2024 Edition

Administrative and Service Environment Introduction

Purpose

The organization’s administrative and service environments are respectful, safe, and accessible and contribute to organizational effectiveness.

Introduction

The Administrative and Service Environment standards reflect the significant impact that accessibility; physical, psychological, and emotional safety; and personal dignity have on an organization’s effectiveness. Specifically, these standards address how accessibility, facility maintenance, safety procedures both on- and off-site, a trauma-informed environment, and emergency response preparedness contribute to organizational productivity and effective service delivery.

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


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

2024 Edition

Administrative and Service Environment (CA-ASE) 1: Promotion of Health and Safety

In its daily operations, the organization ensures:
  1. the health and safety of its personnel and the individuals and families it serves; and
  2. that its administrative and service environments are respectful and promote the dignity of personnel.

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

1
The organization's practices reflect full implementation of the standard. The organization is proactive about health and safety.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement; e.g.,
  • Service quality or organizational functioning may be compromised and staff and/or stakeholders may be at risk.
4
Implementation of the standard is minimal or there is no evidence of implementation at all: e.g.,
  • Staff or stakeholders are at risk due to serious health or safety concerns that remain unaddressed.
2024 Edition

Administrative and Service Environment (CA-ASE) 2: Service Delivery Environment

The service delivery environment promotes respect, healing, and positive behaviour of the service recipient.

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 2 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 2 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 2 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 2 Practice standards.
 

CA-ASE 2.01

Personnel support positive behaviour by:
  1. developing positive relationships with service recipients;
  2. being trauma-informed;
  3. building on service recipients’ strengths and reinforcing positive behaviour; and
  4. responding consistently to all incidents that challenge the safety of service recipients.
Related Standards:
Interpretation: Procedures for responding to incidents must address safety measures used in emergency situations, including whether restrictive behaviour management interventions may be used to protect service recipients from harming themselves or others. 

NA The organization is only assigned the Financial Education and Counseling (CA-FEC) standards. 

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements is not fully addressed.
3
Practices are basically sound but there is room for improvement; e.g.,
  • Two of the elements are not fully implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of elements is not addressed at all.
 
Fundamental Practice

CA-ASE 2.02

The organization:
  1. monitors the service population for emerging physical, psychological, and emotional safety needs; and
  2. modifies the service environment or procedures as necessary to respond to the safety needs of the population.

NA The organization is only assigned the Financial Education and Counseling (CA-FEC), Early Childhood Education (CA-ECE), and/or Out-of-School Time Services (CA-OST) standards.

Examples: Mechanisms that can be used to respond to the safety needs of the population include, but are not limited to:

  1. monitoring interactions among service recipients and staff to ensure they remain respectful, calming, and empowering;
  2. establishing and enforcing rules that promote a transparent and therapeutic service environment;
  3. soliciting and responding to feedback from service recipients regarding their perceived safety in the service environment; and
  4. staggering scheduling or providing separate entrances when survivors of violence or exploitation and individuals with histories of violent behaviour are served in the same facility.

1
The organization monitors safety risks, responds to safety needs of service recipients and has implemented procedures for ensuring psychological, emotional, and physical safety as per the requirements of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Communications with service recipients about available protections and procedures could be improved at some locations, and the organization is working to address the issue.
3
Practice requires significant improvement; e.g.,
  • Safety needs are monitored inconsistently; or
  • Safety risks have been identified but protections are not yet fully in place in at least one program site; or
  • Safety procedures are vague because the organization has not paid sufficient attention to the safety needs of service recipients.
4
The organization does not monitor safety risks of service recipients and safety needs are not met as required by the standard.
 

CA-ASE 2.03

The organization informs service recipients and parents or legal guardians about its procedures for:
  1. maintaining a safe service environment, including procedures that address harassment and violence towards other service recipients and personnel; and
  2. preventing the need for emergency interventions, including restrictive behaviour management interventions.

NA The organization is only assigned the Financial Education and Counseling (CA-FEC) standards.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Information provided needs minor clarification; or
  • One of the required elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Neither of the two elements is fully addressed; or
  • One element is not addressed at all; or
  • Parents or legal guardians are frequently not notified.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
Fundamental Practice

CA-ASE 2.04

The organization maintains a work environment for its personnel that is conducive to effectively providing services to individuals and families in a private and confidential manner, as needed.
Related Standards:

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

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Some of the organization's facilities are cramped or in need of updating or expansion to better ensure confidentiality.
3
Practice requires significant improvement; e.g.,
  • Some of the organization's facilities lack sufficient space for confidential staff conferences or meetings where client cases are discussed; or
  • Some service delivery sites lack enough, or sufficiently private, interviewing space at peak periods.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The work environment in at least one service delivery site is wholly inadequate for effective, confidential service delivery; or
  • The organization makes no provision for confidential interactions with persons served; or
  • A number of sites lack adequate provisions for privacy for interviewing or for conducting the collective business of the organization such as meetings, case conferences, etc.
 

