Legal Guardianship Forms in Pa by tyg11802

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									                        Administration and Management (PA-AM)
                                  Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If you are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
                                    Community Demographic Profile.
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-AM 1Mission/vision statement
                                    PA-AM 1Long-term or strategic plan
                                    PA-AM 2Table of organization
                                           Summary overview/listing of community education and
                             PA-AM 4       outreach activities
                             PA-AM 5       Enabling legislation for oversight entities/entity charge
                             PA-AM 5       Entity member bios
                             PA-AM 6       Functional table of organization
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                    Ethical Practice (PA-ETH)
                                       Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this checklist.
If your are completing a hard copy self-study, add a page number column, complete the checklist, print it out,
and place it in the front of each assigned section of standards. If you're completing an electronic self-study,
complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete.
Narrative Attachments
   Yes        No           NA      Evidence
                                   All COA-approved NA requests.
                                   A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA- ETH 1Mission Statement
                                   PA-ETH 1 Annual Report or other publicly available documents
                                            Review of Network website, as applicable (for Networks
                             PA- ETH 1      only)
                             PA- ETH 1      Review of Network written materials. (for Networks only)
                             PA- ETH 2      Conflict of interest policy
                             PA- ETH 2      Nepotism policy
                             PA- ETH 2      Network Management Manual (for Networks only)
                                            Utilization data to review referral and utilization patterns (for
                             PA- ETH 2      Networks only)
                             PA- ETH 3      Policies and procedures for all fundraising practices
                             PA- ETH 4      EEOC policy
                                            Whistle-blower provisions in legislation or administrative
                             PA- ETH 4      code
                             PA- ETH 5      Statement and practices of ethical conduct
                             PA- ETH 5      Network Management Manual (for Networks only)
                                            Utilization data to review referral and utilization patterns (for
                             PA- ETH 5      Networks only)
                             PA- ETH 6      Human subject research policy and procedures
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                 Financial Management (PA-FIN)
                                       Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Internal financial control procedures
                                    PA-FIN 1
                                           Table of organization (financial management personnel
                             PA-FIN 1      only)
                             PA-FIN 3      Budget planning procedures/process
                                           List of programs that draw down federal money and internal
                             PA-FIN 4      audit procedures for ensuring compliance
                                           Procedures for verifying accuracy of services billed (for
                             PA-FIN 4      Networks only)
                                           Procedures for informing providers of a possible delay in
                             PA-FIN 4      payment (for Networks only)
                                           Procedures regarding provider appeal of payment denials
                             PA-FIN 4      (for Networks only)
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                         Human Resources Management (PA-HR)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of administrative personnel.
                                    An agency chart that includes all the agency’s departments or divisions
                                    and programs.
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-HR 1 Copies of legal counsel, administrative agency, or court opinions
                                    PA-HR 1 Discrimination prohibition policy
                                    PA-HR 1 Harassment policy
                                    PA-HR 3 Recruitment and selection procedures
                                            Enabling legislation/regulations pertaining to background
                             PA-HR 3        checks
                             PA-HR 3        Policy and procedures regarding background checks
                                            Credentialing and verification procedures (for Networks
                             PA-HR 3        only)
                             PA-HR 4        Personnel grievance policies and procedures
                             PA-HR 4        Aggregate personnel satisfaction and retention information
                             PA-HR 5        Relevant policies and procedures
                             PA-HR 5        Applicable regulations
                             PA-HR 5        Table of Contents for Personnel Manual
                                            Annual Network-wide Analysis report (HR 5.04) (for
                             PA-HR 5        Networks only)
                                            Performance review forms/templates or description of
                             PA-HR 6        ongoing review process
                             PA-HR 7        Sample of five job descriptions
Other Documents Not Listed on the Table of Evidence
1
2
3
Explanation for any "No" or "NA" checked above
                              Network Administration (PA-NET)
                                    Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing
an electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece
of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes        No         NA      Evidence
                                 The Narrative is complete.
Narrative Attachments
   Yes        No         NA      Evidence
                                 Updated list of contractors with contact information, services provided to the
                                 network, accredited or not, and if so by whom.
                                 Network agency chart.
                                 Completed Network Standards Matrix.
                                 All COA-approved NA requests.
                                 A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA        Evidence
                                 PA-NET 1     Mission Statement
                                 PA-NET 1     Articles of Incorporation/Bylaws
                                              List of Governing Body and Advisory Body members and
                                 PA-NET 1     affiliations
                                              A narrative describing agency structure, the scope of services,
                                 PA-NET 1     network partners/owners
                                              Narrative overview of how the network management entity
                                 PA-NET 2     ensures clear communication throughout the network
                                 PA-NET 2     Narrative overview of service delivery system
                                              List of network provider agencies and individual providers
                                 PA-NET 2     including the network services they provide
                                 PA-NET 2     Grievance/complaint procedures for network service providers
                                 PA-NET 3     Long-term and annual plans
                                 PA-NET 3     Planning procedures
                                              Network-level workforce analysis and documentation of actions
                                 PA-NET 3     taken
                                 PA-NET 4     Service coordination procedures
                                 PA-NET 4     Admissions procedures/criteria
                                 PA-NET 4     Eligibility criteria
                                 PA-NET 4     Level of care procedures
                              PA-NET 5   Access procedures and guidelines
                              PA-NET 5   Triage and critical care criteria
                              PA-NET 6   Screening procedures
                              PA-NET 7   A description of the scope of utilization management activities
                              PA-NET 7   Utilization management procedures
                              PA-NET 10 Network application procedures
                             PA-NET 10 Network application(s)
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
n (PA-NET)
klist
 electronic and hard copy self-study, and a
 our agency is required to complete this
a page number column, complete the
d section of standards. If you're completing
hyperlink to the cell with the relevant piece


f explanation in the area provided. For
  "Agreement with my COA Coordinator that
NA," the explanation may be: "NA request




contact information, services provided to the
if so by whom.

Matrix.
.
ur agency provided within the standards.



 ation/Bylaws
Body and Advisory Body members and

ing agency structure, the scope of services,
wners
 of how the network management entity
munication throughout the network
 of service delivery system
vider agencies and individual providers
ork services they provide
 nt procedures for network service providers
nual plans
es
kforce analysis and documentation of actions

on procedures
dures/criteria


edures
s and guidelines
care criteria
ures
e scope of utilization management activities
ment procedures
n procedures
n(s)
                     Performance and Quality Improvement (PA-PQI)
                                  Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this checklist. If
your are completing a hard copy self-study, add a page number column, complete the checklist, print it out, and
place it in the front of each assigned section of standards. If you're completing an electronic self-study, complete
the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example if
your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will be
reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete.
Narrative Attachments
   Yes        No           NA      Evidence
                                   Completed List of Survey Recipients Form.
                                   Completed Survey Distribution Totals Form.
                                   All COA-approved NA requests.

                                   A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA          Evidence

                                   PA-PQI 1     Long-term or strategic plan (See PA-AM 7.01)

                                   PA-PQI 2     PQI Plan

                                   PA-PQI 2     Short-term/annual plan(s)
                                                Job description of primary personnel assigned to PQI coordinating
                                   PA-PQI 2     responsibilities (PA-PQI 2.05)
                                                A document or chart that describes PQI structure including
                                   PA-PQI 2     committees, work groups, and member lists, as appropriate
                                                Description of what is being measured; including outcomes,
                                   PA-PQI 3     outputs, indicators, and tools and instruments.
                                   PA-PQI 3     Network performance measures (for Networks only)

                                   PA-PQI 4     Sample reports of aggregated data
                                   PA-PQI 4     Stakeholder satisfaction survey instruments
                                                Pre-Commisson Review Report (PCR) (For organizations seeking
                                   PA-PQI 4     re-accreditation only)
                                                Final Accreditation Report (FAR) (For organizations seeking re-
                                   PA-PQI 4     accreditation only)
                                                Maintenance of Accreditation (MOA) Reports for the three most
                                   PA-PQI 4     recent years (For organizations seeking re-accreditation only)
                                                Annual performance score card, reports of gains made against
                                                goals, or other summary documents or reports provided to internal
                                   PA-PQI 5     and external stakeholders
                              PA-PQI 6   PQI information provided to stakeholders

                             PA-PQI 6 New personnel PQI orientation materials (PA-PQI 6.02)
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                      Risk Prevention and Management (PA-RPM)
                                  Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                                   A letter signed by the agency head certifying the agency is
                                                   presently in compliance with license requirements,
                                    PA-RPM 1       regulations and decrees
                                                   Narrative describing the risk prevention and management
                                    PA-RPM 1       system
                                                   Procedures for ensuring provider compliance applicable
                                                   licenses, regulations, and decrees for services provided by
                                    PA-RPM 1       the network (for Networks only)
                                                   List of risks the agency manages and monitors annually and
                                    PA-RPM 2       quarterly
                                                   Procedures for quarterly review of incidents, accidents, and
                                    PA-RPM 2       grievances.
                                                   Procedures for conducting annual assessments of potential
                                    PA-RPM 2       organizational risks
                                                   Table of contents for personnel training in medication
                                    PA-RPM 3       management
                                    PA-RPM 3       Medication management procedures/protocols
                                    PA-RPM 4       List of insurance policies
                                                   Procedures for identifying and verifying provider insurance
                                    PA-RPM 4       (for Networks only
                                                   Copy of written communication to providers regarding
                                    PA-RPM 4       required insurance (for Networks only)
                                                   Record content and maintenance procedures (for Networks
                                    PA-RPM 7       only)
                                    PA-RPM 8       Case record access policies and procedures
                                    PA-RPM 9       Contracting procedures
                                            List of contracts/service agreements/memoranda of
                               PA-RPM 9     understanding
                                            List of contracts/service agreements/memoranda of
                                            understanding (MOU) between the network and providers
                             PA-RPM 9       (for Networks only)
                             PA-RPM 10 Contract monitoring procedures
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                 Administrative and Service Environment (PA-ASE)
                                Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of licenses applicable to your programs and services including the
                                    oversight bodies that issue and monitor them.
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Smoking policies and/or procedures
                                    PA-ASE 1
                                           Facility maintenance procedures
                                    PA-ASE 4
                                           Maintenance procedures for tools and equipment
                                    PA-ASE 5
                                           Safety procedures
                                    PA-ASE 6
                                           Procedures for serving perpetrators
                                    PA-ASE 6
                                           Emergency Response Plan
                                    PA-ASE 7
                                           Emergency preparedness procedures
                                    PA-ASE 7
                                           Emergency Response Plan re: coordinating among service
                                           provider agencies and individual providers (for Networks
                             PA-ASE 7      only)
                                           A description of the activities conducted or system in place
                                           used to ensure compliance with applicable legal and
                                           regulatory requirements associated with risk of exposure to
                             PA-ASE 8      contagious and infectious disease
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Behavior Support and Management (PA-BSM)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                           A narrative describing the agency’s BSM philosophy
                                           including: 1. programmatic and preventive approaches. 2.
                                           the spectrum of BSM interventions. 3. prohibited
                             PA-BSM 1      procedures/interventions.
                             PA-BSM 1      BSM policy and procedures
                             PA-BSM 1      Incident review procedures
                                           Aggregate of the two most recent quarterly reviews of
                                           incidents requiring restrictive behavior management
                             PA-BSM 1      interventions
                                           BSM philosophy and procedures given to persons served
                             PA-BSM 2      and parents/legal guardians at admission
                             PA-BSM 2      Parental/guardian notification protocol
                                           Criteria used to assess potential need/risk regarding
                             PA-BSM 2      behavior management
                                           Table of contents for personnel and foster parent BSM
                             PA-BSM 3      training curriculum
                                           Table of contents for personnel and foster parent restrictive
                             PA-BSM 4      behavior management training curriculum
                                           Authorization procedures (may be included in BSM policies
                             PA-BSM 5      and procedures)
                                           Debriefing protocol (may be included in BSM policies and
                             PA-BSM 6      procedures)
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                        Client Rights (PA-CR)
                                         Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CR 1        Client rights policy and procedures
                                    PA-CR 2        Confidentiality policy and procedures
                                    PA-CR 2        Sample consent form
                                    PA-CR 3        Grievance policy or procedures for individuals and families
                                                   Procedures for use of interventions that limit movement,
                                                   diminish sensory experience, limit personal freedom, or
                                    PA-CR 4        cause personal discomfort, as applicable

                                    PA-CR 4        Procedures for helping persons access assistive technology
                                           Procedures for providing or making referrals for family
                             PA-CR 4       support services
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                              Training and Supervision (PA-TS)
                                     Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete.
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA requests.
                                    A list of all NAs applicable to your agency provided within the standards.
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-TS 2        Table of contents for the agency's orientation curriculum
                                                   Table of contents for training regarding topics outlined in PA-
                                    PA-TS 2        TS 2.02
                                                   Agency chart(s) for administrative offices that illustrates
                                    PA-TS 3        lines of supervision.

