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 5: Restrictive Behavior Management Interventions

Restrictive behavior management interventions are used in a manner that protects the safety and well-being of service recipients and personnel in emergency or crisis situations when less-restrictive measures have proven ineffective.

Interpretation: This standard prohibits the use of isolation, locked seclusion, and manual or mechanical restraint for the purposes of routine discipline, compliance, or convenience.

Note: COA accreditation standards prohibit the use of isolation, locked seclusion, and mechanical restraint by foster parents. Only those standards that address manual restraint apply to foster parents.

The use of mechanical restraints is prohibited for public or private non-medical, community-based facilities that serve children and youth according to the Public Health Service Act, as amended by the Children’s Health Act of 2000. As referenced in BSM 1.01, organizations serving youth involved with the juvenile justice system may be subject to different laws and regulations, and should familiarize themselves with any laws and regulations addressing the behavior management interventions they are permitted to employ.

NA The organization prohibits 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 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the BSM 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the BSM 5 Practice standard; and/or
  • One of the BSM 5 Fundamental Practice Standards received a 3 or 4 rating.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the BSM 5 Practice standards; and/or
  • Two or more of the BSM 5 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Authorization and reauthorization procedures including qualifications of authorized personnel
    • Incident reports
    • Behavior management logs
    • Documentation of compliance with legal requirements
    • Interview:
      1. Authorizing personnel
      2. Direct service personnel
      3. Supervisory personnel
      4. Persons served
    • Seclusion room observation

  • BSM 5.01

    Qualified personnel authorize each restrictive behavior management intervention, in accordance with any applicable federal or state requirements.

    Interpretation: The organization should develop protocols for foster parents that use manual restraint to address compliance with federal or state requirements.

    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., 
    • Authorization procedures need clarifying; or
    • Protocols for foster parents need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • There have been instances of restrictive intervention without authorization by qualified personnel but corrective action is occurring; or
    • Documentation is weak.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There have been instances of restrictive intervention without authorization by qualified personnel and corrective action has not been initiated; or
    • Practices are in violation of applicable legal requirements; or
    • Written procedures do not address use of qualified personnel.

  • FP
    BSM 5.02

    Service recipients are monitored continuously, face-to-face, and assessed at least every 15 minutes for any harmful health or psychological reactions.

    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., 
    • In a few rare instances there was a lapse in monitoring or assessment but corrective action was taken immediately.
    3
    Practice requires significant improvement; e.g.,
    • In more than a few instances there was a lapse in monitoring or assessment but corrective action was taken immediately; or
    • Documentation is weak; or
    • Procedures need significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
    • Lapses occur with some frequency and corrective action is not taken; or
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    BSM 5.03

    Procedures address safe methods for escorting individuals.

    NA The organization does not escort individuals or use locked seclusion.

    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., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed; or
    • Documentation is weak.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    BSM 5.04

    Isolation and seclusion rooms conform to existing licensing and/or fire safety requirements and are limited to one person at a time.

    Note: Unlike seclusion rooms, isolation rooms do not have a lock or locking device.

    Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

    NA The organization does not use isolation or locked seclusion.

    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 does not have evidence of conformance to licensing and/or fire safety requirements for one of its isolation or seclusion rooms, but has initiated a process to obtain it.
    3
    Practice requires significant improvement; e.g.,
    • The organization does not have evidence of conformance with licensing and/or fire safety requirements for one or more of its isolation or seclusion rooms and has not initiated a process to obtain it; or
    • There have been instances where a seclusion or isolation room has been used for more than one person.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    BSM 5.05

    During a restrictive behavior management intervention staff assess the service recipient’s need for food, water, and use of bathroom facilities and provide access when safe and appropriate.

    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., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    BSM 5.06

    Restrictive behavior management interventions are used only in emergency or crisis situations, when less-restrictive measures have proven ineffective, are discontinued as soon as possible, and are limited to the following maximum time periods per episode:

    1. 15 minutes for children aged nine and younger, for all restrictive behavior management interventions;
    2. 30 minutes for individuals aged ten and older, undergoing manual or mechanical restraint;
    3. 30 minutes for individuals aged ten to thirteen in isolation or locked seclusion; and
    4. one hour for individuals aged fourteen and older in isolation or locked seclusion.

    Interpretation: Restrictive behavior management interventions are discontinued immediately if they produce adverse side effects such as illness, severe emotional or physical stress, or physical injury. Timeframes may be extended on a case-by-case basis, but qualified personnel with the authority to make such decisions must approve all extensions, as referenced in BSM 5.07.

    Interpretation: As referenced in BSM 1.02, organizations serving youth involved with the juvenile justice system may be authorized to use restrictive interventions to prevent escapes or protect property, but should only do so when absolutely necessary, as referenced throughout these standards.

    Further, although organizations serving youth involved with the juvenile justice system may be authorized to use time limits that exceed those listed in the standard, COA expects these organizations to meet the timeframes outlined in the standard whenever possible. When it is necessary to extend timeframes in order to maintain safety, security, and order (for example, when youth must be transported in mechanical restraints in order to prevent escape, and travel time is greater than 30 minutes), qualified personnel must approve the extension, and the intervention should be discontinued as soon as possible.

    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., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.

  • FP
    BSM 5.07

    Reauthorization by a physician or another qualified clinician is required for each instance of isolation, locked seclusion, manual restraint, or mechanical restraint that exceeds the maximum time limit.

    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., 
    • Procedures need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • There have been instances where procedures were not followed, but corrective action has been initiated; or
    • Documentation needs significant strengthening.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • There are no procedures; or
    • Procedures are not routinely followed.
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