2024 Edition

Adult Day Services Definition

Purpose

Individuals who participate regularly in Adult Day Services achieve and maintain an optimal level of well-being, functioning and health, and remain in their preferred community residence.

Definition

Adult Day Services provide daytime, community-based services for adults who are in need of supervised support, stimulation, and care and who return home in the evening. Services are designed to maintain or improve social, psychological, and physical functioning. Health, social, educational, and/or supportive services are offered to individuals who need some supervision and assistance, but are not in need of intensive medical monitoring, rehabilitative services, more than minimal assistance with activities of daily living, or overnight care.

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


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

2024 Edition

Adult Day Services (CA-AD) 1: Person-Centered Logic Model

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

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

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

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

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

  • Logic models need improvement or clarification; or
  • Logic models are still under development for some of its programs, but are completed for all high-risk programs such as protective services, foster care, residential treatment, etc.; or
  • At least one outcome has been identified for all of its programs.
3

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

  • Logic models need significant improvement; or
  • Logic models are still under development for a majority of programs; or
  • A logic model has not been developed for one or more high-risk programs; or
  • Outcomes have not been identified for one or more programs.
4

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

  • Logic models have not been developed or implemented; or
  • Outcomes have not been identified for any programs.
 

CA-AD 1.01

A program logic model, or equivalent framework, identifies:

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

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


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

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

CA-AD 1.02

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

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

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

2024 Edition

Adult Day Services (CA-AD) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of service recipients.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised; or
  • Supervisors provide additional support and oversight, as needed, to the few staff without the listed qualifications; or 
  • Most staff who do not meet educational requirements are seeking to obtain them; or 
  • With few exceptions, staff have received required training, including applicable specialized training; or
  • Training curricula are not fully developed or lack depth; or
  • Training documentation is consistently maintained and kept up-to-date with some exceptions; or
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies when needed; or
  • With few exceptions, caseload sizes are consistently maintained as required by the standards or as required by internal policy when caseload has not been set by a standard; or
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services and are adjusted as necessary; or
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards.  Service quality or program functioning may be compromised; e.g.,
  • A significant number of staff (direct service providers, supervisors, and program managers) do not possess the required qualifications, including education, experience, training, skills, temperament, etc.; and as a result, the integrity of the service may be compromised; or
  • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur; or 
  • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications; or
  • A significant number of staff have not received required training, including applicable specialized training; or
  • Training documentation is poorly maintained; or
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies; or
  • There are numerous instances where caseload sizes exceed the standards' requirements or the requirements of internal policy when a caseload size is not set by the standard; or
  • Workloads are excessive, and the integrity of the service may be compromised; or 
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards.
 

CA-AD 2.01

Personnel are qualified by:
  1. the skill and experience to meet the psychosocial and medical needs of care recipients; and 
  2. the personal characteristics and temperament suitable for working with adults with special needs.
 

CA-AD 2.02

The program director or administrator is available full time at each site and is qualified:
  1. as a registered nurse; or 
  2. has a bachelor’s degree in a human service field and relevant experience.
Interpretation: If qualified directors or administrators are not employed full-time at every site, a qualified director or administrator should oversee a limited number of sites.
 

CA-AD 2.03

All direct service personnel are trained on, or demonstrate competency in the following areas, as appropriate to the services provided:
  1. crisis prevention and intervention techniques;
  2. identification of changes in service recipient functioning; 
  3. identification of medical needs or problems;
  4. the organization’s plans for handling medical or psychiatric emergencies;
  5. use of adaptive equipment, such as braces and wheelchairs;
  6. providing personal care; and
  7. specific skills necessary to serve the target population.
 

CA-AD 2.04

Personnel who lead or facilitate group activities have relevant training or experience.
 
Fundamental Practice

CA-AD 2.05

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

CA-AD 2.06

A recreational therapist is on staff or available for consultation.
 

CA-AD 2.07

Day programs with a health focus employ an RN or LPN.
NA The day program does not have a health focus.
 
Fundamental Practice

CA-AD 2.08

An organization that serves a high percentage of multiply handicapped or frail individuals obtains the specialized services of dietitians, nurses, physicians, and physical and/or occupational therapists for consultation, evaluation, or training.
Interpretation: If specialized services are provided off-site, support and transportation are arranged.
NA The organization does not serve a high percentage of handicapped or frail individuals.
 

CA-AD 2.09

The organization minimizes the number of workers assigned to the individual over the course of their contact with the organization by:
  1. assigning a worker at intake or early in the contact; and
  2. avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
 

CA-AD 2.10

Employee workloads support the achievement of client outcomes and are regularly reviewed.

