COA Self-Report Form

HIDDEN DATA

Organization ID

Special Service Provider

It is important to consult COA’s Accreditation Policies and Procedures Manual, Section X. for detailed information on self-reporting requirements. The manual is located in your MyCOA portal. If you have any questions about COA’s self-reporting requirements please log a case in your MyCOA portal under "Contact COA."

Please know that a separate electronic form must be completed for each incident or occurrence.

Uploaded files must not exceed 5Mb.

For your reference please find the reporting timeframes for incidents/occurrences at the end of this form.

IDENTIFYING INFORMATION

Organization Name

Organization ID#

Person Completing the Report

Title

Email Address

Only one email should be entered in this field. Email addresses must be written in the correct format and cannot contain spaces before or after the email address.

Phone Number

Extension

Date of the Incident/Occurrence

INCIDENTS/OCCURRENCES

Category of the Incident/Occurrence

Is this incident in relation to your opioid treatment program?

YesNo

Revocation

(Loss of Authorization or Revocation of Domestic License or Loss of Authorization from a Foreign Government [e.g., inter-country adoption])

Provide a description of the reason(s) for revocation/the loss of authorization:

Upload a copy of the written notification from licensing or other regulatory/governmental authority regarding loss of authorization/revocation, and the corrective action(s) taken/to be taken by the organization in response to the revocation/loss of authorization.

Suspension of License

(Licensing/Regulatory, Other Governmental Authority (local/state/provincial), or Federal)

Provide a description of the reason(s) for the suspension of a license and action(s) being taken/to be taken by the organization in response to the suspension:

Upload a copy of the written notification of the suspension received from the licensing authority, investigative findings, and corrective action(s) taken by/being taken by the organization in response to the suspension:

Termination of Medicaid or Medicare Provider Certification or other Type of Certification

Provide a description of the reason(s) for the termination of Medicaid or Medicare certification or other type of certification:

Upload a copy of the written notification of the termination received from the governmental/other authority, investigative findings, and corrective action(s) taken by/being taken by the organization in response to the termination:

License Change

(Licensing/Regulatory, Other Governmental Authority (local/state/provincial), or Federal)

License change to (check only one)

If other compromised status, please describe:

What is the period of time for the provisional/probationary/compromised license status? (check only one)

Provide a brief description of the reason(s) for the change in license status:

Upload a copy of the notification received from licensing authority, investigative findings, and corrective action(s) taken by/being taken by the organization in response to the licensing action:

Initiation of Investigation

(Licensing/Regulatory, Other Governmental Authority (local/state/provincial), Federal, Foreign Government [e.g., inter-country adoption], Non-Governmental Investigative Entity, or Contractor)

Provide the name of the entity initiating the investigation and provide a description of the reason(s) for the initiation of the investigation:

Upload, if applicable, a copy of the notification of the investigation’s initiation received by the organization:

Request for Corrective Action

(Licensing/Regulatory, Other Governmental Authority (local/state/provincial), Federal, Foreign Government [e.g., inter-country adoption]), Non-Governmental Investigative Entity, or Contractor) NOTE: When a Public Agency is placed under a Consent Decree/Court Ordered Reform Plan this should be reported under the corrective action category.

Provide a brief description of the reason(s) for the required corrective action:

Upload a copy of the written notification requesting corrective action, investigative findings, the organization’s corrective action plan, and, as applicable, written notification of acceptance of the plan:

Application of Financial Sanctions or Penalties

(Licensing/Regulatory, Other Governmental Authority (local/state/ provincial), Federal, or Contractor)

Provide a brief description of the reason(s) for financial sanctions/penalties:

Upload a copy of the written notification of financial sanctions received, investigative findings, and the organization’s corrective action plan in response to the financial sanction/penalty:

Placement of a Hold on Referrals or Contract Award

(Licensing/Regulatory, Other Governmental Authority (local/ state/provincial), Federal, Foreign Government [e.g., inter-country adoption], or Contractor)

Provide a description for the reason(s) for the placement of a hold on referrals or contract award:

Upload a copy of the written notification, investigative findings, the organization’s corrective action plan, and, as applicable, written notification of acceptance of the plan:

Change in Exempt Status

Provide a description of the reason(s) for the involuntary discontinuation of accreditation, or other change in accredited status (sanction/adverse action), or voluntary discontinuation of accreditation for a service(s) accredited by another accreditation body, including the names of the services(s) or a listing of the service(s) impacted:

As applicable, upload a copy of the notification received by the organization from the accrediting body regarding the changed accreditation status:

Organization Closure

Provide a description of the reason(s) for closing (bankruptcy, loss of funding), the closing date, and transition/referral plan for consumers:

Discontinuation of Any COA-Accredited Service

Provide the name of the service(s) being discontinued, discontinuation date(s), and transition/referral plan for consumers:

Upon submission of this report, please also go to the Sites & Program page to close the respective program. The Sites & Programs page is located on the Accredited cycle under the Intake tab.

Opening of a New Program

Please note: To add a new site to applicable accredited programs, please go to the Sites & Programs page located on the Accredited cycle under the Intake tab.

New programs are added during the Reaccreditation process or through a Single Service review process. If applicable, organizations not currently pursuing Reaccreditation can elect to conduct a Single Service review.

