PCE Accreditation Request for Engagement



7451090-251460007603490-990600077558905334000790829020574000806069035814000SECTION ONEIdentifying InformationOrganization: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????Zip: FORMTEXT ?????Telephone: FORMTEXT ????? Fax: FORMTEXT ?????Date Submitted: FORMTEXT ?????Chief Executive Officer/Executive Director/OwnerName: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????E-mail Address: FORMTEXT ?????Organization Contact (Primary contact for coordination):Name: FORMTEXT ?????Title: FORMTEXT ?????Phone: FORMTEXT ?????E-mail Address: FORMTEXT ?????BillingContact name: FORMTEXT ?????Address (if different from above): FORMTEXT ?????Phone: FORMTEXT ?????E-mail Address: FORMTEXT ?????Scheduling Preference: (must have at least 3 months for preparation)1st Choice: FORMTEXT ?????2nd Choice: FORMTEXT ?????3rd Choice: FORMTEXT ?????Please list any weeks during these months that are unavailable for the review: FORMTEXT ?????Types of Services Provided by the OrganizationPlease check all that apply: FORMCHECKBOX Direct and/or support services for young children and their families (ages 0-5). Number of people served: FORMTEXT ????? FORMCHECKBOX Direct and/or support services for children and youth (ages 6-18). Number of people served: FORMTEXT ????? FORMCHECKBOX Employment and/or support services for adults (ages 16 and above) with disabilities. Number of people served: FORMTEXT ????? FORMCHECKBOX Direct and/or support services for adults (ages 19 and above) with disabilities. Number of people served: FORMTEXT ????? FORMCHECKBOX Direct and/or support services for adults (ages 19 and above) with behavioral health issues as their primary diagnosis. Number of people served: FORMTEXT ????? FORMCHECKBOX Service coordination/Case Management services for young children and their families (ages 0-5) Number of people served: FORMTEXT ????? FORMCHECKBOX Service coordination/Case Management services for children and youth (ages 6-18). Number of people: served: FORMTEXT ????? FORMCHECKBOX Service coordination/Case Management services for adults (ages 19 and above) Number of people served: FORMTEXT ????? FORMCHECKBOX Other services not falling under these categories (describe briefly): FORMTEXT ????? Number of people served: FORMTEXT ?????Information About People Served by the Organization Please indicate the number of people served by the organization in each of the categories listed. BelowAge 6Age6-18Age19-55Over Age 55TOTALTotal FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Total number of people served (unduplicated) FORMTEXT ?????Total number of service locations FORMTEXT ?????Please indicate if you provide services in multiple counties or states FORMTEXT ?????Organization’s Operating BudgetPlease Select: FORMCHECKBOX $0 - $1,000,000 FORMCHECKBOX $1,000,001 - $2,500,000 FORMCHECKBOX $2,500,001 - $5,000,000 FORMCHECKBOX $5,000,001+SECTION TWOSelection of Desired Accreditation Please select the accreditation model that best suits the needs of your organization from the options below. Please note that the accreditation model selected for your organization must be approved by CQL. Descriptions of the accreditation models can be found in Addendum A (attached). FORMCHECKBOX CQL Systems Accreditation FORMCHECKBOX CQL Quality Assurances Accreditation FORMCHECKBOX CQL Person-Centered Excellence Accreditation FORMCHECKBOX CQL Person-Centered Excellence With Distinction Accreditation (Please refer to pages 15-17 for additional requirements for this level of accreditation and evidence that must be submitted with this Request for Engagement. Failure to submit requested documents will result in your agency’s request to be denied for PCE-D. SECTION THREEAdditional InformationIn addition to the completion of all forms, please submit the following information: FORMDROPDOWN Is your organization currently accredited by CQL? Current Accreditation Expiration Date: FORMTEXT ????? FORMDROPDOWN Has your organization changed names, merged, split, or otherwise structurally changed since the last review? If so, please check box and clearly identify those changes. FORMDROPDOWN Has your organization undergone review or to the best of your knowledge, will your organization undergo review under CMS’ heightened scrutiny for Home and Community-Based Settings? (For US Organizations only)If yes, please describe the feedback from CMS below: FORMTEXT ????? FORMCHECKBOX Please include your organization’s Mission Statement--Values and Vision Statements here. FORMTEXT ????? FORMCHECKBOX Please provide an organizational biography. FORMTEXT ????? FORMCHECKBOX Please provide your reasons for seeking CQL Accreditation and expectations for CQL Accreditation. FORMTEXT ?????Please describe the organization’s exposure, if any, to the Personal Outcome Measures?. FORMDROPDOWN Does the organization currently utilize