Examples: Examples of factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of need and frequency of contact with persons served.
2024 Edition

Adult Day Services (CA-AD) 3: Intake and Assessment

The organization’s intake and assessment practices ensure that individuals receive prompt and responsive access to appropriate services.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • In a few rare instances, urgent needs were not prioritized; or
  • For the most part, established timeframes are met; or
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized; or 
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or 
  • Assessment and reassessment timeframes are often missed; or
  • Assessments are sometimes not sufficiently individualized; 
  • Culturally responsive assessments are not the norm, and this is not being addressed in supervision or training; or
  • Several client records are missing important information; or
  • Client participation is inconsistent; or
  • Intake or assessment is done by another organization or referral source and no documentation and/or summary of required information is present in case record. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing.  
 

CA-AD 3.01

Individuals are screened and informed about: 
  1. how well their request matches the organization's services; and
  2. what services will be available and when.
NA The organization accepts all referrals, as defined in a contract.
 
Fundamental Practice

CA-AD 3.02

Prompt, responsive intake practices:
  1. gather information necessary to identify critical service needs and/or determine when a more intensive service is necessary;
  2. give priority to urgent needs and emergency situations;
  3. support timely initiation of services; and
  4. provide placement on a waiting list or referral to appropriate resources when individuals cannot be served or cannot be served promptly.
 

CA-AD 3.03

Persons served participate in an individualized, culturally and linguistically responsive assessment that is:
  1. completed within established timeframes;  
  2. updated as needed based on the needs of persons served; and
  3. focused on information pertinent for meeting service requests and objectives.

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

2024 Edition

Adult Day Services (CA-AD) 4: Service Planning and Monitoring

Each person participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, client or staff signatures are missing and/or not dated; or
  • With few exceptions, staff work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc.; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In several instances, client or staff signatures are missing and/or not dated; or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is clearly inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or  
  • Documentation is routinely incomplete and/or missing; or
  • Individual staff members work with persons served, when appropriate, to help them receive needed support, access services, mediate barriers, etc., but this is the exception.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.  
 

CA-AD 4.01

An assessment-based service plan is developed in a timely manner with the full participation of persons served, and their family when appropriate, and includes:
  1. agreed upon goals, desired outcomes, and timeframes for achieving them;
  2. services and supports to be provided, and by whom; 
  3. possibilities for maintaining and strengthening family relationships and other informal social networks; 
  4. procedures for expedited service planning when crisis or urgent need is identified; and
  5. the individual’s signature.
Interpretation: Service planning is conducted in such a way that individuals and families retain as much personal responsibility and self-determination as possible and/or desired. Individuals with limited ability in making independent choices can receive help with making decisions for themselves and assuming more responsibility for making decisions.
 

CA-AD 4.02

The organization works in active partnership with persons served to:
  1. assume a service coordination role, as appropriate, when the need has been identified and no other organization has assumed that responsibility;
  2. ensure that they receive appropriate advocacy support;
  3. assist with access to the full array of services to which they are eligible; and
  4. mediate barriers to services within the service delivery system.
 

CA-AD 4.03

The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly, or more frequently depending on the needs of persons served, to assess:
  1. service plan implementation;
  2. progress towards achieving service goals and desired outcomes; and
  3. the continuing appropriateness of the agreed upon service goals.
Interpretation: When experienced workers are conducting reviews of their own cases, the worker’s supervisor must review a sample of the worker’s evaluations as per the requirements of the standard.
 

CA-AD 4.04

The worker and individual, and his or her family when appropriate:
  1. review progress towards achievement of agreed upon service goals; and 
  2. sign revisions to service goals and plans.
2024 Edition

Adult Day Services (CA-AD) 5: Service Elements

Social, education, health, and supportive services promote regular participation, optimal functioning, and independence.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
 

CA-AD 5.01

A varied program of social, educational, and supportive activities developed with program participants provides opportunities for:
  1. stimulation of talents and abilities;
  2. skill development and maintenance;
  3. acquiring and using practical information; and
  4. supported or competitive employment, as applicable to the service population.

Examples: Programming takes into account issues such as age-related dementia, brain injuries, mental illness, HIV/AIDS, gender/sexuality, and race/ethnicity.
 

CA-AD 5.02

Programs are:
  1. age-appropriate;
  2. culturally diverse; and
  3. adjusted to the functional levels of individual program participants.
 

CA-AD 5.03

An activity schedule is published and provides participants with choices.
 

CA-AD 5.04

Service recipients have the opportunity to interact with the community through:
  1. presentations, lectures, or workshops provided by community members; and
  2. planned trips within the community.
 
Fundamental Practice

CA-AD 5.05

The health and well-being of each service recipient is promoted through:
  1. contact with the person's physician at intake, as needed;
  2. education designed to enhance the individual’s optimum level of functioning and independence;
  3. basic assistance with activities of daily living;
  4. a nutrition program that meets individual needs and preferences;
  5. emergency medical and dental services, and first aid when needed; and
  6. notification of caregivers when changes in functioning are observed.

