resources have been made available to the family and that active effort requirements are fulfilled. Organizations may work with tribal leadership, elders, religious figures, or professionals with expertise concerning the given tribe to determine culturally responsive active efforts and identify culturally appropriate services for the family.

2023 Edition

Residential Treatment Services (RTX) 8: Service Culture

A supportive and trauma-informed approach to service promotes engagement, healing, and empowerment. 

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Sample of activity schedules
  • Procedures for involving persons served in decisions about their own care/daily life
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records
  • Observe the program

 

RTX 8.01

Personnel at all levels develop and maintain positive, caring, supportive, and trust-based relationships with persons served. 

Examples: All personnel, from clinical staff to direct care workers, can aim to develop and maintain positive relationships with persons served. Given the amount of time direct care workers spend with persons served, the relationships they form can be especially influential.


Personnel can support the development of positive relationships by, for example: (1) engaging with individuals in a respectful manner; (2) using kind and supportive language; (3) encouraging the development of trust by being consistent and dependable; (4) listening actively to what individuals say; (5) checking in with individuals to see how they are doing; (6) trying to understand individuals’ perspectives; (7) making an effort to truly get to know persons served; (8) being sensitive to individuals’ cultures, circumstances, and experiences; (9) expressing interest in individuals’ interests; (10) providing support when individuals need someone to talk to; (11) comforting individuals when they are scared or anxious; (12) providing helpful assistance as needed; and (13) incorporating humor into daily interactions. The organization’s approach to behavior support and management, as addressed in RTX 8.06, can also impact relationship development. 



Examples: Some organizations promote the development of positive relationships by hiring Peer Partners who have experienced residential care themselves and are thus uniquely qualified to provide empathetic support to persons served. Including Peer Partners on staff can also help organizations foster an overall culture of respect and prioritize a person-driven approach to service. 


 

RTX 8.02

The organization establishes a daily routine that:

  1. provides predictability, stability, and structure;  
  2. is clearly communicated to persons served, including advanced posting of schedules for structured and supervised activities; and
  3. offers flexibility to support the individualized program and needs of each person served.



 

RTX 8.03

Persons served are actively engaged in making decisions about their own care and treatment and have regular opportunities to exercise choice and control in their daily life at the program. 

Examples: Individuals may exercise choice and control in daily life by, for example: (1) decorating and personalizing their sleeping areas; (2) assisting with meal planning and preparation; and (3) choosing clothing based on their personal preferences. Due to length of stay and safety concerns, individuals in crisis stabilization units, short-term diagnostic centers, and withdrawal management programs may have fewer opportunities to exercise choice and control in these activities.  

Note: Expectations regarding the role of persons served in assessment, service planning, and aftercare planning are addressed in RTX 4, RTX 5, and RTX 19.


 

RTX 8.04

The organization provides persons served with meaningful opportunities to influence program policies and practices by: 

  1. contributing to program planning and decision making;
  2. assuming an appropriate level of leadership; and 
  3. sharing feedback regarding the program environment and operations, including dissatisfaction with aspects of care.

Interpretation: Elements (a) and (b) may not be applicable for crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.




Interpretation: The organization should have mechanisms in place to receive and respond to input. Persons served should be informed of how the organization will use their input and be made aware of any changes that were made in response.

Examples: Organizations can involve persons served by, for example: (1) seeking input during house and/or community meetings; (2) soliciting feedback through satisfaction surveys; (3) establishing resident advisory councils; (4) inviting persons served to play a role in orienting newcomers to the program; and (5) hiring former service recipients to serve as peer partners. This type of engagement can be beneficial to both persons served and the organization. 


Examples: Persons served may have valuable insights regarding many different aspects of service, (e.g., staff, activities, rules, food, sense of safety and support, living environment, and overall experience at the program). For example, they can contribute to decisions about how to make living areas inviting, comfortable, and reflective of their interests and diversity.  



 

RTX 8.05

Treatment, services, and activities are appropriate for and sensitive to the needs of persons served and consider:

  1. age and developmental level; 
  2. language;
  3. ability; 
  4. gender and gender identity;
  5. culture, race, and ethnicity;
  6. religion;
  7. socioeconomic status;
  8. sexual orientation;
  9. past experiences of trauma;
  10. social and emotional needs; and
  11. strengths and interests. 


Interpretation: Individuals should have the right to choose whether they wish to participate in religious activities that take place at the program. 


Interpretation: When planning group activities, the organization should also consider the characteristics of the entire group.



 

RTX 8.06

The organization’s approach to behavior support and management emphasizes the importance of crisis prevention and focuses on: 

  1. recognizing the influence of the past on current behaviors and functioning;
  2. understanding the root cause, and functional purpose, of challenging behaviors;
  3. striving to eliminate coercive and restrictive practices that emphasize compliance over learning and threaten a person’s sense of safety and control; 
  4. ensuring individuals have the support they need to manage their emotions and behavior; and
  5. setting consistent limits but offering flexibility when appropriate and in the individual’s best interest.


Examples: Regarding element (d), organizations can ensure individuals have the support they need to manage their emotions and behavior by, for example: (1) training personnel to respond with curiosity and empathy when individuals are struggling to control their emotions and behavior; (2) encouraging the development of strong, trust-based relationships with staff, as addressed in RTX 8.01; (3) developing individualized plans for emotional and behavioral support that identify triggers, warning signs, and prevention strategies, as addressed in RTX 5.04; (4) ensuring personnel are aware of and prepared to implement plans for emotional/behavioral support; and (5) helping individuals develop skills and strategies that facilitate self-regulation and pro-social behavior, as addressed in RTX 9.


Examples: Regarding element (e), being flexible with codified rules that contradict an individual's best interest can allow the organization to provide care that is tailored to the individual's needs. For example, being flexible with bedtimes for an individual who may have experienced nighttime trauma rather than strictly enforcing a lights-out time allows the organization to be responsive to individual needs.

 

Examples: This approach may be especially critical when individuals have a history of trauma. Staff may be better able to support individuals who have experienced trauma if they: (1) understand the concept of trauma; (2) recognize that individuals' social, emotional, and behavioral difficulties may be the result of trauma; and (3) are prepared to manage difficult behaviors and trauma reminders.