CQL’s Personal Outcome Measures?: If Yes: Describe the information gathering process and how data is collected and analyzed. FORMTEXT ?????Describe how information gleaned from Personal Outcome Measures? is used at your organization (i.e. individual discovery and planning, organizational evaluation and planning, etc.) FORMTEXT ?????Does your organization have any Certified Personal Outcome Measures? Trainers or Interviewers employed at your organization? FORMDROPDOWN If yes, please list all Certified Personal Outcome Measures? Trainers or Interviewers currently employed at the ments: FORMTEXT ?????SECTION FOURCertification of Compliance (to be submitted with the Request for Engagement)Organization Name: FORMTEXT ?????Address: FORMTEXT ?????CEO Name: FORMTEXT ?????Phone: FORMTEXT ?????I certify that (org name) FORMTEXT ????? is in compliance with all required local, state, and federal regulations relevant to the supports and services we provide including:Licensing and certification requirements;Sanitation/fire and safety codes;Reporting compliance for incidents, abuse and/or neglect; andAny other that may apply.I affirm that there are no current open or unresolved issues related to:Outstanding fiscal or legal sanctions;Non-compliance with regulations;Licensing exceptions;Unfavorable third-party reviews;Abuse, neglect, or other circumstances being investigated by local, state or federal entities; andAny related circumstances that require a plan of correction in order to remain licensed, certified, or funded.Outstanding negative publicityI confirm that we have:current external monitoring reports and responses for all services and supports provided;current external monitoring reports and responses for all licensed buildings showing that all required safety/compliance standards are met;clear policies that state the procedures for meeting local, state, funding, and federal requirements;current plans of correction showing all outstanding issues have been (or are being) addressed. I agree to provide completed copies of evidence of compliance for any external monitoring reports and if appropriate, approved corrective plans to CQL as requested. If your regulating/licensing body publishes licensure or certification information, please include the website/hyperlink or other means to access that information here: FORMTEXT ?????Name (type or print): FORMTEXT ????? Date: FORMTEXT ????? FORMTEXT ?????CEO Signature:If you are submitting this form electronically, please type name above and check this box FORMCHECKBOX to confirm that this emailed document is a binding agreement without the actual signature of the Chief Executive Officer.SECTION FIVEList of Organization Leadership staff: Purpose:This list will be used to coordinate a Pre-engagement Planning Call which is designed to provide the organization’s leadership staff with information about the accreditation process, preparation activities and responsibilities. #NAMETITLEPHONEEMAIL ADDRESS1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????5 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????6 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????7 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????8 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????9 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????10 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????11 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????12 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????13 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????14 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????15 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION SIXTravel Advice for CQL TeamAirport InformationNearest Major Airport: FORMTEXT ?????Distance from Organization (miles): FORMTEXT ?????Lodging InformationHotel/MotelCityTelephoneDistance to Organization FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION SEVENEngagement AgreementThe undersigned hereby agrees to work with CQL | The Council on Quality and Leadership for CQL Accreditation and/or related activities, agrees to pay the established fee, and grants permission to licensing agencies and any other relevant examining or reviewing entity or group to release official records and information to CQL for its consideration during the accreditation process.Upon receipt, CQL will process this request and, if accepted upon review of documentation, set dates for the initial accreditation. In the event that the scheduled accreditation is canceled or postponed by the organization, the organization is responsible for payment of any expenses incurred by anization Name: FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Signature of Chief Executive Officer:Date: FORMTEXT ?????If you are submitting this form electronically, please type name above and check this box FORMCHECKBOX to