                                    PA-TS 3        Criteria for assigning supvervisory responsibilities
                                                   Description of the network's training program (for Networks
                                    PA-TS 4        only)
                                                   Tables of contents of orientation and training curricula (for
                                    PA-TS 4        Networks only)
                                                   Annual training calendar and/or training schedules (for
                                    PA-TS 4        Networks only)
                                                   Outline of required training and timeframes for completion
                                    PA-TS 4        (for Networks only)

                             PA-TS 5        Table of contents of training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                       PA- Generic Narrative
                                        Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing
an electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of
evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes        No         NA      Evidence
                                 The Narrative is complete.
Narrative Attachments
   Yes        No         NA      Evidence
                                 A list of all program sites
                                 A demographic profile of persons and families served by the program(s) being
                                 reviewed under this service section
                                 As applicable, a list of groups or classes
                                 A list of any programs that were opened, merged with other programs or
                                 Two quarterly reports from the case record review process
                                 Two quarterly reports of accidents, incidents, and grievances
                                 Outcomes measurement/data collection procedures
                                 Outcomes results reported for the previous two quarters
ative
list
 lectronic and hard copy self-study, and a
our agency is required to complete this
 page number column, complete the
  section of standards. If you're completing
yperlink to the cell with the relevant piece of


explanation in the area provided. For
"Agreement with my COA Coordinator that
A," the explanation may be: "NA request




s and families served by the program(s) being
on
classes
opened, merged with other programs or
ase record review process
 s, incidents, and grievances
 llection procedures
e previous two quarters
                                   Adoption Services (PA-AS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
                                    Domestic Adoption Service (PA-AS) Profile
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-AS 2        Procedures for child assessments
                                                   Procedures for identifcation and collaboration in ICWA
                                    PA-AS 2        cases
                                    PA-AS 2        Procedures for birth parent assessments
                                    PA-AS 2        Assessment tools and/or criteria included in assessment
                                    PA-AS 3        Description of homestudy process
                                    PA-AS 3        Homestudy tool and/or procedures
                                    PA-AS 3        Procedures for background checks
                                    PA-AS 4        Service planning and monitoring procedures
                                                   Procedures for establishing continued contact and
                                    PA-AS 7        openness in adoption
                                    PA-AS 8        Matching and placement procedures
                                                   Procedures for involving expectant/birth parents, when
                                    PA-AS 8        applicable
                                    PA-AS 10       Case closing procedures
                                    PA-AS 12       Fee policy and procedures
                                PA-AS 12   Fee scale
                                PA-AS 12   Record retention procedures
                                PA-AS 12   Procedures for releasing information
                                PA-AS 13   Program staffing chart that includes lines of supervision
                                PA-AS 13   List of program personnel
                                PA-AS 13   Chart that specifies caseload size per worker
                                           Procedures or criteria used for assigning and evaluating
                             PA-AS 13      workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                  Adult Day Services (PA-ADS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-AD 1        Description of outreach efforts
                                    PA-AD 2        Screening and intake procedures
                                    PA-AD 3        Assessment procedures
                                    PA-AD 3        Assessment tool and/or criteria
                                    PA-AD 4        Service planning and monitoring procedures
                                    PA-AD 8        List of programs and activities
                                    PA-AD 8        Policies for prohibited interventions

                                    PA-AD 9Both the defined and actual ratios for the past two quarters
                                           Case closing procedures
                                    PA-AD 10
                                           Aftercare and follow-up procedures
                                    PA-AD 11
                                           Program staffing chart that includes lines of supervision
                                    PA-AD 12
                                           List of program personnel
                                    PA-AD 12
                                           Table of contents of training curricula
                                    PA-AD 12
                                           Procedures and criteria used for assigning and evaluating
                             PA-AD 12      workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                Adult Guardianship Services (PA-AG)
                                       Evidence Checklist


Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this checklist. If
your are completing a hard copy self-study, add a page number column, complete the checklist, print it out, and
place it in the front of each assigned section of standards. If you're completing an electronic self-study,
complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example if
your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will be
reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete.
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s) being
                                   reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests

                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-AG 3     Screening and intake procedures
                                   PA-AG 3     Current staff to client ratio
                                   PA-AG 4     Assessment procedures
                                   PA-AG 4     Assessment tools and/or criteria included in assessment
                                   PA-AG 5     Service planning and monitoring procedures
                                   PA-AG 6     Adult Guardianship Conflict of Interest Policy
                                               Procedures for assessing service needs and indentifying
                                   PA-AG 6     appropriate service providers
                                   PA-AG 6     Procedures for submitting court petitions
                                   PA-AG 7     Procedures and criteria used to assign and evaluate workload
                                   PA-AG 7     Procedures governing frequency of contact
                                   PA-AG 8     Procedures for ethical decision-making
                                   PA-AG 8     Service monitoring and re-assessment procedures
                                   PA-AG 9     Procedures for conducting inventory of client assets
                                               Procedures for sharing financial information with service recipient
                                   PA-AG 9
                                   PA-AG 9 Guardian of the Estate financial management procedures
                                   PA-AG 10 Case closing procedures
                             PA-AG 11 Program staffing chart that includes lines of supervision
                             PA-AG 11 List of program personnel
                             PA-AG 11 Table of contents of guardianship worker training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                               Adult Protective Services (PA-APS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-APS 1       Description of the community education program
                                    PA-APS 3       Description of the access line and how it is publicized
                                    PA-APS 3       Screening procedures
                                    PA-APS 3       Decision making criteria
                                    PA-APS 3       Removal procedures
                                    PA-APS 3       Procedures for submitting court petitions
                                    PA-APS 4       Investigation procedures
                                    PA-APS 4       Assessment procedures
                                    PA-APS 4       Assessment tools or criteria included in assessments
                                    PA-APS 4       Procedures for safety management plans
                                    PA-APS 5       Service planning and monitoring procedures
                                                   Procedures or criteria for determining the most beneficial
                                    PA-APS 6       and least intrusive service
                                                   Procedures for establishing voluntary agreements and
                                    PA-APS 7       submitting court petitions
                                    PA-APS 7       Removal procedures
                                    PA-APS 7       Home visit procedures
                                 PA-APS 8  Case closing procedures
                                 PA-APS 9  Aftercare/follow-up procedures
                                 PA-APS 10 Program staffing chart that includes lines of supervision
                                 PA-APS 10 List of program personnel
                                 PA-APS 10 Procedures or criteria used to assign and evaluate
                                           Chart that specifies caseload size, per worker for the past
                             PA-APS 10 six months
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                 Case Management Services: Case Management; Care
                Coordination; Intensive Case Management (PA-CM)
                                Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CM 2       Screening and intake procedures
                                    PA-CM 3       Assessment procedures
                                    PA-CM 3       Assessment tool and/or criteria included in assessment
                                    PA-CM 4       Service planning procedures
                                    PA-CM 5       Service monitoring and re-assessment procedures
                                                  Provide staff/client ratios for each staff member for the past
                                    PA-CM   7     six months
                                    PA-CM   8     Case closing procedures
                                    PA-CM   9     Aftercare and follow-up procedures
                                    PA-CM   10    Program staffing chart that includes lines of supervision
                                    PA-CM   10    List of program personnel
                                    PA-CM   10    Table of contents of training curricula
                                                  Provide caseload size, per worker, for the past six months,
                                                  and procedures or criteria used to assign and evaluate
                                    PA-CM 10      caseloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Child and Family Development and Support Services
                                       (PA-CFD)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CFD 2      Screening procedures
                                    PA-CFD 3      Assessment procedures
                                    PA-CFD 3      Assessment tools and/or criteria included in assessment
                                    PA-CFD 4      Service planning and monitoring procedures
                                                  Procedures for linking individuals to services and providing
                                    PA-CFD 9      ongoing monitoring and follow-up (Health Services)

                                                  Procedures for linking individuals to services and providing
                                    PA-CFD 10     ongoing monitoring and follow-up (Family Support Services)
                                    PA-CFD 11     Table of contents of educational curricula
                                                  Procedures for linking individuals to services and providing
                                                  ongoing monitoring and follow-up (Positive Child
                                    PA-CFD 12     Development Services)
                                                  Procedures for linking individuals to services and providing
                                                  ongoing monitoring and follow-up (Early Intervention
                                    PA-CFD 13     Services)
                                PA-CFD 14  Case closing procedures
                                PA-CFD 14  Aftercare/follow-up procedures
                                PA-CFD 15  Program staffing chart that includes lines of supervision
                                PA-CFD 15  List of personnel
                                PA-CFD 15  Table of contents of training curricula
                                           Average caseload size, per worker, for the last month, if
                             PA-CFD 15 applicable
                                           Procedures and criteria used for assigning cases, and for
                             PA-CFD 15 assigning and evaluating workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                               Child Protective Services (PA-CPS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CPS 4       Screening procedures

                                    PA-CPS 4       Procedures for identification and notification in ICWA cases
                                    PA-CPS 4       Criteria for decision making
                                    PA-CPS 5       Investigation procedures
                                                   Sample of information about rights and responsibilities given
                                    PA-CPS 5       to parents
                                    PA-CPS 5       Procedures for risk assessment
                                    PA-CPS 5       Copy of the risk assessment tool
                                    PA-CPS 6       Procedures for safety assessment and safety planning
                                    PA-CPS 6       Copy of the safety assessment tool
                                    PA-CPS 7       Assessment procedures
                                    PA-CPS 7       Copy of the assessment tool
                                    PA-CPS 8       Service planning and monitoring procedures
                                    PA-CPS 9       Guidelines or description of worker visits
                                                   Procedures for establishing voluntary agreements and
                                    PA-CPS 10      submitting court petitions
                                 PA-CPS 10 Procedures or protocols for removing a child
                                 PA-CPS 11 Placement Procedures
                                 PA-CPS 12 Procedures for permanency planning
                                 PA-CPS 13 Case closing procedures
                                 PA-CPS 14 Program staffing chart that includes lines of supervision
                                 PA-CPS 14 Table of contents of training curricula
                                           Chart that specifies caseload size, per worker for the past
                             PA-CPS 14 six months
                                           Procedures and criteria used for assigning and evaluating
                             PA-CPS 14 workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                         Community Changes Initiatives (PA-CCI)
                                Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're
completing an electronic self-study, complete the checklist and create a hyperlink to the cell with the
relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator
that evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA
request granted by COA."