Note: When an organization permits staff to use restrictive behavior management interventions as a last resort in crisis situations to prevent imminent harm to the individual or another person, implementation of this standard will overlap with the implementation of the Behavior Support and Management Standards (BSM).


 

RTX 8.07

Individuals are provided with opportunities for peer socialization and are helped to develop healthy relationships with others at the program.

Interpretation: Implementation of this standard may be limited in crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.

2023 Edition

Residential Treatment Services (RTX) 9: Therapeutic and Skill-Building Services

Individuals are helped to develop skills and strategies that will enable them to overcome challenges and live successfully at home and in the community following the residential intervention. 

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • See sample activity schedules submitted in RTX 8
  • Procedures for obtaining clearance to participate in athletic activities
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records
  • Observe the program

 

RTX 9.01

Individuals participate in: 

  1. treatment for severe emotional disturbance or mental health disorders;
  2. individual counseling and education;
  3. group counseling and education; and
  4. family therapy, unless contraindicated.

Interpretation: Family therapy may not always be provided in crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.


 

RTX 9.02

Therapeutic and educational interventions are designed to help individuals develop the awareness, skills, and strategies they need to: 

  1. manage social, emotional, and behavioral challenges;
  2. develop and utilize healthy and effective coping and self-regulation strategies; and
  3. improve functioning.


Interpretation: The specific areas targeted, and skills developed, will vary based on the needs of the population served.

Examples: Individuals may need help developing skills that can enable them to, for example: (1) communicate effectively; (2) make decisions; (3) resolve conflicts; (4) manage anger; (5) control impulses; and (6) engage in positive social interactions.


 

RTX 9.03

When individuals have experienced trauma, they are engaged in treatment services that are designed to help them:

  1. maximize their sense of safety;
  2. process the traumatic experience and understand the connection between past experiences and current functioning;
  3. identify, anticipate, and manage their responses to trauma reminders; and
  4. create and sustain positive attachments to caring individuals.


Note: See RTX 6.06 regarding the importance of also involving family members in supporting the individual’s recovery. See RTX 8 for more information regarding the range of trauma-informed practices that can help to support individuals’ sense of safety. 


 

RTX 9.04

Individuals have opportunities to participate in activities that support healing, self-regulation, and well-being, including:

  1. opportunities to be physically active through sports, fitness, or other types of movement; 
  2. mindfulness activities;
  3. creative arts activities;
  4. cultural enrichment activities;
  5. time outdoors;
  6. religious observances in a faith or spirituality of choice; and
  7. free time. 


Interpretation: While all individuals may not choose to engage in all types of activities, they should have the opportunity to do so. Activities can be offered within the treatment program itself and/or within the surrounding community. When activities occur in the community, implementation of this standard may overlap with RTX 12.02.


 

RTX 9.05

Individuals are helped to develop skills that support their ability to advocate for themselves and others and assume leadership roles.

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program. 


 

RTX 9.06

Individuals are helped to practice new skills and strategies in daily life at the program, including during:

  1.   informal interactions with peers and staff; 
  2.   structured activities in the residential milieu; and
  3.   activities and events in the surrounding community.

Interpretation: Element (c) may not be applicable for crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.


 

RTX 9.07

To promote sustained gains following the residential intervention, the organization provides support and opportunities that enable individuals to: 

  1. understand how to apply new skills and strategies in real-life home and community settings;
  2. practice new skills and strategies during time spent with family and/or other visitors at the program; and
  3. practice new skills and strategies during time spent in their home community.


Interpretation: Elements (b) and (c) may not be applicable for crisis stabilization units, short-term diagnostic centers, and withdrawal management programs due to length of stay and program design.


 

RTX 9.08

The organization supports positive functioning and social and community integration by helping individuals develop life skills related to: 

  1. activities of daily living; 
  2. promoting and managing health;
  3. maintaining personal safety;
  4. accessing educational opportunities;
  5. obtaining and maintaining employment;
  6. accessing community resources and public assistance;
  7. obtaining stable housing and managing their households;
  8. money management, including budgeting, saving, investing, buying on credit, and debt counseling; and
  9. participating in recreational activities, volunteer opportunities, and/or hobbies.


Interpretation: This standard is applicable for all individuals regardless of age. Organizations should tailor life skills training to meet the age and developmental level of persons served. 

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.


 
Fundamental Practice

RTX 9.09

The organization evaluates individuals for their ability to participate in athletic activities and obtains: 

  1. a written, signed permission slip from the individual’s legal guardian;
  2. a medical records release;
  3. a signed document from a qualified medical professional stating that the individual is physically capable of participating; and/or
  4. an adult waiver and release of liability.


Interpretation: This evaluation may occur in the context of the physical examination addressed in RTX 10.02.

NA The organization does not offer athletic activities.


 
Fundamental Practice

RTX 9.10

Organizations that purchase services from providers that operate adventure-based activities with a significant degree of risk request proof of accreditation, licensure, or certification with a nationally recognized authority for the activity being conducted, when available. 

NA The organization does not purchase services from providers that operate adventure-based activities.

Examples: Adventure-based activities with a significant degree of risk can include white water rafting, climbing walls, or ropes courses.

2023 Edition

Residential Treatment Services (RTX) 10: Healthcare Services

Individuals receive comprehensive healthcare services to promote optimal physical, emotional, and developmental health.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Initial health screening procedures
  • Procedures for the coordination and provision of healthcare and dental examinations and services
  • See sample activity schedules submitted in RTX 8
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records

 
Fundamental Practice

RTX 10.01

An initial health screening is conducted by a qualified medical practitioner for all individuals within 24 hours of admission to identify the need for immediate medical care and assess for communicable disease.

Interpretation: Qualified medical practitioner refers to a licensed physician, registered nurse, nurse practitioner, physician’s assistant, or other healthcare professional that is permitted by law and the organization to provide medical care and services without direction or supervision. For the purposes of this standard, qualified medical practitioners are distinct from other clinicians who are not permitted by law to provide medical care and services without direction or supervision (e.g., clinical social workers, licensed vocational/practical nurses, and medical assistants). To meet the standard, the initial medical screening must be administered by a qualified medical practitioner.