As applicable, please select the below option:

Single Service Review requested

Provide the program name(s), a list of services for which you are requesting a single service review, and the contact information (name, email, phone) for the person whom we should contact to set up a single service review:

Merger/Acquisition

(The organization has merged with, acquired, or has been acquired by another organization/entity, regardless of whether the other organization/entity is COA-accredited or not. See Section XV of the COA’s Accreditation Policies and Procedures Manual for required documentation to be provided to COA.)

Provide a brief description of the upcoming or effected merger/acquisition:

Send the merger/acquisition information required by Section XV. to the following email address: clientrelations@coanet.org.

Change in CEO/Executive Director/Commissioner/Agency Head/Program or Site Director

Provide the name and contact information of the interim, acting, or new individual:

Bankruptcy or Other Forms of Insolvency Proceedings

Provide a description of the reason(s) for bankruptcy/other insolvency proceedings and next steps/actions for the organization, and a detailed plan for how the organization will address the needs of consumers for ongoing service delivery:

Upload a copy of the bankruptcy/other insolvency filing and proceedings:

Judgements

(civil or criminal judgments received by the organization for employment practices or malpractice/ professional liability)

Provide a brief description of the judgment and action(s) initiated/to be initiated by the organization in response to the judgment:

Consumer Death

When self-reporting a consumer serious injury or consumer death in order safeguard consumer privacy, COA requests that the organization/agency/program NOT report the following consumer primary identifying information within the COA Self-Report Form:
•   Name of the consumer,
•   Age of the consumer,
•   Date of birth,
•   Gender,
•   Address of consumer (including the zip code), or
•   Address of the program (including the zip code) that the consumer attended.

Upon conclusion of the organization’s internal review process, provide a description of the incident, a description of the organization’s internal review process of the incident, and, as applicable, action/improvement steps implemented to prevent re-occurrence:

What type of programming/services was the consumer/family receiving from the organization?

Twenty-four hour/seven day week services (residential, group home)Outpatient/community based/school basedOut of home care (foster/kinship/therapeutic foster care/resource family services)

Which age category best fits the consumer? (Check only one):

Consumer Serious Injury

When self-reporting a consumer serious injury or consumer death in order safeguard consumer privacy, COA requests that the organization/agency/program not report the following consumer primary identifying information within the COA Self-Report Form:
•   Name of the consumer,
•   Age of the consumer,
•   Date of birth,
•   Gender,
•   Address of consumer (including the zip code), or
•   Address of the program (including the zip code) that the consumer attended.

What type of programming/services was the consumer/family receiving from the organization?

Twenty-four hour/seven day week services (residential, group home)Outpatient/community based/school basedOut of home care (foster/kinship/therapeutic foster care/resource family services)

Which age category best fits the consumer? (Check only one):

Other Occurrence or Critical Event

Provide a description of the other occurrence or critical event:

Incident / Occurrence	Reporting Time Frame
Loss of Authorization or Revocation of Domestic License or Loss of Authorization from a Foreign Government (e.g., inter-country adoption)	Ten (10) business days of notification.
Licensing/Regulatory, Other Governmental Authority (local, state/provincial), Federal or Foreign Government (e.g., inter-country adoption), or Non-Governmental Investigative Entity, or Contractor Action(s): Suspension of license Termination of Medicaid/Medicare certification or other certification License change Initiation of investigation Corrective action Financial sanctions/penalties Placement of a hold on referrals or contract award	Twenty (20) business days of notification.
Change in Exempt Status (e.g., CARF, TJC, NAEYC, etc.)	Twenty (20) business days of the “other” accreditation body decision or the organization’s decision to voluntarily discontinue accreditation by the other accreditor.
Organization Closure	Twenty (20) business days prior to closure of the organization.
Discontinuation of Any COA-Accredited Service	Twenty (20) business days prior to the discontinuation of service(s) to consumers.
Opening of a New Program(s)	Twenty (20) business days from the date of beginning to provide services to consumers
Merger/Acquisition	Twenty (20) business days prior to the expected legal date to merge with, acquire or be acquired
Change in CEO/Executive Director/Commissioner/Agency Head. A change in Program Director is only reportable for CYD or Military/Family Readiness program accreditations	Twenty (20) business days of the change
Bankruptcy or Other Forms of Insolvency Proceedings	Ten (10) business days from the date of the bankruptcy filing.
Judgments	Twenty (20) business days of notification of judgment.
Consumer Death Consumer death occurring while the consumer is under the organization’s regular/periodic care and/or relating to service delivery. See Section XB of COA’s Accreditation Policies and Procedures Manual for additional information and examples.	Ten (10) business days of completion of the organization’s incident/quality improvement review process.
Consumer Serious Injury Consumer serious injury occurring while the consumer is under the organization’s regular/periodic care, and/or relating to service delivery and results in debilitating or permanent loss of function (paralysis, brain trauma, loss of limb, etc.), serious physical impairment (fracture, concussion, coma, physical disfigurement, etc.), psychological injury (assault, sexual exploitation, rape, etc.), or serious impairment of health. See Section XB of COA’s Accreditation Policies and Procedures Manual for additional information and examples.	Ten (10) business days of completion of the organization’s incident/quality improvement review process.

Contact Information