confirm that this emailed document is a binding agreement without the actual signature of the Chief Executive Officer.SECTION EIGHTChecklist(to be completed by the organization) FORMCHECKBOX All sections that apply are completed FORMCHECKBOX CEO signature or electronic signature box is checked as confirmation of Certification of Compliance and Engagement Agreement FORMCHECKBOX Submit form electronically to: RFE@ FORMCHECKBOX Engagement fee of $2500 (NON-REFUNDABLE) for all accreditation options except for Systems Accreditation. The Engagement Fee for Systems Accreditation is $1,000. FORMCHECKBOX Pay by check – mail to: CQL | The Council on Quality and Leadership PO Box 824904, Philadelphia, PA 19182-4904 FORMCHECKBOX Pay by Credit Card using our Secure Payment Portal. Click or cut and paste this link: Next Steps You will receive a Letter of Engagement with the onsite dates and cost of accreditation along with a Preparation Packet once the request has been processed and accepted. Addendum A: Accreditation Model DescriptionsCQL Systems AccreditationTermCriteria To Achieve AccreditationIntended For1 yearCompleted Basic Assurances? and Shared Values? Self-Assessments by OrganizationCQL validation of 100% Compliance with Shared Values? and applicable systems related to Basic Assurances?NOTE: Once services have been initiated, the organization must apply for CQL Quality Assurances Accreditation to maintain accreditationOrganizations not yet providing direct servicesCQL Quality Assurances AccreditationTerm Criteria To Achieve AccreditationIntended For3 yearsINITIAL VISIT-ONSITE: Completed Basic Assurances? and Shared Values? Self-Assessments by OrganizationCQL validation of 100% Compliance with Shared Values? and applicable Basic Assurances?Successful implementation of the accreditation partnership agreement, including implemented plan of correction completed within 9 months (if applicable) for any Basic Assurances? not present during initial visitSECOND VISIT-ONSITE: Completed Responsive Services? and Community Life? Self-Assessments by OrganizationCQL validation of implementation of Personal Outcome Measures? on an individual and organizational levelCQL validation of implementation of recommendations from first visit and 100% compliance with applicable Responsive Services? and Community Life? IndicatorsCQL validation of the implementation of an integrated quality management plan including Personal Outcome Measures? dataNOTE: CQL reserves the right to require a third onsite visit if criteria is not metOrganizations new to CQL or those wanting to enhance systems and practices related to health, safety and human securityOrganizations dedicated to Responsive Services? and Community Life?Organizations committed to improving personally defined quality of life through the implementation of CQL’s Personal Outcome Measures?CQL Person-Centered Excellence AccreditationTerm CriteriaIntended For4 yearsINITIAL VISIT-ONSITE: Completed Basic Assurances? and Shared Values? Self-Assessments by OrganizationCQL validation of 100% Compliance with Shared Values? and applicable Basic Assurances?Successful implementation of the accreditation partnership agreement, including implemented plan of correction completed within 9 months (if applicable) for any Basic Assurances? not present during initial visitCQL validation of implementation of Personal Outcome Measures? on an individual and organizational levelCQL facilitation of Person-Centered Excellence stakeholder group and What Really Matters plan developmentSECOND VISIT-OFFSITE: CQL validation of implementation of recommendations from first visit and of progress made on What Really Matters plan short range goalsTHIRD VISIT-OFFSITE: CQL validation of implementation of recommendations from second visit and of progress made on What Really Matters plan longer range goalsCQL validation of ongoing implementation and enhancement of an organizational integrated quality management systemOrganizations wanting to focus on health, safety and human securityOrganizations dedicated to Responsive Services? and Community Life?Organizations currently implementing CQL’s Personal Outcome Measures?Organizations with an established integrated quality management system (Refer to Basic Assurances? Factor 10 for details) that incorporates Personal Outcome Measures? dataOrganizations committed to engaging stakeholders in the development and implementation of an organizational plan focused on What Really Matters to peopleCQL Person-Centered Excellence With Distinction AccreditationTerm Criteria To Achieve AccreditationIntended For4 yearsINITIAL VISIT-ONSITE: Completed Basic Assurances? and Shared Values? Self-Assessments by OrganizationCQL validation of alignment with Shared Values? and applicable Basic Assurances?Successful implementation of the accreditation partnership agreement, including implemented