If the organization does not have a qualified medical practitioner on staff, it should research community resources and consider creating a formal arrangement or a memorandum of understanding (MOU) with a local physicians group, local health department, federally-qualified health center, urgent care clinic, community-based health clinic, or telehealth providers.


When possible, the screening should be performed by the individual’s primary care physician who has knowledge of the individual’s medical history or a physician that can serve as the individual’s medical home while in care. For children in care, the local child welfare agency may be responsible for ensuring the initial health screening is completed or may assist the organization to identify possible medical resources.


Interpretation: When an individual returns following a runaway episode, a health screen should be conducted within 24 hours of entry back into care to identify whether the individual was victimized or otherwise hurt or injured while on the run.


Interpretation: In situations where the individual is unable to receive an initial health screening by a qualified medical practitioner within 24 hours, the organization can receive a rating of 2 if it has procedures in place for accommodating exceptional circumstances and is able to provide evidence that the screening occurred within 72 hours of admission. Examples of exceptional circumstances include, but are not limited to: 

  1. weekend placements; and
  2. when a person is transferring from the care of a public agency that has arranged for an initial health screening to be conducted within 72 hours of admission to the program.



Examples: Conditions that require immediate or prompt medical attention include but are not limited to: (1) signs of abuse or neglect; (2) serious or accidental injury; (3) signs of infection or communicable diseases; (4) hygiene or nutritional problems; (5) pregnancy; and (6) significant developmental or mental health disturbances.


 
Fundamental Practice

RTX 10.02

Every individual receives: 

  1. a comprehensive medical examination within seven days after admission, unless the individual has received a medical exam within the last year, and annually thereafter; and
  2. a dental examination within six months prior to or one month after admission, with appropriate follow-up thereafter.


Interpretation: When records from the most recent medical and dental examinations are unavailable, or examinations are incomplete, the organization must ensure that examinations are completed within the required timeframes.


Interpretation: The purpose of the medical examination is to identify and assess medical, developmental, and mental health conditions that require treatment, additional evaluation, and/or referrals to other healthcare professionals or specialists. The examination must be comprehensive, build on history gathered during the initial medical screening, and focus on specific assessments that are appropriate to the individual’s age and developmental level. Findings from the exam should be used to develop individualized treatment plans, as well as inform follow-up assessments and services.


Interpretation: In situations where resources are not available for preventive dental care to occur every six months, the organization can receive a rating of 2 if there is an annual preventive exam and evidence that recommendations from the dental practitioner indicate the child is not in need of more frequent care. Children with dental issues or at high risk of dental problems must be receiving the care they need. Families should be engaged in the process and solution for getting their child the needed dental care.

NA The organization only operates a crisis stabilization unit or a short-term diagnostic center.


 
Fundamental Practice

RTX 10.03

The organization provides needed health services directly or by referral, and: 

  1. retains documentation of the individual’s and family’s known medical history, including immunizations, operations, medications, and medical conditions and illnesses; and
  2. provides the information to the individual and/or their legal guardian upon request.



 

RTX 10.04

To promote physical health and development of healthful habits, individuals are engaged in adequate exercise and provided with nutritious meals and snacks that address any unique dietary needs or restrictions.


 
Fundamental Practice

RTX 10.05

To promote their ability to maintain positive health practices, individuals receive appropriate support and education regarding: 

  1. proper nutrition and exercise;
  2. personal hygiene;
  3. substance use and smoking;
  4. sexual development;
  5. safe and healthy relationships;
  6. family planning and pregnancy options;
  7. pregnancy, prenatal care, and effective parenting; and
  8. prevention and treatment of diseases, including sexually transmitted infections/diseases and HIV/AIDS.


NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.


 

RTX 10.06

The organization provides or arranges specialized health services to meet the needs of the service population, as appropriate.

 

Examples: Specialized health services may be needed by older adults, pregnant and parenting individuals, individuals with eating disorders, individuals with substance-use related conditions, or children with autism and pervasive developmental disorders. These services may include, for example: 

  1. tobacco cessation programs;
  2. fetal alcohol syndrome screening;
  3. speech, language, and occupational therapy;
  4. prenatal care, well-baby care, and help accessing child and infant health insurance programs;
  5. gender identity counseling; and
  6. screening for the onset or existence of common cancers.
2023 Edition

Residential Treatment Services (RTX) 11: Education Services

The organization provides or arranges for individuals to receive services and supports to help them achieve their educational and/or vocational goals.

Interpretation: Organizations that do not offer educational services on-site should coordinate with community-based providers to meet the educational needs of all individuals and document advocacy for areas of unmet educational need. Education services will vary depending on the population served.

NA The organization only operates a crisis stabilization unit or withdrawal management program.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for developing and/or integrating education plans
  • Procedures for coordinating education services with community-based providers, if applicable
  • Employment policy
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records

 

RTX 11.01

A comprehensive, coordinated education plan is developed and integrated into the service plan for any individual who has educational goals, or vocational goals that include an educational component.

Interpretation: If the organization does not participate in the development of the education plan it is responsible for integrating everyone’s education plan into their service plan.


 

RTX 11.02

Individuals pursuing educational goals are enrolled in an appropriate education program on-site or in the community that is approved, certified, accredited, registered, or operated by or in conjunction with the local school district.


 

RTX 11.03

The educational program incorporates effective instructional practices, quality curriculum design, and educational tools and supports for diverse learning needs of children and youth.

NA The organization does not provide residential services to school-age children or youth.


NA The organization does not directly provide the educational program nor develop the education plans for children or youth.

Examples: Children and youth with diverse learning needs can include those who: (1) require support due to a learning disability; (2) are learning English as an additional language; or (3) are intellectually gifted.


 

RTX 11.04

The organization provides or arranges, as needed: 

  1. tutoring;
  2. preparation for a high school equivalency diploma;
  3. college preparation;
  4. parent/teacher meetings;
  5. vocational or continuing education opportunities; and/or
  6. advocacy and support.



 

RTX 11.05

When the organization offers employment or employment-related training to individuals, organization policy: 

  1. ensures individuals are matched with jobs and training opportunities that reflect their goals and interests;
  2. maximizes choice, and does not mandate participation; and
  3. prohibits exploitation of persons served.


NA The organization does not provide employment or employment-related training.