CA-ASE 2.05

The environment promotes a non-threatening, welcoming, and inclusive approach that fosters trust and engagement for all people.

Interpretation: Programs should provide a supportive, safe, and welcoming environment for all people. Programs can help to signal that they provide an environment that is safe and welcoming by posting “visual cues” of their commitment to equity, diversity, and inclusion in the reception or common area such as a copy of the nondiscrimination policy, a copy of the equity statement, culturally diverse décor, LGBTQ+ symbols, or posters and stickers promoting racial justice.

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement; e.g.,

  • Some visual cues are present in all the organization’s facilities, but more could be done to reflect the diversity of staff and persons served; or
  • Visual cues are lacking in some of the organization’s facilities, but staff and persons served report feeling welcome and safe in the service delivery environment.


3

Practice requires significant improvement; e.g.,

  • Some staff and persons served report feeling unwelcome or unsafe in the service delivery environment; or
  • Visual cues are lacking in several of the organization’s facilities.


4

Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-ASE 2.06

Organization policy prohibits activities or interventions that are harassing, threatening, or otherwise harmful to an individual’s well-being. 

Interpretation: The activities or interventions that will be prohibited by organization policy may vary based on service type, population served, and the service delivery setting but should include, as appropriate:

  1. corporal punishment;
  2. the use of aversive stimuli and/or therapies;
  3. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain;
  4. the use of demeaning, shaming, degrading, or bullying language or activities;
  5. forced physical exercise to eliminate behaviours;
  6. unnecessarily punitive restrictions, including restricting family contact, celebrations, or prescribed treatment interventions as a disciplinary action;
  7. unwarranted use of invasive procedures or activities as a disciplinary action;
  8. punitive work assignments;
  9. punishment by peers;
  10. conversion or reparative therapies;
  11. deliberate misgendering;
  12. disciplinary room confinement; and
  13. group punishment or discipline for individual behaviour.
2024 Edition

Administrative and Service Environment (CA-ASE) 3: Accessibility and Accommodation

Services and facilities are accessible, inclusive, and accommodate the diverse needs of service recipients.

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 3 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 3 Practice standards.
 

CA-ASE 3.01

In planning the location and use of offices and branches, the organization considers:
  1. accessibility, availability, and affordability of public transportation;
  2. location of other relevant community resources; and
  3. the special needs of the defined service population as well as the needs of persons with disabilities.

Interpretation: If some of the organization's administrative or service facilities are not accessible to people with physical disabilities, the organization provides or arranges for equivalent services at an alternate convenient, and accessible location. 

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

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements is not fully addressed, but the organization has taken steps to strengthen practice.
3
Practice requires significant improvement; e.g.,
  • The organization does not consider the availability of public transportation nor does it formally review the distribution of persons within the service population in relation to facility locations; or
  • Does not formally consider the needs of persons with special needs when planning and locating service delivery sites.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
Fundamental Practice

CA-ASE 3.02

The organization designs and adapts its programs and services, as appropriate, to accommodate the visual, auditory, linguistic, and motor abilities of persons served.
Related Standards:

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

CA-ASE 3.03

The organization accommodates the written and oral communication needs of clients by:
  1. communicating, in writing and orally, in the languages of the major population groups served;
  2. providing, or arranging for, bilingual personnel or translators or arranging for the use of communication technology, as needed;
  3. providing telephone amplification, sign language services, or other communication methods for deaf or hard of hearing persons;
  4. providing, or arranging for, communication assistance for persons with special needs who have difficulty making their service needs known; and
  5. considering the person's literacy level.