Narrative
   Yes        No         NA     Evidence
                                The Narrative is complete
Narrative Attachments
   Yes        No         NA     Evidence
                                A list of all program sites
                                A demographic profile of stakeholders
                                Two quarterly reports of accidents, incidents, and grievances
                                All COA-approved NA Requests

                                A list of all NAs applicable to your agency provided within the standards
                                Outcomes measurement/data collection procedures
                                Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA       Evidence
                                PA-CCI 2 List of community partners and stakeholders
                                PA-CCI 2 Outreach procedures and informational materials
                                         Procedures for communicating and collaborating with
                                         stakeholders, including procedures for collecting stakeholder
                                PA-CCI 2 feedback
                                PA-CCI 2 Procedures for group decision making
                                         Procedures for linking stakeholders to opportunities provided by
                                PA-CCI 3 other organizations, agencies or parties
                                PA-CCI 3 Table of contents of training curricula, if applicable
                                PA-CCI 4 Copy of community assessment
                                PA-CCI 4 Assessment procedures
                                PA-CCI 4 Assessment tools and/or criteria included in assessment
                                PA-CCI 5 Copy of the initiative’s plan
                                PA-CCI 5 Planning procedures
                                         Procedures for communicating and collaborating with
                                         stakeholders, including procedures for collecting stakeholder
                                PA-CCI 7 feedback
                                PA-CCI 7 Procedures for monitoring and reevaluating the initiative’s plan
                                         Copy of the initiative’s revised plan with revisions highlighted, if
                                PA-CCI 7 applicable
                                         Copies of agreements with stakeholders stating when/how the
                                PA-CCI 7 agency will transition out of the initiative, if applicable
                                PA-CCI 8 List of personnel
                                PA-CCI 8 Table of contents of training curricula
                             PA-CCI 8 Procedures and criteria for assigning and evaluating workloads
                             PA-CCI 8 Program staffing chart that includes lines of supervision
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                      Counseling, Support, and Education Services
                                     (PA-CSE)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CSE 2       Screening and intake procedures
                                    PA-CSE 2       Assessment tool and/or criteria included in assessment
                                    PA-CSE 6       Crisis response procedures
                                                   Program staffing chart that includes lines of supervision
                                    PA-CSE 7       (Individual)
                                    PA-CSE 7       List of program personnel (Individual)
                                                   Procedures and criteria used for assigning and evaluating
                                    PA-CSE 7       workload (Individual)
                                    PA-CSE 8       Program staffing chart that include lines of supervision
                                    PA-CSE 8       List of program personnel (Group)
                                    PA-CSE 8       Table of contents of training curricula (Group)
                                                   Procedures and criteria used for assigning and evaluating
                                    PA-CSE 8       workload (Group)
                                                   Program staffing chart that include lines of supervision
                                    PA-CSE 9       (Information and Referral)
                                    PA-CSE 9       List of program personnel (Information and Referral)
                             PA-CSE 9      Table of contents of training curricula (Information and
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
             Crisis Response and Information Services: Crisis Intervention;
             Crisis Hotline Services; Information and Referral Services (PA-
                                           CRI)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-CRI 2       Screening procedures

                                    PA-CRI 2       Risk assessment tool and/or criteria included in assessment
                                    PA-CRI 5       Service coordination procedures
                                    PA-CRI 6       Crisis response procedures
                                    PA-CRI 6       Treatment and referral procedures
                                                   Program staffing chart that includes lines of supervision
                                    PA-CRI 9       (Crisis Intervention and Hotline Services)
                                                   List of program personnel (Crisis Intervention and Hotline
                                    PA-CRI 9       Services)
                                                   Table of contents of training curricula (Crisis Intervention
                                    PA-CRI 9       and Hotline Services)
                                    PA-CRI 10      Program staffing chart that includes lines of supervision
                                    PA-CRI 10      List of program personnel
                                PA-CRI 10  The table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-CRI 10     workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                           Day Treatment Services: Social Adjustment Services;
                         Intensive Outpatient Treatment; Partial Hospitalization
                                                (PA-DTX)
                                          Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No        NA     Evidence
                                 The Narrative is complete
Narrative Attachments
   Yes         No     NA         Evidence
                                 A list of all program sites
                                 A demographic profile of persons and families served by the program(s)
                                 being reviewed under this service section
                                 As applicable, a list of groups or classes
                                 A list of any programs that were opened, merged with other programs or
                                 services, or closed
                                 Two quarterly reports from the case record review process
                                 Two quarterly reports of accidents, incidents, and grievances
                                 All COA-approved NA Requests
                                 A list of all NAs applicable to your agency provided within the standards
                                 Outcomes measurement/data collection procedures
                                 Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes        No      NA         Evidence
                                 PA-DTX 2        Screening and intake procedures
                                 PA-DTX 3        Assessment procedures
                                 PA-DTX 3        Assessment tool and/or criteria
                                 PA-DTX 4        Service planning and monitoring procedures
                                                 Procedures for use of non-traditional or unconventional
                                 PA-DTX 5        practices, as applicable
                                 PA-DTX 5        Table of contents of training curricula
                                 PA-DTX 5        Policies for prohibited interventions
                                                 Provide procedures for involving the family of the primary
                                 PA-DTX 7        person served
                                 PA-DTX 8        Procedures for enrolling participants in school
                                 PA-DTX 8        Procedures for developing educational plans
                                 PA-DTX 9        Client/staff ratios and coverage schedules
                                 PA-DTX 10       Case closing procedures
                              PA-DTX 11  Aftercare/follow-up procedures
                              PA-DTX 12  Program staffing chart that includes lines of supervision
                              PA-DTX 12  List of program personnel
                              PA-DTX 12  Table of contents of training curricula
                                         Procedures and criteria used for assigning and evaluating
                            PA-DTX 12 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                            Domestic Violence Services (PA-DV)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-DV 2        Screening procedures
                                    PA-DV 3        Safety assessment and safety planning procedures
                                                   Procedures for protecting the safety of survivors when
                                    PA-DV 3        perpetrators are involved in services, if applicable
                                    PA-DV 4        Assessment procedures
                                    PA-DV 4        Assessment tool and/or criteria included in assessment
                                    PA-DV 4        Procedures and/or policies for reporting abuse and neglect
                                    PA-DV 5        Service planning and monitoring procedures
                                                   Procedures for linking survivors to services and providing
                                    PA-DV 8        ongoing monitoring and follow-up
                                                   Procedures for linking children to services and providing
                                    PA-DV 9        ongoing monitoring and follow-up
                                    PA-DV 9        Policy prohibiting corporal punishment
                                                   Procedures for evaluating educational needs and
                                    PA-DV 9        collaborating with schools, if applicable
                                    PA-DV 10       Crisis response procedures
                                    PA-DV 11       Safety protocols and procedures
                                    PA-DV 11       Table of contents of training curricula
                                PA-DV 12   Shelter or safe home rules
                                PA-DV 12   Policies and procedures for expelling survivors
                                PA-DV 14   Table of contents of training curricula
                                PA-DV 15   Case closing procedures
                                PA-DV 16   Aftercare/follow-up procedures
                                PA-DV 17   Record keeping procedures
                                PA-DV 18   Program staffing chart that includes lines of supervision
                                PA-DV 18   List of personnel
                                PA-DV 18   Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-DV 18      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                 Employee Assistance Program Services (PA-EAP)
                              Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.


Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Access and intake procedures
                                    PA-EAP 1
                                           Procedures for addressing life-threatening emergency
                                    PA-EAP 1
                                           Procedures for implementation planning
                                    PA-EAP 3
                                           Copy of a sample contract between EAP and customer
                             PA-EAP 3      organization
                                           Narrative describing how client confidentiality is maintained
                             PA-EAP 3      in EAP’s reporting process
                             PA-EAP 4      Sample affiliate agreement
                             PA-EAP 4      Procedures for conducting random quality improvement
                             PA-EAP 5      Record-keeping procedures
                             PA-EAP 6      Assessment procedures
                             PA-EAP 6      Assessment tool and/or criteria included in assessment
                             PA-EAP 7      Service planning procedures
                             PA-EAP 8      Referral procedures
                             PA-EAP 8      Aftercare/follow-up procedures
                                           Table of contents of training curricula for supervisors and
                             PA-EAP 8      union representatives
                             PA-EAP 9      Procedures for reporting and reviewing incidents
                             PA-EAP 11 Case closing procedures
                             PA-EAP 12 Program organization chart showing lines of supervision
                             PA-EAP 12 List of program personnel
                             PA-EAP 12 Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-EAP 12 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
               Employee Assistance Program Services (PA-EAP-OLD)
                               Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a checklist
for all documentation included in your self-study. Your agency is required to complete this checklist. If your are
completing a hard copy self-study, add a page number column, complete the checklist, print it out, and place it in
the front of each assigned section of standards. If you're completing an electronic self-study, complete the
checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example if
your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will be
reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s) being
                                   reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-EAP-OLD 1       Access and intake procedures
                                                      Procedures for addressing life-threatening emergency
                                   PA-EAP-OLD 1       situations
                                                      Copy of a sample contract between EAP and customer
                                   PA-EAP-OLD 3       organization
                                                      Narrative describing how client confidentiality is maintained
                                   PA-EAP-OLD 3       in EAP’s reporting process
                                   PA-EAP-OLD 4       Sample affiliate agreement
                                                      Procedures for conducting random quality improvement
                                   PA-EAP-OLD 4       reviews of affiliates and subcontractors
                                   PA-EAP-OLD 5       Record-keeping procedures
                                   PA-EAP-OLD 6       Assessment procedures
                                   PA-EAP-OLD 6       Assessment tool and/or criteria included in assessment
                                   PA-EAP-OLD 7       Service planning procedures
                                   PA-EAP-OLD 8       Referral procedures
                                   PA-EAP-OLD 8       Aftercare/follow-up procedures
                                               Table of contents of training curricula for supervisors and
                                PA-EAP-OLD 8   union representatives
                                PA-EAP-OLD 10  Case closing procedures
                                PA-EAP-OLD 11  Program organization chart showing lines of supervision
                                PA-EAP-OLD 11  List of program personnel
                                PA-EAP-OLD 11  Table of contents of training curricula
                                               Procedures and criteria used for assigning and evaluating
                             PA-EAP-OLD 11 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
ces (PA-EAP-OLD)



 nd hard copy self-study, and a checklist
ed to complete this checklist. If your are
 e the checklist, print it out, and place it in
 electronic self-study, complete the
dence.

n in the area provided. For example if
 COA Coordinator that evidence will be
e: "NA request granted by COA."




  families served by the program(s) being

ses
 ed, merged with other programs or

ecord review process
cidents, and grievances

ency provided within the standards
 on procedures
 vious two quarters


 procedures
dressing life-threatening emergency

contract between EAP and customer

 g how client confidentiality is maintained
 process
 reement
nducting random quality improvement
s and subcontractors
 ocedures
 dures
 nd/or criteria included in assessment
 rocedures
 s
  procedures
of training curricula for supervisors and
ves
edures
ion chart showing lines of supervision
rsonnel
of training curricula
iteria used for assigning and evaluating
                                 Early Childhood Education (PA-ECE)
                                         Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing an
electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of
evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes          No         NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No      NA           Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s)
                                   being reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
                                   Early Childhood Education (PA-ECE) Data Sheet
Self-Study Documentation
   Yes       No       NA           Evidence
                                   PA-ECE 2       Enrollment procedures
                                   PA-ECE 4       Cleaning and sanitation procedures
                                   PA-ECE 4       Diaper changing procedures