2023 Edition

Residential Treatment Services (RTX) 12: Community and Social Connections

The organization promotes well-being by helping individuals cultivate and sustain connections with both their home community and the community in which the program is located.

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for facilitating community and social connections
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records

 

RTX 12.01

Individuals have opportunities to spend time in their home communities during residential care, to the extent possible and appropriate.


 

RTX 12.02

Individuals have opportunities to participate in a variety of community activities that match their skills and interests, including social, cultural, religious, recreational, educational, vocational, and volunteer activities.


 

RTX 12.03

Individuals are:

  1. helped to develop social support networks and build healthy, meaningful relationships with caring individuals of their choosing; and
  2.   connected with peer support opportunities appropriate to their needs.

Interpretation: Peer support may be provided at the program or in the community.

Examples: “Caring individuals” can include both people known to the individual before the residential intervention, and people the individual meets through their involvement with the program. Caring individuals already known may include, for example, friends, classmates, co-workers, and other community members, as well as siblings, cousins, grandparents, extended family members, and former foster parents. Caring individuals met through the program may include, for example, mentors and other participants in the community activities addressed in RTX 12.02.


Examples: Peer support is offered by individuals who have shared, lived experience and can be provided through interactions with peer partners (as per RTX 2.06), peer-to-peer counseling, peer mentoring or coaching, self-help/mutual aid groups, or other consumer-run services.

2023 Edition

Residential Treatment Services (RTX) 13: Crisis Stabilization

The organization provides individuals in crisis with structured stabilization and treatment services to help them return to their previous level of functioning.

NA The organization does not operate a crisis stabilization unit.

Examples: Children and adults seeking crisis stabilization services may be experiencing an acute psychiatric crisis, a substance use related crisis, or severe emotional or mental distress.
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for delivering crisis stabilization services
  • Supervision and scheduling criteria
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records

 
Fundamental Practice

RTX 13.01

Organizations that offer crisis stabilization focus on crisis resolution and provide the following services on a 24/7 basis: 

  1. emergency reception;
  2. assessment and evaluation;
  3. observation and monitoring;
  4. crisis counseling;
  5. medication management;
  6. structured, therapeutic activities;
  7. support services and psychoeducation for family members; and
  8. referrals to specialists and other community-based services, as needed.


Interpretation: In regard to element (a), emergency reception means that individuals in crisis are accepted on a 24-hour basis without undue delays or barriers.

Examples: Structured, therapeutic activities may be recreational, social, and/or educational in nature in accordance with the individual’s service plan. Organizations can also address these services in RTX 9.


 

RTX 13.02

Individuals receive a crisis assessment within 24 hours of admission to determine the appropriate level of care.

Note: Organizations that operate a crisis stabilization unit will also complete the applicable assessment standards in RTX 4.



 

RTX 13.03

Individuals participate in the development of an initial service plan within 24 hours of admission and a comprehensive service plan within five days.

Interpretation: When care extends beyond thirty days the organization must review and update the individual’s service plan according to the change in the individual’s clinical condition.

Note: This standard is specific to service planning timeframes. Organizations that operate a crisis stabilization unit will also complete the applicable service planning standards in RTX 5.


 

RTX 13.04

The organization engages individuals and involved family members in crisis and/or safety planning that: 

  1. is appropriate to individual needs and centered around individual strengths;
  2. identifies individualized warning signs of a crisis; and
  3. specifies interventions that may or may not be implemented to help the individual de-escalate and promote stabilization.


Interpretation: A safety plan includes a prioritized written list of coping strategies and sources of support that individuals who have been deemed to be at high risk for suicide can use. Individuals can implement these strategies before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings to prevent a suicide attempt or death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required. Components of a safety plan can also include internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction.


Interpretation: The plan can be part of, and reviewed with, the individual’s overall service plan.


 

RTX 13.05

Organizations arrange educational services and supports, as appropriate, to ensure that individuals can pursue their educational goals once they achieve a crisis resolution.


 
Fundamental Practice

RTX 13.06

During the first 48 hours an individual is in care, a minimum of two staff members are on-duty 24 hours per day to ensure that adequate care and supervision are provided.

Note: For additional information on care ratios, please see RTX 18.01.

2023 Edition

Residential Treatment Services (RTX) 14: Services for Pregnant and Parenting Individuals

The organization utilizes a family-driven treatment model to empower pregnant and parenting individuals and support the well-being of their children and other family members.

Interpretation: “Parenting individuals” refers to individuals that bring their children with them to the program. Organizations will be responsible for determining whether a child should be admitted to the program.

NA The organization does not serve pregnant and/or parenting individuals.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for referring individuals to services
  • Table of contents of education curricula, if applicable
  • Procedures for evaluating educational needs and collaborating with schools
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served, and their children if appropriate
  • Review case records

 

RTX 14.01

The organization supports individuals’ efforts to care for and nurture their children, and provides or arranges for children to receive services that address, as appropriate: 

  1. health and medical needs;
  2. mental health needs;
  3. trauma history;
  4. educational needs;
  5. social and recreational needs;
  6. developmental needs, including any developmental delays;
  7. attachment to parents and extended family; and
  8. behavioral issues.


NA The organization does not allow individuals to bring their children to the program.

Examples: Examples of services for younger children can include: (1) play groups; (2) counseling; (3) therapeutic services; (4) therapeutic day care; (5) Head Start; and (6) other early childhood programs. Examples of services for older youth can include: (1) peer support groups; (2) afterschool programs and tutoring; (3) recreational activities; (4) employment assistance; and (5) substance use education or treatment services, such as tobacco cessation.


 

RTX 14.02

Organizations evaluate the educational status and needs of school-age children and youth and: 

  1. inform individuals of their children’s educational rights;
  2. help individuals coordinate educational services with relevant school districts; and
  3. assist children and youth to stay current with the curricula.


NA The organization does not allow individuals to bring their children to the program.


 

RTX 14.03

The organization provides or arranges childcare while the individual is receiving treatment services.

NA The organization does not allow individuals to bring their children to the program.