Examples: Examples of ways the organization can demonstrate standard implementation include, but are not limited to:
  1. providing basic program information in languages representative of service recipient groups;
  2. proactively reaching out to ensure that all individuals can use its services and fully participate in planning;
  3. hiring sufficient numbers of bilingual personnel or has made arrangements for translators/interpretors for all programs in which confidential interpersonal communication is necessary for adequate service delivery;
  4. ensuring there is a bilingual worker on staff or a translator/interpretor is available for each language group large enough to comprise an average-sized caseload;
  5. offering trained translators or interpreters in non-counseling services when bilingual personnel are not available without depending upon children or other individuals unable to maintain the integrity of the client-provider relationship; and
  6. using assistive technology, such as amplification for deaf or hard of hearing persons or a language telephone line, when appropriate.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The organization has been unable to secure the services of enough bilingual personnel or translators to cover its consumers’ needs but efforts to do so are underway; or
  • Accommodations for one of the populations served needs some minor improvement; e.g. better access to communication assistance.
3
Practice requires significant improvement; e.g.,
  • Accommodation is made for some, but not all primary groups served; or
  • Little effort is made to address communication needs other than language barriers.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
Fundamental Practice

CA-ASE 3.04

The organization supports equitable delivery of its programs and services to individuals with intellectual and developmental disabilities (IDD) by:

  1. providing services to individuals based on assessed needs, individual and organization capacity, and the wishes of the person; and
  2. connecting individuals and families to appropriate providers when specific needs cannot be met by the organization.

Interpretation: Regarding element (a), the decision to serve individuals with intellectual and developmental disabilities should be made based on how well the organization’s services can meet the service requests and identified needs of the individual and not be made based solely on the presence or absence of an intellectual or developmental disability.

1

The organization's practices reflect full implementation of the standard.

2

Practices are basically sound but there is room for improvement.

3

Practice requires significant improvement.

4

Implementation of the standard is minimal or there is no evidence of implementation at all.

2024 Edition

Administrative and Service Environment (CA-ASE) 4: Facility Safety and Maintenance

The organization's facilities and grounds are safely maintained and are routinely monitored.
Related Standards:

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 4 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 4 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 4 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 4 Practice standards.
 
Fundamental Practice

CA-ASE 4.01

All facilities in which the organization operates are properly maintained through:
  1. monthly inspections to ensure the organization’s facilities are safe and heating, lighting, and other systems are functioning properly;
  2. preventive maintenance by a qualified professional; and
  3. quick responses to emergency maintenance issues and potentially hazardous conditions.
Related Standards:
Interpretation: If the organization is a tenant in its facilities, some or all of the above activities may be conducted by the landlord. In such instances, the organization must be able to demonstrate that it monitors and documents the completion of elements (a) through (c) to provide a safe environment for people to work and receive services.

Examples: “Emergency maintenance issues” can include: overflowing toilets, flooded basements, defective heating systems, and other situations that can damage property, pose a threat to clients, or interfere with service delivery.
 
Examples of “hazardous conditions” include: uncovered electrical outlets, improper storage of cleaning supplies and other hazardous materials, unsecured floor coverings or equipment, stairs without handrails, harmful water temperatures, inadequate lighting, improper ventilation, uncomfortable room temperatures, unscreened areas or unmarked glass doors, broken or malfunctioning tools or equipment, including electrical appliances.

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

1
The organization's practices reflect full implementation of the standard. All administrative and service-delivery facilities are safe and well-maintained in accordance with comprehensive maintenance procedures as per the requirements of the standard.
2
Practices are basically sound and facilities are generally safe and well-maintained, but there is room for improvement; e.g.,
  • Inspections are conducted regularly on a timeframe established in procedures at all administrative and program sites, but non-emergency or non-hazardous issues identified as needing maintenance are not always resolved in a timely manner; or
  • The organization rarely reviews the need for, or conducts, preventive maintenance, instead making repairs on an "as needed" basis; or
  • Review of the physical plant at some programs or sites is conducted less than monthly but at least quarterly; or
  • Maintenance records are not always up-to-date at rented facilities.
3
Practice requires significant improvement and potentially unsafe conditions exist at at least one administrative or service-delivery site; e.g.,
  • One of the standard's elements is not addressed at all; or
  • Poorly written or incomplete maintenance procedures, or use of unqualified staff have resulted in the failure to recognize critical problems needing attention; or
  • Maintenance procedures are implemented in a cursory or haphazard manner; or
  • Needed repairs are typically not made in a timely manner; or
  • There are ongoing problems with critical systems, like the hot water supply or heat, that the organization is attempting to remediate, thus far unsuccessfully; or
  • There are deficiencies in regard to health, sanitation, and safety codes and regulations, and remedial action is being taken under direction from authorities; or
  • Maintenance at rented facilities is not routinely monitored and/or documented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • At least two of the standard's elements have not been addressed at all; or
  • Staff and/or clients are at risk due to the organization's failure to conduct routine inspections or maintenance, make critical repairs of emergency issues or hazardous conditions, or otherwise properly maintain at least one of its owned or rented facilities; or
  • Licensure or certification has been denied or revoked due to failure to meet applicable health and safety codes and regulations.
 