                                   PA-ECE 4       Hand washing procedures

                                   PA-ECE 4       Bottle handling procedures
                                   PA-ECE 4       Infant sleep procedures to reduce risk of SIDS
                                   PA-ECE 4       Child abuse and neglect reporting procedures
                                                  Procedures for reporting, responding to and recording
                                   PA-ECE 4       health problems and accidents
                                   PA-ECE 6       Behavior management policy and procedures
                                   PA-ECE 7       Curriculum or developmental plan for each age group
                                   PA-ECE 7       Sample daily activity plans for each age group
                                PA-ECE 7      Assessment procedures
                                PA-ECE 9      Procedures for child pick-up
                                              Procedures for covering staff breaks and other situations
                                              that require a teaching staff person to leave the classroom
                                PA-ECE 9      for 5 minutes or more
                                PA-ECE 9      Policy and procedures governing mixing age groups
                                           Procedures for transitioning to another classroom of age
                                PA-ECE 10  group
                                PA-ECE 10  Procedures for transitioning to another school or program
                                PA-ECE 11  Program staffing chart that includes lines of supervision
                                           List of program personnel that includes: name, title, degree
                                           and/or other credential, FTE or volunteer, length of service
                             PA-ECE 11 at agency and in current position
                             PA-ECE 11 Table of contents of training curricula
                             PA-ECE 12 Screening criteria for family child care homes
                             PA-ECE 12 Matching procedures for family child care homes
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                  Early Child Care and Development Services; Child Care
                       Centers; Family Child Care Homes (PA-ECCD)
                                    Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing an
electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of
evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes          No         NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No      NA           Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s)
                                   being reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
                                   Early Child Care Development Services (PA-ECCD) Data Sheet
Self-Study Documentation
   Yes       No       NA           Evidence
                                   PA-ECCD 1 Screening procedures
                                   PA-ECCD 1 Matching procedures for family based care, if applicable
                                   PA-ECCD 4 Relevant portions of the health protocol provided to parents
                                              Procedures for the prevention and control of contagious or
                                   PA-ECCD 4 infectious diseases
                                              Procedures for reporting, responding to and recording
                                   PA-ECCD 4 health problems and accidents
                                   PA-ECCD 5 Screening criteria for family child care homes
                                   PA-ECCD 7 Curriculum or developmental plan for each age group
                                   PA-ECCD 7 Sample daily activity plans for each age group
                                   PA-ECCD 9 Procedures for monitoring children as they transition
                                              Policies or procedures for prohibited behavioral
                                   PA-ECCD 9 interventions
                                   PA-ECCD 11 Transition procedures
                                   PA-ECCD 12 Program staffing chart that includes lines of supervision
                             PA-ECCD 12 List of program personnel
                             PA-ECCD 12 Table of contents of training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Financial Education and Counseling Services (PA-FEC)
                                 Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're
completing an electronic self-study, complete the checklist and create a hyperlink to the cell with the
relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator
that evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA
request granted by COA."

Narrative
   Yes        No         NA     Evidence
                                The Narrative is complete
Narrative Attachments
   Yes        No         NA     Evidence
                                A list of all program sites
                                A demographic profile of persons and families served by the program(s) being
                                reviewed under this service section
                                As applicable, a list of groups or classes
                                A list of any programs that were opened, merged with other programs or
                                services, or closed
                                Two quarterly reports from the case record review process
                                Two quarterly reports of accidents, incidents, and grievances
                                All COA-approved NA Requests

                                A list of all NAs applicable to your agency provided within the standards
                                Outcomes measurement/data collection procedures
                                Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA       Evidence
                                PA-FEC 1 Screening, Intake, and Assessment procedures
                                PA-FEC 1 Procedures for telephone or internet counseling
                                PA-FEC 1 Procedures regarding DMP initiation
                                PA-FEC 3 Privacy policy and disclosure statement
                                PA-FEC 3 Procedures regarding fees
                                PA-FEC 4 Procedures for development of action plans
                                PA-FEC 5 Financial counseling procedures
                                PA-FEC 5 Financial education materials provided to clients
                                         Program evaluations or other documents assessing the
                                         educational needs of the consumers and describing the agency’s
                                PA-FEC 5 financial education and counseling services
                                PA-FEC 6 Housing counseling procedures
                                PA-FEC 6 Housing education materials provided to clients
                                         Program evaluations or other documents assessing the
                                         educational needs of the consumers and describing the agency’s
                                PA-FEC 6 housing counseling and education services
                                PA-FEC 7 DMP procedures
                                          Sample copy of the "Agreement of Services," "DMP Agreement,"
                                PA-FEC 7 or other document that highlights client disclosures
                                          Procedures for DMP administration, that include:
                                          debt management, proposal letters, development of client status
                                PA-FEC 8 reports, discontinuation of DMPs
                                PA-FEC 9 Procedures regarding segregation and deposit of client funds
                                          Procedures for maintaining credit balances in accord with legal
                                PA-FEC 9 requirements
                                          Procedures for providing creditor information about agency
                                PA-FEC 10 practice
                                PA-FEC 10 Procedures for informing and communicating with creditors
                                PA-FEC 11 Referral procedures
                                PA-FEC 13 Provide information given to consumers
                                PA-FEC 14 Policy regarding financial incentives and penalties
                                PA-FEC 14 Referral policy
                                PA-FEC 14 Policy regarding client loans and debt
                                PA-FEC 15 Program staffing chart that includes lines of supervision
                                PA-FEC 15 List of program personnel

                             PA-FEC 15 Table of contents of training curricula
                                         Procedures and criteria used for assigning and evaluating
                             PA-FEC 15 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Family Preservation and Stabilization Services
                                       (PA-FPS)
                                  Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-FPS 2       Screening procedures
                                    PA-FPS 2       Procedures for identification and collaboration in ICWA
                                    PA-FPS 3       Assessment procedures
                                    PA-FPS 3       Assessment tools and/or criteria included in assessment
                                    PA-FPS 4       Service planning and monitoring procedures
                                    PA-FPS 6       Procedures and/or criteria for extending services
                                                   Procedures for linking families to services and providing
                                    PA-FPS 7       ongoing monitoring and follow-up
                                    PA-FPS 8       Procedures for assessing the need for out-of-home care
                                    PA-FPS 8       Assessment tools and/or criteria included in assessment
                                    PA-FPS 9       Case closing procedures
                                    PA-FPS 10      Aftercare/follow-up procedures
                                    PA-FPS 11      Program staffing chart that includes lines of supervision
                                    PA-FPS 11      List of personnel
                                    PA-FPS 11      Table of contents of training curricula
                               PA-FPS 11   Average caseload size, per worker, for the last month
                                           Procedures and criteria used for assigning cases, and for
                             PA-FPS 11 assigning and evaluating workloads
                                           Description of how agency ensures adequate staff coverage
                             PA-FPS 11 and compensates personnel appropriately
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Financial Management and Debt Counseling
                                     (PA-FMDC)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes         No         NA      Evidence
                                  The Narrative is complete
Narrative Attachments
   Yes        No      NA          Evidence
                                  A list of all program sites
                                  A demographic profile of persons and families served by the program(s)
                                  being reviewed under this service section
                                  As applicable, a list of groups or classes
                                  A list of any programs that were opened, merged with other programs or
                                  services, or closed
                                  Two quarterly reports from the case record review process
                                  Two quarterly reports of accidents, incidents, and grievances
                                  All COA-approved NA Requests
                                  A list of all NAs applicable to your agency provided within the standards
                                  Outcomes measurement/data collection procedures
                                  Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No       NA          Evidence
                                  PA-FMDC 1      Screening, intake, and assessment procedures
                                  PA-FMDC 1      Procedures for telephone or internet counseling
                                  PA-FMDC 1      Procedures regarding DMP initiation
                                  PA-FMDC 3      Procedures for development of action plans
                                  PA-FMDC 4      Privacy policy
                                  PA-FMDC 4      Procedures regarding fees
                                  PA-FMDC 4      Summary of data provided to clients, creditors, or media
                                  PA-FMDC 5      DMP procedures
                                                 Sample copy of the “Agreement for Services,” “DMP
                                                 Agreement,” or other document that highlights client
                                  PA-FMDC 5      disclosures
                                  PA-FMDC 6      Procedures for DMP administration
                                                 Long-term plans, program evaluations, or additional
                                                 documents assessing the educational needs of the
                                                 consumers and describing the agency’s financial
                                  PA-FMDC 7      management educational programs
                              PA-FMDC 8   Procedures regarding segregation and deposit of client funds
                                          Procedures for maintaining credit balances in accord with
                            PA-FMDC 8 legal requirements
                                          Procedures for providing creditor information about agency
                            PA-FMDC 9 practice
                            PA-FMDC 9 Procedures for informing and communicating with creditors
                            PA-FMDC 10 Referral procedures
                            PA-FMDC 12 Provide information given to consumers
                            PA-FMDC 13 Policy regarding financial incentives and penalties
                            PA-FMDC 13 Referral policy and procedures
                            PA-FMDC 13 Policy or procedures regarding client loans and debt
                            PA-FMDC 14 Program staffing chart that includes lines of supervision
                            PA-FMDC 14 List of program personnel
                            PA-FMDC 14 Table of contents of training curricula
                                          Procedures and criteria used for assigning and evaluating
                            PA-FMDC 14 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                  Foster Care Services (PA-FC)
                                       Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a checklist
for all documentation included in your self-study. Your agency is required to complete this checklist. If your are
completing a hard copy self-study, add a page number column, complete the checklist, print it out, and place it
in the front of each assigned section of standards. If you're completing an electronic self-study, complete the
checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example if
your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will be
reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s)
                                   being reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
                                   Foster Care (PA-FC) Service Profile
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-FC 1        Screening procedures
                                   PA-FC 1        Procedures for identification and collaboration in ICWA cases
                                   PA-FC 2        Assessment procedures
                                   PA-FC 2        Procedures for initial health screening
                                   PA-FC 2        Assessment tool and/or criteria included in assessment
                                   PA-FC 3        Service planning and monitoring procedures
                                   PA-FC 6        Matching and placement procedures
                                   PA-FC 7        Visitation procedures
                                                  Guidelines or procedures for providing educational supports
                                   PA-FC 9        and collaborating with school systems
                                   PA-FC 10       Health care procedures
                                   PA-FC 12       Procedures or guidelines for worker visits and monitoring
                                   PA-FC 14       Case closing procedures
                                   PA-FC 15       Aftercare/follow-up Procedures
                                                  Material that specifies required pre- and in-service training
                                   PA-FC 16       requirements
                                 PA-FC 16     Protocols for responding to emergencies
                                 PA-FC 17     Homestudy tool