Examples: Nutrition programs can include:
  1. culturally competent nutrition;
  2. education;
  3. nutritious snacks; and 
  4. one or more balanced meals prepared according to the dietary needs of persons served and the current Canada Food Guide.
Health services can include:
  1. health assessments and monitoring;
  2. medication administration and help with self-administered medications; and 
  3. skilled nursing services.
 
Fundamental Practice

CA-AD 5.06

The ratio of personnel to participants is defined for all programs and activities, and is:
  1. adjusted according to degree of frailty or disability; 
  2. frequently reassessed in response to the changing needs of the group; and
  3. reviewed annually.
Interpretation: Generally, the ratio is at least one adult for every five to ten participants. The ratio for Alzheimer's patients is one adult for every four participants. Ratios may be achieved by use of volunteers in support positions.
2024 Edition

Adult Day Services (CA-AD) 6: Support Services for Caregivers

Caregivers receive coordinated services and support to help resolve issues related to caretaking.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
 

CA-AD 6.01

Providers work with service recipients and their caregivers to:
  1. coordinate services; and
  2. resolve obstacles to accessing or receiving services, including transportation or fees.
 

CA-AD 6.02

Caregivers receive support to address issues related to caretaking and caregiver stress, and are provided with referrals for needed services including:
  1. support groups and counselling services;
  2. health, mental health, and substance use services;
  3. domestic violence services;
  4. shelter and housing services;
  5. respite care;
  6. social, recreational and day programs; and
  7. mentor services.
 

CA-AD 6.03

The organization maintains a comprehensive, up-to-date list of community resources.

Note: Adult Day Services can be considered a form of respite care for caregivers. See also COA’s Home Care and Support Services (CA-HCS), and Respite Care (CA-RC) standards.
2024 Edition

Adult Day Services (CA-AD) 7: Service Environment

Program activities take place in a safe, supportive setting that fosters personal growth and healthy development.
Interpretation: If the organization offers program activities in a variety of different settings, it should ensure that all settings are safe, supportive, and appropriate to the service population.

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VIEW THE STANDARDS

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing.      
 

CA-AD 7.01

Program space and materials are welcoming, engaging, culturally responsive, and designed to encourage participation.
 

CA-AD 7.02

The program setting provides adequate space and materials to accommodate a range of functionally appropriate activities.

Examples: Spaces can accommodate a variety of indoor and outdoor activities, including small group activities, large group activities, and socialization with peers.
 

CA-AD 7.03

Program rules, behavioural expectations, and participant rights and responsibilities are developed with input from individuals enrolled in the program and are enforced in a fair and consistent manner.
2024 Edition

Adult Day Services (CA-AD) 8: Case Closing and Aftercare

The organization works with persons served and family members, when appropriate, to plan for case closing and, when possible, to develop aftercare plans.

1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice Standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice Standards; e.g.,   
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions, procedures are understood by staff and are being used; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations and training; or
  • In a few instances, the organization terminated services inappropriately; or  
  • Active client participation occurs to a considerable extent; or
  • A formal case closing evaluation is not consistently provided to the public authority per the requirements of the standard.
3
Practice requires significant improvement, as noted in the ratings for the Practice Standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Services are frequently terminated inappropriately; or  
  • Aftercare planning is not initiated early enough to ensure orderly transitions; or
  • A formal case closing summary and assessment is seldom provided to the public authority per the requirements of the standard; or  
  • Several client records are missing important information; or
  • Client participation is inconsistent. 
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice Standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or 
  • Documentation is routinely incomplete and/or missing. 
 

CA-AD 8.01

Planning for case closing:
  1. is a clearly defined process that includes assignment of staff responsibility;
  2. begins at intake; and
  3. involves the worker, persons served and others, as appropriate to the needs and wishes of the individual.
 

CA-AD 8.02

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

CA-AD 8.03

If an individual has to leave the program unexpectedly, the organization makes every effort to identify other service options and link the person with appropriate services.
Interpretation: The organization must determine on a case-by-case basis its responsibility to continue providing services to persons whose third-party benefits are denied or have ended and who are in critical situations.
 

CA-AD 8.04

When appropriate, the organization works with persons served and their family to:
  1. develop an aftercare plan, sufficiently in advance of case closing, that identifies short- and long-term needs and goals and facilitates the initiation or continuation of needed supports and services; or
  2. conduct a formal case closing evaluation, including an assessment of unmet need, when the organization has a contract with a public authority that does not include aftercare planning or follow-up.
 

CA-AD 8.05

The organization follows up on the aftercare plan, as appropriate, when possible, and with the permission of persons served.
NA The organization has a contract with a public authority that prohibits or does not include aftercare planning or follow-up.

Examples: Reasons why follow-up may not be appropriate, include, but are not limited to, cases where the person's participation is involuntary, or where there may be a risk to the individual such as in cases of domestic violence.
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