Fundamental Practice

CA-ASE 4.02

An organization that permits or requires the use of agency- or privately-owned vehicles to transport clients requires:
  1. the use of age-appropriate passenger restraint systems;
  2. adequate passenger supervision, as mandated by statute or regulation;
  3. proper maintenance of agency-owned vehicles;
  4. current registration and vehicle safety review;
  5. annual validation of licenses and driving records for staff who are permitted to transport clients; and
  6. motor vehicle insurance.
Related Standards:
Interpretation: This standard does not apply to vehicles owned by resource families, which are covered by CA-FKC 18.05 and CA-AS 10.06.

Interpretation: When the organization has a contract with an outside transportation provider, it must include relevant safety expectations in the contract.
NA The organization does not permit or require transporting clients in agency- or privately-owned vehicles.

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

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • In rare instances routine vehicle maintenance or driver’s license checks are delayed.
3
Practice requires significant improvement; e.g.,
  • The process for validating drivers licenses or driving records of staff currently using organization-owned vehicles to transport clients in their own vehicles is backlogged; or
  • Vehicle maintenance, insurance, or other records are poorly maintained resulting in confusion about how well the standard is being implemented.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.
 

CA-ASE 4.03

When services are offered on a consistent and on-going basis, in a location that is not owned or leased by the organization, prior to using the facility, the organization develops a memorandum of understanding (MOU) or a contractual agreement with the host that includes:
  1. space and equipment needs;
  2. health and safety expectations; and
  3. each group’s responsibility for cleaning, maintenance, liability risk, and other costs (e.g., utilities, insurance, and repairs).
NA The organization does not offer services on a consistent and on-going basis at locations it does not own or lease.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Procedures need strengthening; or
  • One element has not been fully addressed.
3
Practice requires significant improvement; e.g.,
  • Agreements/contracts are often poorly executed and maintained, e.g., terms and conditions are general, nonspecific, or unclear; or
  • At least two of the elements have not been fully addressed; or
  • One element has not been addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
2024 Edition

Administrative and Service Environment (CA-ASE) 5: Safety and Security

The organization ensures that all buildings, grounds, and facilities promote the safety and security of persons served, personnel, and visitors.
Related Standards:

1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 5 Practice standards; health or safety concerns are promptly addressed.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 5 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 5 Practice standards.
 
Fundamental Practice

CA-ASE 5.01

The organization assesses its safety and security needs and:
  1. takes appropriate measures to protect the safety of all persons who are in its facilities or on its grounds; and
  2. develops safety and communication protocols for staff, including staff that work off-site, as applicable.
Related Standards:

Examples: Appropriate measures can include procedures and protocols for public health emergencies, bars on windows, alarm systems, and written policies prohibiting the possession of weapons on the facilities premises except by qualified security and law enforcement personnel.

1
The organization regularly assesses the safety and security of its facilities and grounds as per the requirements of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Some non-critical recommendations of the safety assessment have not been addressed; or
  • Safety and communication protocols for off-site workers lack clarity or are somewhat outdated.
3
Practice requires significant improvement; e.g.,
  • The organization's approach to assessing safety and security of its facilities and grounds is inconsistent across programs and sites or not thorough, and as a result, appropriate measures are not in place, e.g., staff are not notified in advance when maintenance requires shutting off water, or staff report insufficient lighting in parking areas, or areas in need of repair are not cordoned; or
  • Communication protocols lack clarity or are outdated; or
  • Security systems for deterring break-ins are not in place in at least one site.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization’s buildings, grounds and facilities are unsafe.
 
Fundamental Practice

CA-ASE 5.02

The organization trains staff on:
  1. safety procedures and protocols;
  2. potential risks they may encounter on-site, in the community, or in service recipients’ homes; and
  3. self-protection techniques, as necessary.
FEC Interpretation: Element (c) does not apply to credit counseling organizations.