 
Fundamental Practice

RTX 14.04

Pregnant individuals are provided or linked with specialized services that include, as appropriate: 

  1. pregnancy counseling;
  2. prenatal health care;
  3. genetic risk identification and counseling services;
  4. fetal alcohol syndrome screening;
  5. labor and delivery services;
  6. postpartum care;
  7. mental health care, including information, screening, and treatment for prenatal and postpartum depression;
  8. pediatric health care, including well-baby visits and immunizations;
  9. peer counseling services; and
  10. children’s health insurance programs.


NA The organization does not serve pregnant individuals.


 

RTX 14.05

Pregnant individuals are educated about the following prenatal health topics: 

  1. fetal growth and development;
  2. the importance of prenatal care;
  3. nutrition and proper weight gain;
  4. appropriate exercise;
  5. medication use during pregnancy;
  6. effects of tobacco and substance use on fetal development;
  7. what to expect during labor and delivery; and
  8. benefits of breastfeeding.


Interpretation: These topics may be addressed by qualified medical personnel in the context of prenatal health care.

NA The organization does not serve pregnant individuals.


 

RTX 14.06

The organization provides or refers pregnant and parenting individuals to parent education classes or workshops that address: 

  1. basic caregiving routines;
  2. child growth and development;
  3. meeting children’s social, emotional, and physical health needs;
  4. environmental safety and injury prevention;
  5. parent-child interactions and bonding;
  6. age-appropriate behavioral expectations and appropriate discipline, including alternatives to corporal punishment;
  7. family planning; and
  8. establishing a support network of family members or caring adults.


NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Examples: Organizations can tailor how topics are addressed based on the needs of persons served. For example, when serving expectant parents or parents of young children, education on environmental safety and injury prevention will typically address topics such as safe practices for sleeping and bathing.

2023 Edition

Residential Treatment Services (RTX) 15: Substance Use Services

The organization provides coordinated substance use prevention, treatment, and recovery services based on the person's assessed needs and goals.

Interpretation: Withdrawal management programs should include daily clinical services such as appropriate medical care, therapy, and withdrawal support. A range of therapies (e.g., cognitive, behavioral, medical, and mental health therapies) should be provided to persons served on an individual or group basis. Services should aim to enhance the service recipient's understanding of addiction, completion of withdrawal management, and referral to an appropriate level of care for substance use treatment. The delivery of services will vary and depends on the assessed needs of individuals and their treatment progress.

NA The organization does not provide substance use services.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.




3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Procedures for communication/collaboration among team members
  • Criteria for determining the level of care
  • Procedures for providing withdrawal managementservices
No Site Visit Evidence
  • Interviews may include:
  1. Clinical/Medical director
  2. Relevant personnel
  3. Persons served
  • Review case records
  • Observe facility

 
Fundamental Practice

RTX 15.01

A qualified team of health professionals, with experience, training, and competence in engaging, diagnosing, and treating persons with substance use disorders provide services, including: 

  1. administering or reviewing diagnostic, toxicological, and other health related examinations;
  2. determining the optimal level and intensity of care, including clinical and community support services;
  3. evaluation for psychotropic medications and medication-assisted treatment;
  4. prescribing and managing medication, including appropriate management of pharmacotherapy for individuals with co-occurring conditions;
  5. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect; and
  6. coordinating care with other service providers, including primary care and mental health providers, when appropriate and with the consent of the person served.



 

RTX 15.02

The organization directly provides a comprehensive range of prevention and treatment services, including: 

  1. individual and group therapy;
  2. illness management and psychoeducation interventions;
  3. medication education;
  4. clinical monitoring and drug screening;
  5. coping skills training;
  6. relapse prevention; and
  7. acute care.


Examples: Other prevention and treatment services may include: (1) withdrawal management; (2) inpatient care; (3) intensive outpatient care; (4) medical care; (5) psychiatric rehabilitation; and (6) targeted case management services.


 

RTX 15.03

Therapeutic services help individuals develop the knowledge, skills, and supports necessary to: 

  1. manage mental health and/or substance use disorders;
  2. develop and practice prosocial behaviors;
  3. cultivate and sustain positive, meaningful relationships with peers, family members, and the community;
  4. develop self-efficacy; and
  5. promote recovery, resilience, and whole-person wellness.


Interpretation: Recovery is a holistic, self-directed process of change where individuals learn to overcome or manage their diagnosed symptoms and conditions to improve overall well-being and achieve optimal health.


 

RTX 15.04

Qualified personnel determine the need for and appropriate level of withdrawal management for the person using diagnostic criteria set by clinical decision support tools and clinical practice guidelines.

NA The organization does not provide withdrawal management.

Examples: Organizations can utilize clinical practical guidelines such as the American Society of Addiction Medicine (ASAM) criteria to determine the appropriate level of care.


Examples: Residential Withdrawal Management programs that can be reviewed by COA Accreditation include programs that are: 

  1. Clinically-Managed: Clinically-managed residential programs, also referred to as non-medical or social detox, emphasize peer and social support. Services are primarily provided by appropriately trained, non-medical personnel; or
  2. Medically-Monitored: In medically-monitored residential/inpatient programs, 24-hour medically-supervised withdrawal management services are provided by an interdisciplinary staff under the direction of a licensed physician.

COA Accreditation does not accredit medically-managed intensive inpatient withdrawal management programs. Medically-managed programs involve 24-hour medically-directed evaluation and withdrawal management and require an appropriately trained and licensed physician to provide and manage all diagnostic and treatment services. Medically-managed programs are provided in acute inpatient care settings, such as hospitals, and are specifically designed for individuals with symptoms that require medical and nursing care services.


 
Fundamental Practice

RTX 15.05

Individuals receive withdrawal management services provided by a qualified team of appropriately trained and licensed professionals, including: 

  1. assessment and evaluation;
  2. monitoring and stabilization; and
  3. engagement with substance use treatment to assist with relapse prevention following the discontinuation of substance use.


NA The organization does not provide withdrawal management.

Examples: Staffing may vary depending on the intensity of the services offered. For example, organizations providing medically-monitored withdrawal management will typically employ an interdisciplinary staff of nurses, counselors, social workers, addiction specialists and/or other health and technical personnel, whom all work under the supervision of a licensed physician.


 
Fundamental Practice

RTX 15.06

Prior to discharge from withdrawal management services, all individuals receive: 

  1. education about relapse, overdose, and mortality risk and prevention; 
  2. information on relevant harm reduction activities; and
  3. connection to peer support services appropriate to their request or need for service.