plan of alignment completed within 9 months (if applicable) for any Basic Assurances? not present during initial visitCQL validation of implementation of Personal Outcome Measures? including the use of CQL Certified Reliable Interviewers/TrainersMinimum annual representative sample of 10% of total agency size or 200 POM interviews (whichever number is lower, and which may be negotiated) and included in CQL Database and which must be performed by a CQL Certified Interviewer. Agency-led facilitation of Person-Centered Excellence stakeholder group and What Really Matters plan development (with support from CQL)At least 2 CQL accreditation cycles where the organization has remained in good standing per CQL policy/partnership agreement. At least one cycle must be Person-Centered Excellence Accreditation.Robust quality improvement strategies with accompanying relevant data. Demonstration of organizational transformation (this may be in place of, or in addition to, organization biography)Community impact/influence (how is the agency perceived in the community? Does it have a positive impact on the community as a whole? Is it “of” the community?) This would include a Community Life? Self-Assessment and Validation.Evidence that the agency does not have systems and practices in place that allow:Floor restraints, “take downs,” or standing orders for restraintUse of time out roomsUse of “as needed” psychotropic medications for behavior control.Use of corporal punishment, seclusion, noxious or aversive stimuli, forced exercise, and denial of food or liquids that are part of a person’s nutritionally adequate dietEvidence of advocacy efforts (self-advocacy and supports, local, state and national systems advocacy)Evidence of person-centered planning and person-directed planning meetingsEvidence of innovative strategies to support peopleNew agencies that are applying for PCE-D that have campus type settings, institutions, or large congregate residential or work settings are not eligible to apply unless there is demonstrated access to the community for people that is the same as for those without disabilities; a formal commitment to downsizing that includes objective criteria that can be measured for success; demonstration of a degree of success with downsizing, and demonstration of person-centered planning and support despite the limitations of the physical environment.SECOND VISIT-OFFSITE: CQL validation of implementation of recommendations from first visit and of progress made on What Really Matters plan short term goalsTHIRD VISIT-OFFSITE: CQL validation of implementation of recommendations from second visit and of progress made on What Really Matters plan long range goalsCQL validation of ongoing implementation and enhancement of an organizational integrated quality management system that incorporates reliable Personal Outcome Measures? dataOrganizations wanting to focus on health, safety and human securityOrganizations dedicated to Responsive Services? and Community Life?Organizations committed to improving personally defined quality of life through the implementation of CQL’S Personal Outcome Measures?Organizations with demonstrated internal capacity for collecting reliable data via currently CQL Certified Interviewers/TrainersOrganizations with an established integrated quality management system (Refer to Basic Assurances? Factor 10 for details) that incorporates reliable Personal Outcome Measures? dataOrganizations committed to taking a lead role in engaging stakeholders in the development and implementation of an organizational plan focused on What Really Matters to peopleNOTE: * An agency may apply to be considered for PCE-D. With the application, the agency must also provide evidence of the following:Quality Management plan and strategic planNames and certification dates for certified Personal Outcome Measures? interviewers (CQL will check those against internal records)Evidence of community influence (stories, etc.).Advocacy effortsAccreditation with Distinction will not be decided on-site. “Distinction” will be decided by the accreditation team presenting evidence to a team of 3 or 5 persons consisting of some or each of the following: other QES staff, VP of Accreditation and Training, Director of Accreditation, a Board member with agency experience, and the President/CEO of CQL. This decision by a majority of the panel should be reached within 10 business days of the end of the on-site visit.Accreditation with Distinction will require an additional on-site day of the accreditation team to ensure thorough review of additional criteria. The organization pursuing CQL Accreditation with Distinction is responsible for the additional staff and travel/lodging costs associated with this additional day.Return to Selection of Desired Accreditation ................
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