Note: See CA-ASE 6.04 for more information on training staff on the emergency response plan.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The training curriculum is not fully developed or lacks depth in some areas; or
  • Some personnel, such as new hires, are not yet trained.
3
Practice requires significant improvement; e.g.,
  • A number of staff have not yet been trained on risks they may encounter while working or on self-protection techniques; or
  • One of elements has not been addressed.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization’s buildings, grounds and facilities are unsafe; or
  • Two of the elements have not been addressed.
2024 Edition

Administrative and Service Environment (CA-ASE) 6: Emergency Response Preparedness

The organization plans for and coordinates emergency response preparedness.

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VIEW THE STANDARDS

1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-ASE 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-ASE 6 Practice standards.
 
Fundamental Practice

CA-ASE 6.01

The organization develops an emergency response plan that outlines its response to medical emergencies, facility and security-related emergencies, public health emergencies, and natural disasters, and addresses:
  1. coordination with appropriate authorities and emergency responders;
  2. communication with the governing body, personnel, service recipients and their families, community partners, and as appropriate, the public, and the media;
  3. evacuation procedures including accounting for the whereabouts of staff and service recipients and the evacuation of persons with mobility challenges and other special needs; and
  4. participation with community partners and stakeholders in community recovery efforts, as appropriate.
Related Standards:
Interpretation: It is critical that emergency response plans include arrangements for the provision of needed medications when applicable. Individuals that may require an individualized plan for providing medications in the event of an emergency include: individuals with psychiatric conditions, individuals taking opioid treatment medications, and older adults.

Examples: Emergency situations can include, but are not limited to, accidents, suicide, fire, medical emergencies, flooding, hostage situations, bomb threats, active shooter, unlawful intrusion, physical assault, and other life-threatening situations.

Examples: The organization can help ensure preparedness to enact the emergency response plan by: 
  1. identifying the staff that will communicate with authorities and emergency responders at each program location; 
  2. testing the lines of communication to staff, board, persons served, community partners, and the public; 
  3. identifying staff who are responsible for people with mobility challenges and other special needs; 
  4. confirming availability of sufficient supplies at each site such as masks, gloves, hand sanitizer, first aid kits or supplies, a first aid manual, cleaning supplies, disinfectant, toilet paper, food, maintenance supplies, batteries, etc.; 
  5. maintaining up-to-date emergency contact information for all staff and service recipients;  
  6. ensuring availability of medications for people in residential facilities;  
  7. maintaining a readily available emergency response plan and procedures at all program sites; 
  8. developing plans for programs and administrative offices to operate with increased staff absences due to illness; and
  9. developing plans for managing responsibilities performed by volunteers or contractors, in the event they are prohibited from entering the facility. 

Examples: To ensure uninterrupted services to vulnerable populations in the event of an evacuation, arrangements can include maintaining a list of service recipients likely to be affected and pre-arranging for services outside the area likely to be evacuated.
 
Examples: Response plans in the event of a suicide can include:
  1. procedures for managing information about the death;
  2. coordination of internal or external resources;
  3. supports for those affected by the death;
  4. commemoration of the deceased; and
  5. follow-up with anyone at elevated risk for suicide.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to one of the standard's elements could be more explicit or detailed, or have not been reviewed recently.
3
Practice requires significant improvement; e.g.,
  • Plans or procedures related to at least one of the standard's elements:
    • Are vague and/or confusing and as a result may pose a risk; or
    • Are outdated or have not been reviewed in more than two years; or
    • Do not designate responsibility for coordinating a response, or for taking actions identified as being critical; or
    • Are not readily available to staff who may need them immediately in the event of an emergency.
  • Emergency response plans or procedures are "one-size-fits-all" and are not appropriately tailored to:
    • The specific needs of different geographic locations or jurisdictions; or
    • The needs of different populations (e.g., foster children or the elderly) at different programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.
 
Fundamental Practice

CA-ASE 6.02

The emergency response plan includes provisions for service continuity that ensures ongoing mission-critical functions in the event of a disruption of normal services, and: 
  1. identifies temporary administrative and service delivery sites in the event of facility closure; 
  2. addresses the temporary delegation of decision-making authority when normal channels have been disrupted;
  3. establishes alternative methods of communication with staff and stakeholders during periods of disruption; 
  4. ensures uninterrupted continuity of critical IT operations; and
  5. is reviewed, tested, and updated at least annually.
Related Standards:

Examples: Continuity Plans allow flexible and scalable responses to emergencies and other events that could disrupt operations. "Mission-critical functions" include core services and operational functions that are necessary to the continued operation of the organization.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to one of the standard's elements could be more explicit or detailed, or have not been reviewed recently.
3
Practices are basically sound but there is room for improvement; e.g.,
  • Plans or procedures related to at least one of the standard's elements: 
    • Are vague and/or confusing and as a result may pose a risk; or
    • Are outdated or have not been reviewed in more than two years; or
    • Do not designate responsibility for coordinating a response, or for taking actions identified as being critical; or
    • Are not readily available to staff who may need them immediately in the event of an emergency.
  • Emergency response plans or procedures are "one-size-fits-all" and are not appropriately tailored to: 
    • The specific needs of different geographic locations or jurisdictions; or
    • The needs of different populations (e.g., foster children or the elderly) at different programs.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.
 