NA The organization does not provide withdrawal management. 

Examples: Peer support services can help to promote resiliency and recovery and are provided by individuals who have shared, lived experience. They can include self-help/mutual aid recovery groups, peer-to-peer counseling, peer mentoring or coaching, or other consumer-run services.


 
Fundamental Practice

RTX 15.07

Organizations providing withdrawal management to individuals withdrawing from opioids: 

  1. counsel individuals on the importance of medication-assisted treatment (MAT) and the risks of relapse, overdose, and death following detoxification without transitioning to maintenance medication;
  2. offer MAT following withdrawal management either directly or through linkages with MAT providers;
  3. clearly document when individuals refuse MAT; and
  4. provide a naloxone kit or prescription for any individual who refuses MAT. 


Interpretation: Organizations that do not offer medication-assisted treatment should have MOUs with MAT providers to ensure timely initiation of treatment. Studies have shown the risk of relapse increases dramatically following withdrawal without ongoing treatment, with 25% of readmissions occurring within the first 7 days post discharge.

NA The organization does not provide withdrawal management. 


 
Fundamental Practice

RTX 15.08

The organization maintains a supply of opioid overdose reversal medication on-site.

2023 Edition

Residential Treatment Services (RTX) 16: Residential Facilities

Residential facilities contribute to a physically and psychologically safe, healthy, homelike, non-institutional, therapeutic, and trauma-informed environment.


Note: Please see the Facility Observation Checklist for additional guidance on this standard.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
No Self-Study Evidence
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Observe facilities and outdoor area/grounds

 

RTX 16.01

Living quarters consist of separate cottages or units in a residential building that include: 

  1. a common room, dining and/or kitchen area, and space for indoor recreation;
  2. private areas where persons served can meet with family and friends; and
  3. private facilities for bathing, toileting, and personal hygiene that are developmentally appropriate.



 

RTX 16.02

Personal accommodations are age and developmentally appropriate and include: 

  1. single rooms, rooms for groups of two to four individuals, and/or accommodations for larger groups, if appropriate for therapeutic reasons;
  2. adequately and attractively furnished rooms with a separate bed for each individual, including a clean, comfortable, covered mattress, pillow, sufficient linens, and blankets;
  3. a non-stacking crib for each infant and toddler that is 24 months or younger that meets safety guidelines, as applicable; and
  4. a safe place such as a locker to keep personal belongings and valuables.


Examples: National advocacy standards suggest that single rooms have at least 100 square feet of floor space and rooms housing more than one person have at least 80 square feet per person. Room accommodations may be adjusted as appropriate to the service provided, therapeutic considerations, level of risk, or developmental appropriateness. 


Examples: The Consumer Product Safety Commission (CPSC) provides standards to ensure safety for cribs. 


 

RTX 16.03

The organization promotes living unit compatibility by considering individuals’ unique characteristics, needs, and preferences when grouping people together. 

Interpretation: Characteristics and needs that should be considered include age, developmental level, necessary accommodations, ability to adjust to a group, gender, gender identity, and gender expression. Transgender and gender non-conforming individuals should be given access to sleeping quarters and bathroom facilities based on their preferences and in accordance with applicable federal and state laws.

Examples: Examples of ways that organizations can promote living unit compatibility and demonstrate consideration for diverse needs include but are not limited to: (1) respecting the individual’s name and pronouns; (2) providing gender neutral restrooms where facility structure allows; (3) having individuals use restrooms one at a time; (4) allowing for single bedroom models; and (5) providing LGBTQ+ specific units. 


 

RTX 16.04

Organizations that serve families house families as a unit and keep sibling or family groups together, whenever possible.

NA The program does not serve families, or housing families as a unit is not possible or prohibited by law.

Examples: Allowing families to follow their schedules, routines, and rituals to the greatest extent possible can support family functioning, encourage stability, and minimize stress.


 

RTX 16.05

Facilities meet individuals’ needs by providing the space, supplies, and equipment needed to accommodate: 

  1. individual, small, and large group activities;
  2. provision of on-site services, including therapeutic, educational, and medical services as needed;
  3. social activities, including accommodations for informal gathering;
  4. visits and activities with families and friends;
  5. a variety of recreational and enrichment activities that support well-being;
  6. opportunities to be physically active through sports, fitness, and other types of movement; 
  7. quiet activities, including space specifically designed to encourage comfort, self-soothing, self-reflection, and emotional self-management; and
  8. access to the outdoors.


Interpretation: Some standards elements may not be applicable for crisis stabilization and short-term diagnostic programs due to length of stay and program design.


Interpretation: Playground equipment should meet national safety standards and be appropriate for the number, age, and developmental level of persons served. 



 

RTX 16.06

Residential facilities provide: 

  1. adequate space, supplies, and equipment for food preparation, housekeeping, laundry, maintenance, storage, and administrative support; 
  2. access to a telephone, computer, and the internet, as permitted, for use by personnel and persons served;
  3. at least one room suitably furnished for the use of on-duty personnel; and
  4. private sleeping accommodations for personnel who sleep at the facility, if applicable.



 

RTX 16.07

The organization creates a calming and healing physical environment by:

  1. ensuring the program setting is clean, organized, and maintained in good condition;
  2. using furniture, artwork, lighting, and acoustics to make living areas inviting, comfortable, calming, and reflective of the interests and diversity of persons served; and 
  3. designing the program space to minimize disruption in living quarters, to the extent possible. 


Examples: Organizations can minimize disruption in living quarters by, for example: (1) decreasing the use of overhead paging systems; (2) establishing routes that minimize unnecessary traffic through living areas; and (3) situating access panels for electrical and plumbing systems away from bedrooms.

Note: Persons served can contribute to decisions about how to make living areas inviting, comfortable, and reflective of their interests and diversity, as noted in RTX 8.04

2023 Edition

Residential Treatment Services (RTX) 17: Privacy Provisions

The organization provides for the comfort, dignity, privacy, and safety of persons served.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Privacy policy
  • Privacy procedures
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records
  • Observe facility

 
Fundamental Practice

RTX 17.01

The organization ensures the comfort, dignity, privacy, and safety of persons served by: 

  1. prohibiting the use of surveillance cameras or listening devices in bedrooms;
  2. maintaining doors on sleeping areas and bathroom enclosures;
  3. providing one- or two-person rooms to individuals who need extra sleep, protection from sleep disturbance, or extra privacy for clinical reasons; and
  4. requiring employees and persons served to knock before entering an individual’s room unless there is an immediate health or safety concern.