                                 PA-FC 17  Procedures for background and child abuse registry checks
                                           Criteria for selection of therapeutic foster parents, as
                             PA-FC 17      applicable
                                           Procedures and criteria for matching the child with respite care
                             PA-FC 18      providers
                             PA-FC 18      Health and safety procedures and protocols
                             PA-FC 19      Program staffing chart that includes lines of supervision
                             PA-FC 19      List of program personnel
                                           Description of average workload, including the average
                             PA-FC 19      caseload size for the last four quarters
                             PA-FC 19      Procedures or criteria used to assign and evaluate workload
                             PA-FC 19      Table of contents for training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                  Foster and Kinship Care Services (PA-FC-PA-KC)
                                Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
  Yes        No        NA     Evidence
                              The Narrative is complete
Narrative Attachments
  Yes       No      NA        Evidence
                              A list of all program sites
                              A demographic profile of persons and families served by the program(s) being
                              reviewed under this service section
                              As applicable, a list of groups or classes
                              A list of any programs that were opened, merged with other programs or
                              services, or closed
                              Two quarterly reports from the case record review process
                              Two quarterly reports of accidents, incidents, and grievances
                              All COA-approved NA Requests
                              A list of all NAs applicable to your agency provided within the standards
                              Outcomes measurement/data collection procedures
                              Outcomes results reported for the previous two quarters
                              Foster Care (PA-FC) Service Profile (excluding kinship care placements)
Self-Study Documentation
  Yes       No     NA    Evidence
                         PA-FC 1/
                         PA-KC 1            Screening procedures
                         PA-FC 2/
                         PA-KC 2            Assessment procedures
                         PA-FC 2/
                         PA-KC 2            Procedures for initial health screening
                         PA-FC 2/
                         PA-KC 2            Assessment tool and/or criteria included in assessment
                         PA-FC 3/
                         PA-KC 3            Service planning and monitoring procedures
                         PA-FC 6            Matching procedures for foster care p
                         PA-KC 6            Placement procedures
                         PA-FC 7            Visitation procedures
                         PA-FC 10/
                         PA-KC 10           Health care procedures
                           PA-FC 12/
                           PA-KC 13    Procedures or guidelines for worker contact and monitoring
                           PA-FC 12/   Protocols for preventing and responding to missing children and
                           PA-KC 13    allegations of maltreatment in foster homes
                           PA-FC 14/
                           PA-KC 14    Case closing procedures
                           PA-FC 15/
                           PA-KC 15    Aftercare/follow-up Procedures
                           PA-FC 16/   Material that specifies required pre- and in-service training
                           PA-KC 12    requirements
                           PA-FC 16/
                           PA-KC 12    Protocols for responding to emergencies
                           PA-FC 17/   Homestudy tools used for foster and kinship caregivers and/or
                           PA-KC 6     criteria included in homestudy
                           PA-FC 17/
                           PA-KC 6     Procedures for background and child abuse registry checks
                           PA-FC 17/
                           PA-KC 6     Criteria for selection of therapeutic foster parents, as applicable
                                       Procedures and criteria for matching the child with respite care
                         PA-FC 18      providers
                         PA-FC 18      Health and safety procedures and protocols
                         PA-FC 19/
                         PA-KC 19 Program staffing chart that includes lines of supervision
                         PA-FC 19/
                         PA-KC 19 List of program personnel
                         PA-FC 19/ Description of average workload, including the average caseload
                         PA-KC 19 size for the last four quarters
                         PA-FC 19/
                         PA-KC 19 Procedures or criteria used to assign and evaluate workload
                         PA-FC 19/
                         PA-KC 19 Table of contents for training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                 Group Living Services (PA-GLS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
                                    Group Living Services (PA-GLS) Grouping Chart
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-GLS 1       Access, screening, and intake procedures
                                                   Material that describes family involvement activities and
                                    PA-GLS 2       efforts
                                    PA-GLS 3       Assessment procedures
                                    PA-GLS 3       Assessment tool and/or criteria included in assessment
                                    PA-GLS 4       Service planning and monitoring procedures
                                    PA-GLS 5       Description of the planning process
                                                   Procedures for use of non-traditional or unconventional
                                    PA-GLS 6       practices, as applicable
                                    PA-GLS 6       Table of contents of training curricula
                                    PA-GLS 6       Policies for prohibited interventions
                                    PA-GLS 8       Health-related procedures
                                    PA-GLS 9       Procedures for enrolling participants in school
                                    PA-GLS 9       Procedures for developing educational plans
                                    PA-GLS 10      List of referral resources for substance abuse services
                                    PA-GLS 11      Privacy policy and procedures
                                PA-GLS 14  Resident/personnel care and supervision ratios
                                           Procedures and criteria used for assigning and evaluating
                             PA-GLS 14 workloads
                             PA-GLS 15 Transition planning procedures
                             PA-GLS 16 Case closing procedures
                             PA-GLS 17 Aftercare/follow-up procedures
                             PA-GLS 18 Program staffing chart that includes lines of supervision
                             PA-GLS 18 List of program personnel
                             PA-GLS 18 Table of contents of training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                        Guardianship Services for Minors (PA-GSM)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a checklist
for all documentation included in your self-study. Your organization is required to complete this checklist. If your
are completing a hard copy self-study, add a page number column, complete the checklist, print it out, and place it
in the front of each assigned section of standards. If you're completing an electronic self-study, complete the
checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your organization checks "No" or "NA," provide a brief explanation in the area provided. For example
if your organization checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will
be reviewed on-site" or if your organization checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s) being
                                   reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests

                                   A list of all NAs applicable to your organization provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
                                   Guardianship (GSM) Service Profile
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-GSM 1  Procedures for sharing case information
                                   PA-GSM 3  Procedures for exploring permanency options with the family
                                   PA-GSM 4  Description of the homestudy process
                                   PA-GSM 4  Homestudy tool and/or procedures
                                   PA-GSM 4  Procedures for background checks
                                   PA-GSM 5  Procedures for conducting assessments
                                   PA-GSM 5  Assessment tools and/or criteria included in assessment
                                   PA-GSM 5  Procedures for identifiaction and collaboration in ICWA cases
                                   PA-GSM 6  Service planning and monitoring procedures
                                   PA-GSM 6  Permanency planning procedures
                                   PA-GSM 9  Case closing procedures
                                   PA-GSM 10 Program staffing chart that includes lines of supervision
                                   PA-GSM 10 List of program personnel
                                             Chart that specifies caseload size, per worker, for the past six
                                   PA-GSM 10 months
                             PA-GSM 10 Procedures or criteria used for assigning and evaluating workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
 inors (PA-GSM)
klist

 ronic and hard copy self-study, and a checklist
  is required to complete this checklist. If your
  complete the checklist, print it out, and place it
ting an electronic self-study, complete the
f evidence.

explanation in the area provided. For example
ent with my COA Coordinator that evidence will
nation may be: "NA request granted by COA."




s and families served by the program(s) being
on
classes
opened, merged with other programs or

ase record review process
ts, incidents, and grievances


 r organization provided within the standards
ollection procedures
 e previous two quarters
ofile


aring case information
ploring permanency options with the family
homestudy process
 d/or procedures
ckground checks
nducting assessments
and/or criteria included in assessment
ntifiaction and collaboration in ICWA cases
 nd monitoring procedures
 ing procedures
edures
hart that includes lines of supervision
rsonnel
s caseload size, per worker, for the past six
eria used for assigning and evaluating workload
                 Home Care and Support Services: Home Health Aide
                   Services, Personal Care Aide Services, and
                         Homemaker Services (PA-HCS)
                               Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-HCS 2       Screening and intake procedures
                                    PA-HCS 4       Assessment procedures
                                                   Assessment tools and/or criteria including caregiver
                                    PA-HCS 4       assessment
                                    PA-HCS 4       Service planning procedures
                                    PA-HCS 5       Care monitoring procedures
                                    PA-HCS 7       Case closing procedures
                                    PA-HCS 8       Aftercare and follow-up procedures
                                    PA-HCS 9       Program staffing chart that includes lines of supervision
                                    PA-HCS 9       List of program personnel
                                                   Procedures and criteria used for assigning and evaluating
                                    PA-HCS 9       workloads
                                                   Program staffing chart that includes lines of supervision
                                    PA-HCS 10      (Older Adults and Special Needs Individuals)
                                           List of program personnel (Older Adults and Special Needs
                               PA-HCS 10   Individuals)
                                           Procedures and criteria used for assigning and evaluating
                             PA-HCS 10 workloads (Older Adults and Special Needs Individuals)
                             PA-HCS 11 Table of contents for all training topics
                             PA-HCS 11 Training exemption criteria
                             PA-HCS 11 Supervised practical training evaluation form
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
               Immigrant and Refugee Resettlement: Resettlement
             Practice with Separated and Unaccompanied Children;
               Transition Services; Immigration, Citizenship and
               Naturalization Legal Assistance Services (PA-IRR)
                               Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-IRR 1       Outreach strategy and activities summary
                                                   Description of approach for remaining knowledgeable about
                                    PA-IRR 1       service eligibility and availability
                                    PA-IRR 2       Screening and intake procedures
                                    PA-IRR 2       Issue identification tools and/or tickler system
                                    PA-IRR 3       Assessment procedures
                                                   Assessment tool and/or criteria including child and youth
                                    PA-IRR 3       trauma
                                    PA-IRR 4       Service planning and monitoring procedures
                                    PA-IRR 11      Case closing procedures
                                    PA-IRR 12      Aftercare and follow-up procedures
                                    PA-IRR 13      Program staffing chart that includes lines of supervision
                                    PA-IRR 13      List of program personnel
                                PA-IRR 13  Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-IRR 13     workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
              Juvenile Justice Case Management Services (PA-JJCM)
                                Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing
an electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece
of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes        No         NA      Evidence
                                 The Narrative is complete
Narrative Attachments
   Yes        No         NA      Evidence
                                 A list of all program sites
                                 A demographic profile of persons and families served by the program(s) being
                                 reviewed under this service section
                                 As applicable, a list of groups or classes
                                 A list of any programs that were opened, merged with other programs or
                                 services, or closed
                                 Two quarterly reports from the case record review process
                                 Two quarterly reports of accidents, incidents, and grievances
                                 All COA-approved NA Requests

                                 A list of all NAs applicable to your agency provided within the standards
                                 Outcomes measurement/data collection procedures
                                 Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA        Evidence
                                 PA-JJCM 2     Screening and/or intake procedures
                                 PA-JJCM 2     Assessment procedures
                                 PA-JJCM 2     Assessment tool and/or criteria
                                 PA-JJCM 3     Service planning procedures
                                               Procedures for collaborating with relevant organizations, agencies,
                                 PA-JJCM   4   and other parties
                                 PA-JJCM   4   Confidentiality procedures
                                 PA-JJCM   5   Procedures for linking youth to services
                                 PA-JJCM   6   Service monitoring and re-assessment procedures
                                 PA-JJCM   6   Procedures for conducting searches
                                 PA-JJCM   7   Case closing procedures
                                 PA-JJCM   8   Program staffing chart that includes lines of supervision
                                 PA-JJCM   8   List of program personnel
                                 PA-JJCM   8   Table of contents of training curricula
                                          Caseload size, per worker, for the past six months, and
                                          procedures or criteria used to assign and evaluate caseloads and
                             PA-JJCM 8 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
nt Services (PA-JJCM)
klist
 electronic and hard copy self-study, and a
 our agency is required to complete this
a page number column, complete the
d section of standards. If you're completing
hyperlink to the cell with the relevant piece


 explanation in the area provided. For
 "Agreement with my COA Coordinator that
NA," the explanation may be: "NA request




 s and families served by the program(s) being
 ion
  classes
  opened, merged with other programs or

 ase record review process
nts, incidents, and grievances


ur agency provided within the standards
ollection procedures
he previous two quarters


ntake procedures
dures
nd/or criteria
rocedures
aborating with relevant organizations, agencies,

cedures
 ing youth to services
  and re-assessment procedures
nducting searches
edures
hart that includes lines of supervision
rsonnel
of training curricula
 worker, for the past six months, and
ria used to assign and evaluate caseloads and
                     Juvenile Justice Corrections Services (PA-JJC)
                                   Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing
an electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece
of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
   Yes        No         NA      Evidence
                                 The Narrative is complete
Narrative Attachments
   Yes        No         NA      Evidence
                                 A list of all program sites
                                 A demographic profile of persons and families served by the program(s) being
                                 reviewed under this service section
                                 As applicable, a list of groups or classes
                                 A list of any programs that were opened, merged with other programs or
                                 Two quarterly reports from the case record review process
                                 Two quarterly reports of accidents, incidents, and grievances
                                 All COA-approved NA Requests

