2024 Edition

Administrative and Service Environment Introduction

Purpose

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

Introduction

The Administrative and Service Environment (PA-ASE) standards reflect the significant impact that accessibility; physical, psychological and emotional safety; and personal dignity have on an agency’s effectiveness. Specifically, these standards address how accessibility, compliance with applicable health regulations and codes, facility maintenance, safety procedures both on- and off-site, a trauma-informed environment, and emergency response preparedness contribute to agency productivity and effective service delivery.

Note: Please see PA-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 (PA-ASE) 1: Promotion of Health and Safety

In its daily operations, the agency 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
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
2024 Edition

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

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

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-ASE 2.01

Personnel support positive behavior by:
  1. developing positive relationships with service recipients; 
  2. being trauma-informed;
  3. building on service recipients’ strengths and reinforcing positive behavior; 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 behavior management interventions may be used to protect service recipients from harming themselves or others.
 
Fundamental Practice

PA-ASE 2.02

The agency:
  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.
Related Standards:

NA The agency is only assigned the Early Childhood Education (PA-ECE) and/or Out-of-School Time Services (PA-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 behavior are served in the same facility.
 

PA-ASE 2.03

The agency 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 behavior management interventions.
 
Fundamental Practice

PA-ASE 2.04

The agency 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. 

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

 

PA-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.

 
Fundamental Practice

PA-ASE 2.06

Agency 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 agency 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 behaviors; 
  6. unnecessarily punitive restrictions, including restricting family contact, celebrations, or prescribed treatment interventions as a disciplinary action;  
  7. unwarranted use of invasive procedures or activities as a disciplinary action; 
  8. punitive work assignments; 
  9. punishment by peers; 
  10. conversion or reparative therapies;  
  11. deliberate misgendering; 
  12. disciplinary room confinement; and 
  13. group punishment or discipline for individual behavior. 
2024 Edition

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

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

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 

PA-ASE 3.01

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

Interpretation: If some of the agency’s administrative or service facilities are not accessible to people with physical disabilities, the agency 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.

 
Fundamental Practice

PA-ASE 3.02

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

PA-ASE 3.03

The agency 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 agency can demonstrate standard implementation include, but are not limited to:

  1. providing basic program information in languages representative of consumer 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 for all programs in which confidential interpersonal communication is necessary for adequate service delivery;
  4. ensuring there is a bilingual worker on staff 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.
 
Fundamental Practice

PA-ASE 3.04

The agency 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 agency capacity, and the wishes of the person; and 
  2. connecting individuals and families to appropriate providers when specific needs cannot be met by the agency.  

Interpretation: Regarding element (a), the decision to serve individuals with intellectual and developmental disabilities should be made based on how well the ageny’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.

2024 Edition

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

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

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-ASE 4.01

All facilities in which the agency operates are properly maintained through:
  1. monthly inspections to ensure the agency’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 agency is a tenant in its facilities, some or all of the above activities may be conducted by the landlord. In such instances, the agency 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 personnel and service recipients, 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 temperature; unscreened areas or unmarked glass doors; broken or malfunctioning tools or equipment, including electrical appliances, and unsafe drinking water.

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

 
Fundamental Practice

PA-ASE 4.02

An agency that permits or requires the use of agency- or privately-owned vehicles to transport service recipients requires:
  1. the use of age-appropriate passenger restraint systems in accordance with applicable state and local regulations; 
  2. adequate passenger supervision, as mandated by statute or regulation; 
  3. proper maintenance of agency-owned vehicles; 
  4. current registration and inspection of vehicles; 
  5. annual validation of licenses and driving records; and 
  6. motor vehicle insurance.
Related Standards:
Interpretation: When state inspection is not available (d), the agency should establish alternate procedures for verifying proper maintenance of both privately- and agency-owned vehicles.

Interpretation: This standard does not apply to vehicles owned by resource families, which are covered by PA-CFS 23.05.

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

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

 

PA-ASE 4.03

When services are offered on a consistent and ongoing basis, in a location that is not owned or leased by the agency, prior to using the facility the agency 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 agency does not offer services on a consistent and ongoing basis at locations it does not own or lease.
2024 Edition

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

The agency ensures that all buildings, grounds, and facilities promote the safety and security of personnel, service recipients, and visitors.
Related Standards:

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-ASE 5.01

The agency 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 procedures 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.

 
Fundamental Practice

PA-ASE 5.02

The agency trains staff on:
  1. safety procedures;
  2. potential risks they may encounter on-site, in the community, or in service recipients’ homes; and
  3. self-protection techniques, as necessary.

Note: See PA-ASE 6.04 for more information on training staff on the emergency response plan.
2024 Edition

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

The agency plans for and coordinates emergency response preparedness.

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Related Standards:

1
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
2
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.
3

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
4
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed administration and management infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
 
Fundamental Practice

PA-ASE 6.01

The agency develops an emergency response plan that that outlines its response to medical emergencies, facility and security-related emergencies, public health emergencies, and natural disasters, and addresses:
  1. coordination with appropriate local, state, and federal governmental authorities and emergency responders;
  2. coordination with agency leadership, 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;
  4. plans for maintaining service continuity; and
  5. participation with community partners and stakeholders in community recovery efforts, as appropriate.
Related Standards:
Interpretation: State agency regional offices should maintain separate emergency response plans that build off of the statewide plan but contain specific provisions for regional relocation options and communications within the regional management structure.

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 agency 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. 
 
Fundamental Practice

PA-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; 
  5. includes a plan for the resumption of normal agency operations; an  d 
  6. 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.

 
Fundamental Practice

PA-ASE 6.03

The agency 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 data 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.

 
Fundamental Practice

PA-ASE 6.04

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

  1. the specific types of emergencies faced by the agency;
  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.

 
Fundamental Practice

PA-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 (PA-ECE) and Out-of-School Time (PA-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.
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