Interpretation: When organizations are required to employ alternate practices, documentation must be provided to justify the practice. Documentation may include a judicial order; law; contract; copy of the state's safety plan for an individual; or clear, clinical, written justification for an individual.


Sensitivity should always be taken to ensure that all individuals, especially abuse or trauma survivors and the LGBTQ+ population, feel safe and not violated.

Note: Please see the Facility Observation Checklist for additional guidance on this standard.


 
Fundamental Practice

RTX 17.02

Searches of individuals or their property are conducted according to procedures that: 

  1. are communicated to individuals and families;
  2. define when there is reasonable cause to conduct a search;
  3. minimize the invasiveness of the search;
  4. respect the person’s rights, dignity, and self-determination;
  5. clarify that only trained and qualified personnel are permitted to conduct searches; and
  6. establish a process and timetable for administrative review, including documentation and notification requirements.


Interpretation: Organizations should conduct more invasive searches only when there is reason to do so and should demonstrate that these searches are: (1) conducted by highly qualified personnel, and (2) accompanied by an increased level of administrative review. 


 
Fundamental Practice

RTX 17.03

The organization provides individuals and families with a written policy for reviewing mail and electronic communications that respects their privacy and only allows the organization to review mail or electronic communications when a previous incident involving the individual indicates that: 

  1. the mail/electronic communication is suspected of containing unauthorized, dangerous, or illegal material or substances, in which case it may be opened by the individual in the presence of designated personnel; or
  2. receipt or sending of unopened mail/electronic communications is contraindicated.


Interpretation: Programs serving individuals with substance use disorders may require personnel to review mail without incident due to the reason for which individuals are seeking treatment. If an organization employs this approach, they must provide justification for taking such measures, which may include health, safety, and other security concerns.

Examples: Examples of mail and electronic communications include letters, packages, emails, text messages, and other forms of correspondence via social media and other electronic platforms.


 
Fundamental Practice

RTX 17.04

Individuals can have private telephone conversations, and any restriction is: 

  1. based on contraindications and/or a court order;
  2. approved in advance by the program director or an appropriate designee;
  3. documented in the case record; and
  4. reauthorized weekly by the immediate supervisor of the direct service provider.


2023 Edition

Residential Treatment Services (RTX) 18: Care and Supervision

The organization provides 24-hour-a-day care and supervision and maintains a safe environment where persons served and personnel are protected from harm.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.
3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Care and supervision ratios
  • Supervision and scheduling criteria
  • Procedures for preventing and responding to missing and runaway children
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served
  • Review case records
  • Observe the program

 
Fundamental Practice

RTX 18.01

The organization ensures appropriate care and supervision by providing: 

  1. ratios of direct care workers to persons served for daytime and overnight hours that are appropriate to the program model, length of treatment, and risks and needs of persons served;
  2. enough additional personnel on-site that are qualified to meet special needs during busy/stressful periods, respond to emergency/crisis situations, and carry out the organization’s emergency response plan; 
  3. an on-call, professional clinical staff member available on a 24-hour basis;
  4. rotating after-hours and holiday coverage when needed; and
  5. same-gender and cross-gender supervision when indicated by individual treatment needs.


Interpretation: The organization must demonstrate that based on their program model and the population served, their staffing ratios for daytime and overnight coverage are sufficient to maintain safety, address potential risks, and meet the clinical, developmental, and age-related needs of persons served. 


Interpretation: The direct care workers supervising individuals must always be awake unless convincing evidence demonstrates the group does not need awake supervision during sleeping hours. Examples of reasons certain homes or programs might not have awake personnel are: care for a long-term, stable population; majority of individuals on the unit are ready to move to a less restrictive setting; low runaway rates; and low rates of night-time incidents. Electronic supervision is not an acceptable alternative to supervision by awake personnel.

Examples: National recommendations for the supervision of children is that there are no more than four children per worker during waking hours and no more than eight children per worker during overnight hours. Smaller ratios are recommended for intensive treatment programs and short-term diagnostic centers. Additionally, several sources indicate that improved outcomes, including better engagement and retention, are found in substance use treatment programs with low staffing ratios. For example, low ratios contribute to high quality service and keeping people involved in rehabilitation for longer periods, which helps individuals reach their recovery goals.


 
Fundamental Practice

RTX 18.02

Services are provided in a safe, secure environment that prohibits weapons and gang activity.


 

RTX 18.03

The organization establishes procedures for preventing and responding to missing and runaway children that address: 

  1. creating an environment that provides a sense of safety, support, and community;
  2. identifying risks or triggers that may indicate likeliness to run away from programs;
  3. communication and reporting to relevant staff, authorities, and parents or legal guardians; and
  4. welcoming, screening, and debriefing when children return to the program.


NA The organization does not serve children or families with children.

2023 Edition

Residential Treatment Services (RTX) 19: Planning for Transition

The organization works with individuals and families to plan for transition and prepare for life after the residential intervention.

Interpretation: Level of family involvement in transition planning may vary based on the population served and the expressed wishes of individuals. See RTX 6 for more information on expectations for family involvement.


Interpretation: If another organization or agency is responsible for providing aftercare, they may play a role in implementing the practices addressed in this section. However, the organization is still expected to partner with them to facilitate effective transition planning and ensure that the standards are implemented.

NA The organization only operates a crisis stabilization unit, short-term diagnostic center, or withdrawal management program.

Currently viewing: PLANNING FOR TRANSITION

VIEW THE STANDARDS

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Transition planning is not initiated early enough to ensure orderly transitions; or
  • Timeframes are often missed; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Transition planning procedures
  • Procedures for assessing independent living skills
  • Independent living skills assessment tool
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 19.01

Planning for transition: 

  1. is a clearly defined process that involves relevant personnel and includes assignment of staff responsibility; and
  2. begins at intake.


Interpretation: Implementation of this standard may overlap with RTX 20.01


 

RTX 19.02

The organization works with persons served and their families, and other supportive people when appropriate, to develop a plan for transition and aftercare. 

