WHO IS ACCREDITED?

Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.
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ORGANIZATION TESTIMONIAL

Children's Foundation of Mid America

James W. Thurman, President/CEO

Children’s Foundation of Mid America has been accredited through COA since 1983. The process of accreditation ensures that we meet or exceed the highest standards in the industry.
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Purpose

The organization’s behavior support and management policies and practices promote positive behavior and protect the safety of service recipients and staff.

FOC
BSM 1: Philosophy and Organization Policy

The organization’s governing body and management promote a safe and therapeutic environment and provide necessary supports and resources to:

  1. keep staff, foster parents, and service recipients safe; and
  2. minimize the use of restrictive behavior management interventions.
Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the BSM 1 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the BSM 1 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the BSM 1 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 BSM 1 Practice standards. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Aggregate of the two most recent quarterly reviews of incidents requiring restrictive behavior management interventions
    • A description of the organization’s BSM philosophy in BSM Narrative Question 1 including:
      1. programmatic and preventive approaches
      2. the spectrum of BSM interventions
      3. procedures/ interventions prohibited by the organization
    • BSM policy and procedures
    • Incident review procedures
    • For organizations using restrictive behavior management interventions, provide documentation of clinical director notification of restrictive behavior management interventions
    • Documentation of compliance with applicable laws or regulations
    • Interview:
      1. Clinical or program directors
      2. Supervisors
      3. Personnel
      4. Persons served
      5. Parents/legal guardians

  • BSM 1.01

    The organization’s behavior support and management policies and practices comply with federal, state, and local legal and regulatory requirements.

    Interpretation: The Public Health Service Act, as amended by the Children’s Health Act of 2000 and the Use of Restraint and Seclusion in Psychiatric Residential Treatment Facilities Providing Inpatient Psychiatric Services to Individuals Under Age 21 are federal regulations that govern the use of behavior management in the United States. Organizations serving youth involved with the juvenile justice system may be subject to different laws and regulations.

    Note: COA recognizes that the laws or regulations governing organizations serving youth involved with the juvenile justice system may sometimes authorize practices that conflict with the standards to which COA holds other organizations, and has addressed some of the potential discrepancies throughout the standards in BSM.

    Note: The organization is required to comply with the more stringent standard or regulation.

    Rating Indicators
    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 generally complies with all legal and regulatory requirements, with only minor exceptions noted in reports.
    3
    Practice requires significant improvement; e.g.,
    • The organization does not comply with requirements in at least one major area and is remedying this under the direction of appropriate authorities.
    4
    The organization has a pervasive problem of non-compliance.
    • Implementation of the standard is minimal or there is no evidence of implementation at all.

  • BSM 1.02

    Behavior support and management policies cover:

    1. practices used to maintain a safe environment and prevent the need for restrictive behavior management interventions;
    2. whether isolation, locked seclusion, manual or mechanical restraint are permitted as emergency safety measures;
    3. other practices that may be used and under what circumstances; and
    4. prohibited practices, including chemical restraint.

    Interpretation: In relation to element (d), chemical restraint does not include situations when a psychopharmacological drug:

    1. is used according to the requirements for treatment authorized by a court; or
    2. is provided using specified criteria in a person’s approved treatment plan as per a physician’s order to provide medical treatment for a specific diagnosis and known progression of symptoms, such as in cases of a PRN; or
    3. is administered in an emergency to prevent immediate, substantial, and irreversible deterioration of a person’s mental status when prescribed by a physician or other qualified medical practitioner.

    Interpretation: Organizations serving youth involved with the juvenile justice system may also be legally authorized to use restrictive interventions to prevent escapes, or protect property, in order to maintain safety, security, and order. However, they should still only employ restrictive interventions when absolutely necessary, as referenced throughout these standards.

    Note: Refer to COA’s glossary for a definition of chemical restraint.

    Rating Indicators
    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 needs greater specificity or clarity in policy and/or procedures.
    3
    Practice requires significant improvement; e.g.,
    • Two of the elements need greater specificity or clarity in policy and/or procedures;  or
    • Policies and/or procedures are too vague to provide guidance to personnel.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
    • One of the elements is not implemented.

  • BSM 1.03

    The CEO and senior management conduct regular reviews of the use of behavior support and management interventions and:

    1. review how organization practices compare with current information and research on effective practice;
    2. use findings from quarterly risk management reviews of restrictive behavior management to inform staff about current practice and the need for change;
    3. revise policies and procedures when necessary;
    4. determine whether additional resources are needed; and
    5. support efforts to minimize the use of restrictive behavior management interventions.

    Research Note: Agreement has been reached among experts that the best way to reduce injuries and deaths is to minimize the use of restraints to the greatest extent possible. Reductions in the use of locked seclusion and restraint can also contribute to less staff turnover.

    Rating Indicators
    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 needs to be reviewed more regularly;  or
    • Elements (a) or (e) is not consistently done.
    3
    Practice requires significant improvement; e.g.,
    • Two of the elements are not reviewed regularly ; or
    • Reviews are not done sufficiently often to monitor practices.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g., 
    • Three of the elements are not reviewed regularly.

  • BSM 1.04

    The program or clinical director is notified following each use of locked seclusion or manual or mechanical restraint, and each incident is administratively reviewed no later than one working day following an incident.

    NA The organization prohibits the use of restrictive behavior management interventions.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Notification and administrative review regularly occur, however procedures need clarifying; or
    • Notification has occasionally exceeded one working day.
    3
    Practice requires significant improvement; e.g.,
    • There have been instances where notification or administrative review did not occur; or
    • Procedures need significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Notification or review does not regularly occur.
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