                                 A list of all NAs applicable to your agency provided within the standards
                                 Outcomes measurement/data collection procedures
                                 Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA        Evidence
                                 PA-JJC 1     Screening and intake procedures
                                 PA-JJC 1     Assessment procedures
                                 PA-JJC 1     Assessment tool and/or criteria
                                 PA-JJC 2     Service planning and monitoring procedures
                                              Procedures for use of non-traditional or unconventional practices,
                                 PA-JJC 3     as applicable
                                 PA-JJC 3     Table of contents of training curricula
                                 PA-JJC 3     Policies for prohibited interventions
                                 PA-JJC 4     Procedures for involving youths' families
                                              Procedures for collaborating with relevant organizations, agencies,
                                 PA-JJC 5     and other parties
                                 PA-JJC 5     Confidentiality procedures
                                 PA-JJC 6     Health related procedures
                                 PA-JJC 7     Mental health related procedures
                                 PA-JJC 8     Substance use related procedures
                                 PA-JJC 9     Procedures for developing educational plans
                               PA-JJC 9    Procedures for enrolling participants in local schools, if applicable
                               PA-JJC 13 Procedures regarding visits, phone calls, and mail
                               PA-JJC 14 Youth/ Staff Ratios
                               PA-JJC 14 Procedures for conducting searches
                               PA-JJC 14 Procedures for making housing assignments
                                         Procedures for ensuring safety when youth are locked in their
                               PA-JJC 14 rooms, as applicable
                             PA-JJC 15 Reentry planning procedures
                             PA-JJC 16 Case closing and follow-up procedures
                             PA-JJC 17 Program staffing chart that includes lines of supervision
                             PA-JJC 17 Table of contents of training curricula
                             PA-JJC 17 Procedures and criteria used to assign and evaluate workloads
                             PA-JJC 17 List of program personnel
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
Services (PA-JJC)
klist
 electronic and hard copy self-study, and a
 our agency is required to complete this
a page number column, complete the
d section of standards. If you're completing
hyperlink to the cell with the relevant piece


 explanation in the area provided. For
 "Agreement with my COA Coordinator that
NA," the explanation may be: "NA request




 s and families served by the program(s) being
 ion
  classes
  opened, merged with other programs or
 ase record review process
nts, incidents, and grievances


ur agency provided within the standards
ollection procedures
he previous two quarters


 ke procedures
 dures
 nd/or criteria
 nd monitoring procedures
e of non-traditional or unconventional practices,

of training curricula
ted interventions
olving youths' families
 aborating with relevant organizations, agencies,

cedures
cedures
 ed procedures
ated procedures
veloping educational plans
 olling participants in local schools, if applicable
ing visits, phone calls, and mail

nducting searches
 king housing assignments
suring safety when youth are locked in their
ble
 rocedures
ollow-up procedures
hart that includes lines of supervision
of training curricula
iteria used to assign and evaluate workloads
rsonnel
                         Juvenile Justice Day Services (PA-JJD)
                                   Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're
completing an electronic self-study, complete the checklist and create a hyperlink to the cell with the
relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator
that evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA
request granted by COA."

Narrative
   Yes        No         NA     Evidence
                                The Narrative is complete
Narrative Attachments
   Yes        No         NA     Evidence
                                A list of all program sites
                                A demographic profile of persons and families served by the program(s) being
                                reviewed under this service section
                                As applicable, a list of groups or classes
                                A list of any programs that were opened, merged with other programs or
                                Two quarterly reports from the case record review process
                                Two quarterly reports of accidents, incidents, and grievances
                                All COA-approved NA Requests

                                A list of all NAs applicable to your agency provided within the standards
                                Outcomes measurement/data collection procedures
                                Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA       Evidence
                                PA-JJD 1    Screening and intake procedures
                                PA-JJD 1    Assessment procedures
                                PA-JJD 1    Assessment tool and/or criteria
                                PA-JJD 2    Service planning and monitoring procedures
                                            Procedures for use of non-traditional or unconventional practices,
                                PA-JJD 3    as applicable
                                PA-JJD 3    Table of contents of training curricula
                                PA-JJD 3    Policies for prohibited interventions
                                            Procedures for collaborating with relevant organizations, agencies,
                                PA-JJD 4    and other parties
                                PA-JJD 4    Confidentiality procedures
                                PA-JJD 5    Procedures for involving youths' families
                                PA-JJD 7    Procedures for developing educational plans

                                PA-JJD 7    Procedures for enrolling participants in local schools, if applicable
                                          Procedures for maintaining safety and security, including
                               PA-JJD 9   procedures for conducting searches
                               PA-JJD 9   Youth/ Staff Ratios
                             PA-JJD 10 Transition planning procedures
                             PA-JJD 11 Case closing and follow- up procedures
                             PA-JJD 12 Program staffing chart that includes lines of supervision
                             PA-JJD 12 List of program personnel
                             PA-JJD 12 Table of contents of training curricula
                             PA-JJD 12 Procedures and criteria used to assign and evaluate workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
vices (PA-JJD)
klist
  electronic and hard copy self-study, and a
Your agency is required to complete this
 a page number column, complete the
ed section of standards. If you're
 nd create a hyperlink to the cell with the


 f explanation in the area provided. For
: "Agreement with my COA Coordinator
cks "NA," the explanation may be: "NA




ns and families served by the program(s) being
ction
 r classes
e opened, merged with other programs or
 case record review process
 nts, incidents, and grievances
 s

 ur agency provided within the standards
collection procedures
 he previous two quarters


 ke procedures
 dures
 nd/or criteria
 nd monitoring procedures
e of non-traditional or unconventional practices,


of training curricula
ted interventions
 aborating with relevant organizations, agencies,

cedures
olving youths' families
veloping educational plans

 olling participants in local schools, if applicable
 intaining safety and security, including
nducting searches


g procedures
 ollow- up procedures
hart that includes lines of supervision
rsonnel
of training curricula
 iteria used to assign and evaluate workloads
                                 Kinship Care Services (PA-KC)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-KC 1        Screening procedures
                                    PA-KC 1        Procedures for identification and collaboration in ICWA
                                    PA-KC 2        Assessment procedures
                                    PA-KC 2        Assessment tool and/or criteria included in assessment
                                    PA-KC 2        Procedures for initial health screening
                                    PA-KC 3        Service planning and monitoring procedures
                                    PA-KC 4        Description of permanency planning process
                                    PA-KC 6        Description of homestudy process and/or procedures
                                    PA-KC 6        Homestudy tool and/or criteria included in homestudy
                                    PA-KC 6        Placement procedures
                                    PA-KC 7        Visitation procedures
                                                   Guidelines or procedures for providing educational supports
                                    PA-KC 9        and collaborating with school systems
                                    PA-KC 10       Health care procedures

                                    PA-KC 13       Procedures or guidelines for worker contact and monitoring
                                    PA-KC 14       Case closing procedures
                                 PA-KC 15  Aftercare and follow-up procedures
                                 PA-KC 16  Program staffing chart that includes lines of supervision
                                 PA-KC 16  List of program personnel
                                 PA-KC 16  Table of contents of training curricula
                                           Chart that specifies caseload size, per worker for the past
                             PA-KC 16      six months
                                           Procedures or criteria used for assigning and evaluating
                             PA-KC 16      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                    Opiod Treatment (PA-OTP)
                                       Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-OTP 1       Access procedures
                                    PA-OTP 2       Screening and intake procedures
                                    PA-OTP 3       Assessment procedures
                                    PA-OTP 3       Assessment tool and/or criteria included in assessment
                                    PA-OTP 4       Service planning and monitoring procedures
                                                   Procedures for use of non-traditional or unconventional
                                    PA-OTP 5       practices, as applicable
                                    PA-OTP 5       Table of contents of training curricula
                                    PA-OTP 5       Policies for prohibited interventions
                                    PA-OTP 8       Procedures for obtaining medication blood levels
                                                   Procedures for making referrals to medical or psychiatric
                                    PA-OTP 8       services
                                                   Procedures for evaluating the benefits derived from
                                    PA-OTP 8       treatment
                                    PA-OTP 8       Table of contents of training curricula
                                                   Policies and procedures related to toxicology testing and
                                    PA-OTP 9       record keeping
                                PA-OTP 9      Medical protocols
                                              Policies, procedures, and criteria regarding take-home
                                PA-OTP 10     privileges
                                              Material that is given to persons served that addresses safe
                                PA-OTP 10     storage of take-home medication

                                PA-OTP 11  Procedure for administration of opioid treatment medication
                                PA-OTP 12  Procedures related to detoxification
                                           Procedures for transferring persons from interim to
                             PA-OTP 13 comprehensive maintenance treatment
                                           Procedures for notifying state health officer when a person’s
                             PA-OTP 13 maintenance status changes
                                           Documentation that addresses interim maintenance
                             PA-OTP 13 treatment program restrictions
                                           Procedures that address the provision of prenatal care for
                             PA-OTP 14 pregnant women served
                             PA-OTP 14 Information about education and support groups
                                           Procedures for withdrawal from methadone for pregnant
                             PA-OTP 14 women
                                           Procedures that address monitoring pregnant women and
                             PA-OTP 14 addicted newborns
                             PA-OTP 15 Procedures for medical withdrawal
                             PA-OTP 15 Procedures for administrative discharge
                             PA-OTP 16 Case closing procedures
                             PA-OTP 17 Aftercare procedures
                             PA-OTP 18 Diversion control plan
                             PA-OTP 19 Record-keeping procedures
                             PA-OTP 20 Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-OTP 20 workloads
                             PA-OTP 21 Program staffing chart that includes lines of supervision
                             PA-OTP 21 List of program personnel
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                            Out-Of-School Time Services (PA-OST)
                                     Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a checklist
for all documentation included in your self-study. Your agency is required to complete this checklist. If your are
completing a hard copy self-study, add a page number column, complete the checklist, print it out, and place it in
the front of each assigned section of standards. If you're completing an electronic self-study, complete the
checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example if
your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence will be
reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by COA."

Narrative
   Yes         No          NA      Evidence
                                   The Narrative is complete.
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s) being
                                   reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests

                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-OST 2     Registration or admission form
                                   PA-OST 2     Informational materials provided to children, youth, and families
                                                Policies and/or procedures for maintaining and accessing files of
                                   PA-OST 2     children and youth
                                                Policies and procedures regarding enrolling and serving children
                                   PA-OST 3     and youth with special needs
                                   PA-OST 4     Program rules and behavioral expectations
                                                Policies and/or procedures regarding children and youth with
                                   PA-OST 4     special behavioral needs or issues
                                   PA-OST 4     Policies for prohibited interventions
                                   PA-OST 5     Program activity schedule (for previous quarter)
                                   PA-OST 8     Menus (for previous month)
                                   PA-OST 8     Hygiene procedures, including expectations for hand washing
                                                Procedures for meeting health needs and minimizing risk of
                                   PA-OST 8     exposure to contagious or infectious disease
                                                Procedures for maintaining cleanliness and safety in the indoor
                                   PA-OST 8     and outdoor space
                                           Table of contents of emergency response training for children and
                                           youth, (or include description of training in Service Narrative Part
                                 PA-OST 8 1: Program Information)
                                 PA-OST 9 Table of contents of handbook for families
                                 PA-OST 9 Policies and/or procedures regarding family involvement
                                 PA-OST 10 List of community partners and resources
                                 PA-OST 11 Program ratio
                                 PA-OST 11 Staff coverage schedule (for previous quarter)
                                           Procedures or plan for coverage during absences or emergencies
                                 PA-OST 11