Examples: When developing transition/aftercare plans, involving the same team of supportive individuals that participated in service planning (see RTX 5.02) can help to support a successful transition from the program. 


 

RTX 19.03

Individualized transition/aftercare plans are linked to service plans and address strengths and needs in areas that include, as appropriate:

  1. living arrangements;
  2. family relationships;
  3. informal social supports, including peer networks;
  4. formal social supports, including mentoring or support available through community volunteers, peer advocates, and peer support programs;
  5. ongoing physical and behavioral healthcare, including needed medical, dental, mental health, and substance use treatment;
  6. health insurance; 
  7. educational and vocational services;
  8. employment; 
  9. finances/income, including public assistance or other income supports when available;
  10. cultural, community, and recreational opportunities, activities, and supports;
  11. childcare;
  12. services to which the individual may have access due to a disability; 
  13. transitioning to and navigating adult systems of care when individuals are youth transitioning to adulthood; and
  14. resources to be accessed in case of crisis.


Interpretation: When individuals are transitioning to an independent living situation it will be especially important to ensure they have a safe, stable living arrangement, and basic necessities in place. The organization should help these individuals explore the range of housing options available to them and evaluate the risks and benefits of different alternatives. It will also be critical to ensure that this population leaves care with a source of income, affordable health care, access to education and career development opportunities, and strong, consistent relationships with committed, caring individuals. 

Examples: Appropriate living arrangements will vary based on an individual’s age, developmental level, and needs, and can include living at home with family, foster care, specialized group homes, supportive housing, or fully independent living environments.


 

RTX 19.04

The organization works with resources, services, and supports specified in the transition/aftercare plan to:

  1. ensure that individuals are admitted to appropriate programs before discharge from the program, when possible; and
  2. prepare service providers for the individual’s arrival. 


Examples: Initiating efforts to develop community partnerships early on, as addressed in RTX 4.04 and RTX 5.06, can help the organization promote continuity of care. Supporting family and community engagement throughout treatment, as addressed in RTX 6 and RTX 12, can also help foster the positive connections needed to support an individual after discharge.


 

RTX 19.05

The organization works with individuals and families to assess the independent living skills of individuals 14 years and older, at regular intervals, using a standardized assessment instrument that includes the following areas: 

  1. educational and vocational development;
  2. interpersonal skills;
  3. financial management;
  4. household management; and
  5. self-care.


Interpretation: The first assessment should be completed as soon as possible after a person’s 14th birthday to establish a benchmark for measuring progress in identified areas. Systematic assessment normally reoccurs at six- or twelve-month intervals.

NA The organization does not serve individuals 14 years or older.


 

RTX 19.06

The organization provides individuals transitioning to independent living situations with advance notice of the cessation of any health, financial, or other benefits that may occur at discharge.

NA Individuals are not transitioning to independent living situations.


 

RTX 19.07

The organization assists individuals transitioning to independent living situations in obtaining or compiling documents necessary to function independently, including, as appropriate: 

  1. an identification card or a driver’s license when the ability to drive is a goal;
  2. a social security or social insurance number;
  3. a resume, describing work experience and career development;
  4. medical records and documentation, including a Medicaid card or other health eligibility documentation;
  5. an original copy of the birth certificate;
  6. bank account access documents;
  7. religious documents and information;
  8. documentation of immigration or refugee history and status, when applicable;
  9. death certificates if parents are deceased;
  10. a life book or a compilation of personal history and photographs, as appropriate;
  11. a list of known relatives, with relationships, addresses, telephone numbers, and permissions for contacting involved parties;
  12. previous placement information and health facilities used, when appropriate; and
  13. educational records, such as high school diploma or general equivalency diploma, and a list of schools attended, when appropriate.


NA Individuals are not transitioning to independent living situations.


2023 Edition

Residential Treatment Services (RTX) 20: Case Closing and Aftercare

Case closing is an orderly process and, when possible, aftercare is provided to help maintain the gains made during the residential intervention.

Interpretation: Level of family involvement in case closing and aftercare may vary based on the population served, program model/design, and the expressed wishes of individuals. See RTX 6 for more information on expectations for family involvement.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2

Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  

  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, the organization terminated services inappropriately; or  
  • Active participation of persons served occurs to a considerable extent.


3

Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,

  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Services are frequently terminated inappropriately; or  
  • Planning for case closing is not initiated early enough to ensure orderly transitions; or
  • Several case records are missing important information; or
  • Participation of persons served is inconsistent. 


4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing. 
Self-Study Evidence Site Visit Evidence On-Site Activities
  • Case closing procedures
  • Aftercare and follow-up procedures
No Site Visit Evidence
  • Interviews may include:
  1. Program director
  2. Relevant personnel
  3. Persons served and their families
  • Review case records

 

RTX 20.01

Planning for case closing:

  1. is clearly defined and includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, the person served, a parent or legal guardian, and others, as appropriate to the needs and wishes of the individual.

 

RTX 20.02

Upon case closing, the organization notifies any collaborating service providers, as appropriate.

 

RTX 20.03

If an individual or family must leave the program unexpectedly, the organization makes every effort to identify other service options and link them with appropriate services.

Interpretation: The organization must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.


 

RTX 20.04

The organization provides individuals and families with: 

  1. a transition/aftercare plan summary; and
  2. a list of emergency contacts.



 

RTX 20.05

To promote service continuity and success, the organization follows up on the transition/aftercare plan, as appropriate, when possible, and with the permission of persons served. 

Interpretation: When another entity provides aftercare, the organization may implement this standard by: (1) documenting that is the case; and (2) demonstrating that it has collaborated with that entity to promote service continuity and success.

NA A public authority is responsible for providing aftercare, as specified in a contract. 

Examples: Different organizations may use different strategies to promote service continuity and success. Some organizations may initially provide in-home clinical support, but gradually transition the individual and family to other community-based services and supports. Other organizations may act as a service broker, connecting individuals and families to all needed services and supports and intervening on an ongoing basis to ensure service access and monitor progress and well-being. Some organizations may have a more limited role in the provision of aftercare and will simply link persons served to another entity that is responsible for providing aftercare and follow-up. 


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