Fundamental Practice

CA-ASE 6.03

The organization is prepared to treat injuries and respond to medical emergencies by:
  1. maintaining a readily available communication device, poison control information, and first aid supplies and manuals at all program sites and during off-site activities when applicable;
  2. consulting with a health professional, as necessary, to develop procedures for such situations; and
  3. maintaining emergency contact information for personnel and service recipients.
Related Standards:

Interpretation: Organizations that maintain Naloxone or opioid antagonist kits to treat opioid overdose cases:

  1. maintain at least two unexpired doses in accessible locations; 
  2. store personal protective equipment (PPE) close to the kit to facilitate quick response; 
  3. ensure staff trained in SAMHSA-approved protocols and procedures for reversing opioid drug crisis are available to administer these treatments;
  4. have procedures and appropriate training in place to get affected individuals to medical care immediately following overdose treatment to preempt the reoccurrence or worsening of symptoms;
  5. have procedures for documenting each incident where opioid antagonists were administered; and  
  6. have systems for maintaining and restocking opioid overdose equipment and medication to ensure availability of unexpired medication in an emergency. 

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

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • First aid supplies at one site were outdated.
3
Practice requires significant improvement, e.g., one or more of the following was not readily available at one of the organization's program sites:
  • A telephone or other communication device; or
  • Poison control information; or
  • First aid supplies and manuals.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.
 
Fundamental Practice

CA-ASE 6.04

Personnel from all the organization’s programs and administrative offices, and persons served in residential or daytime group care settings when applicable, receive training on implementing the organization's emergency response plan that is tailored as appropriate to:

  1. the specific types of emergencies faced by the organization;
  2. the level of staff responsibility;
  3. the needs, age, and developmental level of service recipients;
  4. program type; and
  5. geographic location.
Related Standards:

Examples: It may be appropriate for some staff to receive “gatekeeper training” on how to recognize, interpret, and respond to signs of suicide risk, and/or Mental Health First Aid training for recognizing and responding to signs of a mental health crisis.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Training is inconsistent across program sites; or
  • The curriculum related to one of the elements is not fully developed or lacks depth; or
  • A few personnel or service recipients have not yet been trained.
3

Practices are basically sound but there is room for improvement; e.g.,

  • Training is not provided at some programs; or
  • Training addresses some but not all of the types of potential emergencies likely to be encountered; or
  • A significant number of staff or service recipients have not yet been trained.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed at all.
 
Fundamental Practice

CA-ASE 6.05

Fire drills are conducted according to legal requirements, and held at least:
  1. during periods of both activity and rest, as appropriate to the program or service;
  2. once a month for every shift in Early Childhood Education (CA-ECE) and Out of School Time Services (CA-OST) settings;
  3. once a quarter for every shift in residential or daytime group care settings; and/or
  4. annually for other services and at administrative offices.
Interpretation: Residential programs for adults living independently in apartments, single-room-occupancy, or other independent living arrangements are not expected to conduct fire drills during evening and/or overnight shifts where staff do not have a continuous presence onsite. Such programs must still conduct fire drills at each program site during business hours.

1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Fire drills are conducted in accord with required timeframes, but drills during rest periods could be done more often; or
  • Procedures are vague or need clarifying, e.g., do not specify fire drill frequency for some non-residential or day programs.
3
Practice requires significant improvement; e.g.,  
  • Quarterly fire drills are sometimes missed for some shifts, or are rarely conducted at night in residential facilities, or service recipients are not awakened during nighttime drills; or 
  • Fire drill logs are poorly maintained or missing in some programs or sites; or 
  • The organization has not recently reviewed current legal requirements; or 
  • Fire drills are not conducted at some administrative sites; or
  • The staffing patterns for fire drills do not reflect the number of staff that would be present in the event of an actual emergency.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization rarely conducts drills; or
  • The organization never conducts fire drills during rest periods or at night.
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