                                 PA-OST 12 List of program personnel

                             PA-OST 12 Policies and procedures regarding background checks
                             PA-OST 13 Table of contents for orientation curriculum
                             PA-OST 13 Table of contents for training curriculum
                                          Program staffing chart that includes lines of supervision (including
                             PA-OST 13 supervision of volunteers)
                             PA-OST 13 Policies and/or procedures regarding the use of volunteers
                                          Procedures and criteria used for assigning and evaluating
                             PA-OST 13 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                        Outdoor Activities Supplement (PA-OAS)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Procedures for obtaining clearance for persons served to
                                           participate in the described activities
                                    PA-OAS 1
                                           Safety procedures that address the requirements of the
                             PA-OAS 3      standard
                             PA-OAS 4      Environmental protection procedures
                             PA-OAS 4      Personal hygiene procedures
                             PA-OAS 5      Procedures for maintaining equipment
                                           Procedures for activity preparation, including group safety
                             PA-OAS 6      and skill level requirements
                             PA-OAS 6      Guidelines regarding use of protective gear and equipment
                                           Procedures for establishing and adjusting
                             PA-OAS 7      personnel/participant ratios
                             PA-OAS 7      Procedures regarding staff assignment for activities
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                       Outpatient Mental Health Services (PA-MH)
                                  Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-MH 1        Screening and intake procedures
                                    PA-MH 2        Assessment procedures
                                    PA-MH 2        List of standardized assessment tools used
                                    PA-MH 3        Service planning and monitoring procedures
                                                   Procedures for use of non-traditional or unconventional
                                    PA-MH 4        practices, as applicable
                                    PA-MH 4        Table of contents of training curricula
                                    PA-MH 4        Policies for prohibited interventions
                                    PA-MH 6        Crisis planning procedures
                                                   Procedures for determining when psychiatric involvement is
                                    PA-MH 7        necessary
                                    PA-MH 9        Case closing procedures
                                    PA-MH 10       Aftercare procedures
                                    PA-MH 11       Program staffing chart that includes lines of supervision
                                    PA-MH 11       List of program personnel
                                    PA-MH 11       Table of contents of training curricula
                                                   Procedures and criteria used for assigning and evaluating
                                    PA-MH 11       workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                   Outreach Services (PA-OS)
                                      Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No         NA      Evidence
                                   The Narrative is complete
Narrative Attachments
   Yes        No           NA      Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s)
                                   being reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-OS 1  Description of community collaboration efforts
                                            Description of the techniques and strategies used to engage
                              PA-OS 2       and assess homeless individuals and families
                                            Provide description of team composition and roles for
                              PA-OS 4       outreach teams
                              PA-OS 4       Provide safety guidelines for street outreach personnel
                              PA-OS 4       Provide written protocols and documentation of authority
                              PA-OS 5       Expulsion procedures
                              PA-OS 6       Follow-up procedures
                              PA-OS 7       Program staffing chart that includes lines of supervision
                              PA-OS 7       List of program personnel
                              PA-OS 7       Table of contents of training curricula
                                            Procedures and criteria used for assigning and evaluating
                              PA-OS 7       workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                           Pregnancy Support Services (PA-PS)
                                  Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-PS 2        Screening procedures
                                    PA-PS 3        Assessment procedures
                                    PA-PS 3        Assessment tool and/or criteria included in assessment
                                    PA-PS 4        Service planning and monitoring procedures
                                                   Procedures for maintaining confidentiality when involved
                                    PA-PS 6        parties are counseled separately, as applicable
                                    PA-PS 6        Procedures for linking individuals to services
                                                   Procedures for linking individuals to services and providing
                                    PA-PS 7        ongoing monitoring and follow-up
                                    PA-PS 8        Table of contents of educational curricula
                                                   Procedures for linking individuals to services and providing
                                    PA-PS 9        ongoing monitoring and follow-up
                                    PA-PS 10       Case closing procedures
                                    PA-PS 10       Aftercare/follow-up procedures
                                    PA-PS 11       Program staffing chart that includes lines of supervision
                                    PA-PS 11       List of program personnel
                                    PA-PS 11       Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-PS 11      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                 Psychiatric Rehabilitation Services: Psychosocial
                  Rehabilitation Services; Assertive Community
                            Outreach Services (PA-PSR)
                                Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-PSR 1       Screening and intake Procedures
                                    PA-PSR 2       Assessment procedures
                                    PA-PSR 2       List of standardized assessment tools used
                                    PA-PSR 3       Rehabilitation planning procedures
                                                   Procedures for use of non-traditional or unconventional
                                    PA-PSR 4       practices
                                    PA-PSR 4       Table of contents of training curricula
                                    PA-PSR 4       Policies for prohibited interventions
                                    PA-PSR 7       Case closing procedures
                                    PA-PSR 8       Aftercare procedures
                                    PA-PSR 9       Program staffing chart that includes lines of supervision
                                    PA-PSR 9       List of program personnel
                                    PA-PSR 9       Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-PSR 9      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                        Residential Treatment Services (PA-RTX)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
                                    Residential Treatment Services (PA-RTX) Grouping Chart
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-RTX 1       Admission criteria
                                    PA-RTX 1       Scope of services statement
                                    PA-RTX 3       Assessment procedures
                                                   Interdisciplinary assessment tools and/or criteria including
                                    PA-RTX 3       mental health, substance use and trauma screening
                                                   Service planning procedures showing assessment based
                                    PA-RTX 4       planning
                                    PA-RTX 4       Monitoring procedures
                                                   Description of permanency planning process that supports
                                    PA-RTX 5       timely goal setting and achievement
                                                   Procedures related to use of non-traditional or
                                    PA-RTX 6       unconventional practices
                                    PA-RTX 6       Table of contents of training curricula
                                    PA-RTX 6       Policies for prohibited interventions
                                                   Overview of health resources, related procedures, and
                                    PA-RTX 9       oversight
                                           Opportunities and enrollment procedures for residents with
                                PA-RTX 10  education goals
                                           Procedures for coordination with community based
                             PA-RTX 10 education programs
                             PA-RTX 12 List of substance use resources and services continuum
                             PA-RTX 15 Privacy policy and procedures
                             PA-RTX 16 Resident/personnel care and supervision ratios
                             PA-RTX 16 Supervision and scheduling criteria
                                           Criteria and procedures used to assign and evaluate
                             PA-RTX 16 workloads
                             PA-RTX 17 Transition activities list and planning procedures
                                           Case closing procedures indicating planning beginning at
                             PA-RTX 18 intake
                             PA-RTX 18 Aftercare and follow-up procedures
                             PA-RTX 19 Program staffing chart that includes lines of supervision
                             PA-RTX 19 List of program personnel
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                        Respite Care (PA-RC)
                                         Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-RC 2        Screening procedures
                                    PA-RC 3        Assessment procedures
                                    PA-RC 3        Assessment tool and/or criteria included in assessment
                                    PA-RC 4        Service planning and monitoring procedures
                                                   Procedures and criteria for matching service recipients with
                                    PA-RC 7        providers
                                    PA-RC 7        Health and safety procedures and protocols
                                    PA-RC 7        Client/staff ratios
                                    PA-RC 8        Process for reviewing and approving respite homes
                                    PA-RC 8        Policies for prohibited interventions
                                                   Procedures regarding care recipients’ rights to make
                                    PA-RC 8        telephone calls
                                    PA-RC 9        Rules and behavioral expectations
                                    PA-RC 10       Case closing procedures
                                    PA-RC 11       Program staffing chart that includes lines of supervision
                                    PA-RC 11       List of program personnel
                                    PA-RC 11       Table of contents of training curricula
                                    PA-RC 11       Procedures for screening respite providers
                                           Procedures and criteria used for assigning and evaluating
                             PA-RC 11      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                               Services for Individuals with
                            Developmental Disabilities (PA-DDS)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence

                                    PA-DDS 1       Description of community outreach and collaboration efforts
                                    PA-DDS 2       Screening and intake procedures
                                    PA-DDS 3       Assessment procedures
                                    PA-DDS 3       Assessment tool and/or criteria included in assessment
                                    PA-DDS 4       Service planning procedures
                                    PA-DDS 4       Service monitoring procedures
                                                   Procedures for use of non-traditional or unconventional
                                    PA-DDS 5       practices
                                                   Procedures for use of interventions that limit movement,
                                                   diminish sensory experience, limit personal freedom, or
                                    PA-DDS 5       cause personal discomfort
                                    PA-DDS 5       Table of contents of training curricula
                                    PA-DDS 5       Policies for prohibited interventions
                                                   Procedures for helping individuals access assistive
                                    PA-DDS 7       technology
                                 PA-DDS 9  Family visitation procedures
                                 PA-DDS 9  Policy regarding the right to make telephone calls
                                           Description of opportunities and support for the exercise of
                             PA-DDS 9      religious beliefs and practices
                             PA-DDS 10 Program staffing chart that includes lines of supervision
                             PA-DDS 10 List of program personnel
                             PA-DDS 10 Table of contents of training curricula
                                           Caseload size, per worker, for the past six months, and
                             PA-DDS 10 procedures or criteria used to assign and evaluate
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Services for Substance Use Conditions (PA-SA)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-SA 1        Screening and intake procedures
                                    PA-SA 2        Assessment procedures
                                    PA-SA 2        List of any standardized assessment tool used
                                    PA-SA 3        Service planning and monitoring procedures
                                                   Procedures for use of non-traditional or unconventional
                                    PA-SA 4        practices
                                    PA-SA 4        Table of contents of training curricula
                                    PA-SA 4        Policies for prohibited interventions
                                    PA-SA 5        Service coordination procedures
                                                   Procedures regarding the abuse of alcohol or drugs while
                                    PA-SA 5        participating in the program
                                    PA-SA 5        Crisis planning procedures
                                    PA-SA 6        Treatment and referral procedures
                                                   Description of how the service addresses treatment needs
                                                   of persons with co-occurring substance use and mental
                                    PA-SA 7        health conditions
                                    PA-SA 8        Description of child care services
                                PA-SA 8    Procedures for the provision of support services
                                PA-SA 9    Case closing procedures
                                PA-SA 10   Aftercare/follow-up procedures
                                PA-SA 11   Program staffing chart that includes lines of supervision
                                PA-SA 11   List of program personnel
                                           Table of contents of training curricula that address all
                             PA-SA 11      training topics
                                           Procedures and criteria used for assigning and evaluating
                             PA-SA 11      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                                     Shelter Services (PA-SH)
                                       Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-SH 1        Description of community collaboration efforts
                                    PA-SH 2        Intake and assessment procedures
                                    PA-SH 2        Assessment tool and/or criteria
                                    PA-SH 3        Service planning and monitoring procedures
                                    PA-SH 5        Procedures regarding opening shelter residents’ mail
                                    PA-SH 5        Procedures for expelling persons served
                                    PA-SH 5        Policies for prohibited interventions
                                    PA-SH 8        Security protocols
                                    PA-SH 8        Table of contents of training curricula
                                                   Procedures for serving youth without their parent or legal
                                    PA-SH 10       guardian, including parental notification procedures
                                    PA-SH 11       Rules and behavioral expectations
                                    PA-SH 12       Exit planning and aftercare/follow-up procedures
                                    PA-SH 13       Program staffing chart that includes lines of supervision
                                    PA-SH 13       List of program personnel
                                    PA-SH 13       Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-SH 13      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                Supplement for Developmental Disability Programs (PA-SDD)
                               Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're
completing an electronic self-study, complete the checklist and create a hyperlink to the cell with the
relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator
that evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA
request granted by COA."

Narrative
   Yes        No         NA     Evidence
                                The Narrative is complete
Narrative Attachments
   Yes        No         NA     Evidence
                                All COA-approved NA Requests

                                A list of all NAs applicable to your agency provided within the standards
Self-Study Documentation
   Yes       No        NA       Evidence
                                PA-SDD 1 Description of community outreach and collaboration efforts
                                PA-SDD 2 Service planning procedures
                                PA-SDD 2 Service monitoring procedures
                                         Procedures for use of interventions that limit movement, diminish
                                         sensory experience, limit personal freedom, or cause personal
                                PA-SDD 3 discomfort, as applicable
                             PA-SDD 3 Table of contents of training curricula
                             PA-SDD 5 Procedures for helping individuals access assistive technology
                             PA-SDD 7 List of progam personnel
                             PA-SDD 7 Table of contents of training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                     Social Development and Enrichment Services
                            for Children and Youth (PA-SDE)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Screening and assessment procedures
                                    PA-SDE 2
                                           Assessment tool and/or criteria included in assessment
                                    PA-SDE 2
                                           Procedures for terminating service, if applicable
                                    PA-SDE 2
                                           Policies for prohibited interventions
                                    PA-SDE 3
                                           Program staffing chart that includes lines of supervision
                             PA-SDE 8      (including supervision of volunteers)
                             PA-SDE 8      List of program personnel
                             PA-SDE 8      Ratio of personnel to participants, for all activities
                             PA-SDE 8      Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-SDE 8      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3
Explanation for any "No" or "NA" checked above
                     Supported Community Living Services (SCL)
                                Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Description of community collaboration efforts
                                    PA-SCL 1
                                           Screening and intake procedures
                                    PA-SCL 2
                                           Assessment procedures
                                    PA-SCL 3
                                           Assessment tool and/or criteria
                                    PA-SCL 3
                                           Service planning and monitoring procedures
                                    PA-SCL 4
                                           Acceptance procedures
                                    PA-SCL 7
                                           Case closing procedures
                                    PA-SCL 8
                                           Aftercare/follow-up procedures
                                    PA-SCL 9
                                           Program staffing chart that includes lines of supervision
                                    PA-SCL 10
                                           List of program personnel
                                    PA-SCL 10
                                           Table of contents of training curricula
                                    PA-SCL 10
                                           Procedures and criteria used for assigning and evaluating
                             PA-SCL 10 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3
Explanation for any "No" or "NA" checked above
              Vocational Rehabilitation Services Skill Development
               Training; Vocational Evaluation; Work Adjustment;
                       Job Development and Placement;
              Supported Employment; and Work Services (PA-VOC)
                               Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-VOC 2       Screening procedures
                                    PA-VOC 3       Assessment procedures
                                    PA-VOC 3       Assessment tool and/or criteria included in assessment
                                    PA-VOC 4       Vocational planning and monitoring procedures
                                                   Procedures for collaborating with community service
                                    PA-VOC 4       providers
                                    PA-VOC 6       Skill development training curriculum
                                                   Procedures used to evaluate skills, aptitudes, preferences,
                                    PA-VOC 7       abilities, and special needs
                                    PA-VOC 11      Procedures for evaluating progress of persons served
                                    PA-VOC 12      Case closing procedures
                                    PA-VOC 13      Aftercare procedures
                                    PA-VOC 14      Program staffing chart that includes lines of supervision
                                PA-VOC 14  List of program personnel
                                PA-VOC 14  Table of contents of training curricula
                                           Procedures and criteria used for assigning and evaluating
                             PA-VOC 14 workload
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                          Volunteer Mentoring Services (PA-VM)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-VM 2        Policy prohibiting corporal punishment
                                                   Screening and assessment procedures for service
                                    PA-VM 3        recipients
                                    PA-VM 3        Assessment tool and/or criteria included in assessment
                                                   Screening and assessment procedures and criteria for
                                    PA-VM 4        prospective mentors
                                    PA-VM 5        Matching procedures
                                    PA-VM 5        Criteria for matching mentors and service recipients
                                    PA-VM 6        Table of contents of orientation and training curricula
                                    PA-VM 8        Procedures for monitoring and supervising matches
                                    PA-VM 8        Procedures for closing matches
                                    PA-VM 9        Program staffing chart that includes lines of supervision
                                    PA-VM 9        List of personnel
                                    PA-VM 9        Table of contents of training curricula
                                    PA-VM 9        Ratio of personnel to matches
                                                   Procedures and criteria used for assigning and evaluating
                                    PA-VM 9        workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
            Wilderness and Adventure-Based Theraputic Outdoor Services
                                  (PA-WT)
                             Evidence Checklist
Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the
checklist, print it out, and place it in the front of each assigned section of standards. If you're completing an
electronic self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of
evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For
example if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that
evidence will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request
granted by COA."

Narrative
  Yes          No          NA      Evidence
                                   The Narrative is complete
Narrative Attachments
  Yes         No      NA           Evidence
                                   A list of all program sites
                                   A demographic profile of persons and families served by the program(s)
                                   being reviewed under this service section
                                   As applicable, a list of groups or classes
                                   A list of any programs that were opened, merged with other programs or
                                   services, or closed
                                   Two quarterly reports from the case record review process
                                   Two quarterly reports of accidents, incidents, and grievances
                                   All COA-approved NA Requests
                                   A list of all NAs applicable to your agency provided within the standards
                                   Outcomes measurement/data collection procedures
                                   Outcomes results reported for the previous two quarters
                                   Therapeutic Outdoor Services (PA-WT) Grouping Chart
Self-Study Documentation
   Yes       No        NA          Evidence
                                   PA-WT 1 Screening and intake procedures
                                   PA-WT 1 Procedures for expedited admissions
                                   PA-WT 1 Procedures for placement
                                   PA-WT 2 Assessment procedures
                                   PA-WT 2 Assessment tool and/or criteria included in assessment
                                   PA-WT 3 Service planning and monitoring procedures
                                           Procedures for use of non-traditional or unconventional
                             PA-WT 4       practices
                             PA-WT 4       Table of contents for training curriculum
                             PA-WT 4       Policies for prohibited interventions
                                           Family handbook or other material describing family
                             PA-WT 5       involvement
                             PA-WT 5       Procedures for communicating emergency messages
                             PA-WT 8       Health-related procedures
                             PA-WT 9       Procedures for enrolling participants in school
                             PA-WT 9       Procedures for developing educational plans
                             PA-WT 10      Privacy policy and procedures
                             PA-WT 11      Safety procedures that address standards in this section
                             PA-WT 12      Environmental protection procedures
                             PA-WT 12      Personal hygiene procedures
                             PA-WT 13      Procedures for maintaining equipment
                                           Procedures for activity preparation, including group safety
                             PA-WT 14      and skill level requirements
                             PA-WT 14      Guidelines regarding use of protective gear and equipment
                                           Provide safety and training plans for each of the high-risk
                             PA-WT 15      activities conducted by the agency
                                           Procedures for establishing and adjusting
                             PA-WT 16      personnel/participant ratios
                             PA-WT 16      Procedures regarding staff assignment for activities
                             PA-WT 16      Procedures that address solo activities
                             PA-WT 17      Transition planning procedures
                             PA-WT 18      Case closing procedures
                             PA-WT 19      Aftercare and follow-up procedures
                             PA-WT 20      Program staffing chart that includes lines of supervision
                             PA-WT 20      List of program personnel
                                           Procedures and criteria for assigning and evaluating
                             PA-WT 20      workload
                             PA-WT 21      Table of contents of training curricula
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
             Workforce Development and Support Services; and Financial
                      Asset-Building Services (PA-WDS)
                             Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Assessment Procedures
                                    PA-WDS 4
                                           Assessment tool and/or criteria included in assessment
                                    PA-WDS 4
                                           Employment planning and monitoring procedures
                                    PA-WDS 4
                                           Skill development training curriculum
                                    PA-WDS 5
                                           Table of contents for financial literacy curriculum
                                    PA-WDS 7
                                           Program staffing chart that includes lines of supervision
                                    PA-WDS 9
                                           List of program personnel
                                    PA-WDS 9
                                           Table of contents of training curricula
                                    PA-WDS 9
                                           Procedures and criteria used for assessing and evaluating
                             PA-WDS 9 workloads
Other Documents Not Listed on the Table of Evidence
1
2
3
Explanation for any "No" or "NA" checked above
                           Youth Development Services (PA-YD)
                                   Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                    PA-YD 3        Policies and/or procedures for maintaining and accessing
                                                   files of youth
                                    PA-YD 4        Policies and/or procedures regarding enrolling and serving
                                                   youth with special needs
                                                   Policies and/or procedures regarding youth with special
                                    PA-YD 5        behavioral needs or issues
                                    PA-YD 5        Policies for prohibited interventions

                                    PA-YD 6        Daily schedules for past month for all program components
                                    PA-YD 9        Menus (for previous month)
                                                   Hygiene procedures, including expectations for hand
                                    PA-YD 9        washing
                                    PA-YD 9        Procedures for meeting health needs and minimizing risk of
                                                   exposure to contagious or infectious disease
                                    PA-YD 9        Procedures for maintaining cleanliness and safety in the
                                                   indoor and outdoor space
                                    PA-YD 10       Table of contents of handbook for families
                                PA-YD 10     Policies and/or procedures regarding family involvement
                                PA-YD 12     Program ratio
                                PA-YD 12     Staff coverage schedule (for previous quarter)
                                PA-YD 12     Procedures or plan for coverage during absences or
                                             emergencies
                                PA-YD 12     Procedures governing arrivals and dismissals
                                PA-YD 13     List of programs personnel: name, job title, degree held
                                             and/or other credentials, professional preparation, FTE or
                                             volunteer, length of service at organization and current
                                             position
                                PA-YD 13     Policies and procedures regarding background checks
                                PA-YD 14     Table of contents for orientation curriculum
                                PA-YD 14     Table of contents for training curricula
                                PA-YD 14     Program staffing chart that includes lines of supervision
                                             (including supervision of volunteers)
                                             Policies and/or procedures regarding the use of volunteers
                                PA-YD 14     including training supervision, and recognition efforts
                                           Procedures and criteria used for assigning and evaluating
                             PA-YD 14      workloads
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above
                      Youth Independent Living Services (PA-YIL)
                                 Evidence Checklist

Instructions: This tool is both the Table of Contents for your electronic and hard copy self-study, and a
checklist for all documentation included in your self-study. Your agency is required to complete this
checklist. If your are completing a hard copy self-study, add a page number column, complete the checklist,
print it out, and place it in the front of each assigned section of standards. If you're completing an electronic
self-study, complete the checklist and create a hyperlink to the cell with the relevant piece of evidence.

In the event your agency checks "No" or "NA," provide a brief explanation in the area provided. For example
if your agency checks "No," the explanation may be: "Agreement with my COA Coordinator that evidence
will be reviewed on-site" or if your agency checks "NA," the explanation may be: "NA request granted by
COA."

Narrative
   Yes          No          NA      Evidence
                                    The Narrative is complete
Narrative Attachments
   Yes        No            NA      Evidence
                                    A list of all program sites
                                    A demographic profile of persons and families served by the program(s)
                                    being reviewed under this service section
                                    As applicable, a list of groups or classes
                                    A list of any programs that were opened, merged with other programs or
                                    services, or closed
                                    Two quarterly reports from the case record review process
                                    Two quarterly reports of accidents, incidents, and grievances
                                    All COA-approved NA Requests
                                    A list of all NAs applicable to your agency provided within the standards
                                    Outcomes measurement/data collection procedures
                                    Outcomes results reported for the previous two quarters
Self-Study Documentation
   Yes       No        NA           Evidence
                                           Screening procedures
                                    PA-YIL 3
                                           Assessment procedures
                                    PA-YIL 4
                                           Assessment tool and/or criteria
                                    PA-YIL 4
                                           Service planning procedures including youth participation
                                    PA-YIL 5
                                           Description of how the agency serves youth with special
                             PA-YIL 6      needs
                             PA-YIL 9      Transition activities list and planning procedures
                             PA-YIL 10     Aftercare and follow-up procedures
                             PA-YIL 11     Program staffing chart that includes lines of supervision
                             PA-YIL 11     List of program personnel
                             PA-YIL 11     Table of contents for training curricula
                                           Average workload size per worker for the last month and
                             PA-YIL 11     criteria used to assign cases
                             PA-YIL 11     Supervisory ratios
Other Documents Not Listed on the Table of Evidence
1
2
3

Explanation for any "No" or "NA" checked above

								
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