WHO IS ACCREDITED?

Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.
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ORGANIZATION TESTIMONIAL

Domestic Violence Intervention Services, Inc.

Donna Mathews, Associate Director

Becoming accredited and maintaining our accreditation through COA has helped us increase our professionalism and thereby provide better services to domestic violence, sexual assault, stalking, and dating violence survivors.
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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 6: Documentation and Debriefing

The organization assesses restrictive behavior management incidents and effects to reduce future preventable occurrences and untoward consequences.

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 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the BSM 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the BSM 6 Practice standard; and/or
  • One of the BSM 6 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 6 Practice standards; and/or
  • Two or more of the BSM 6 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Debriefing procedures
    • Documentation of debriefing
    • Documentation of Behavior management/incident reviews
    • Behavior management logs
    • Interview:
      1. Governing body
      2. Supervisory/management personnel
      3. Persons served
      4. Parents/legal guardians
    • Case Record Review

  • BSM 6.01

    The use of restrictive behavior management interventions is documented, including:

    1. the justification, use, circumstances, and length of application in the individual’s case record;
    2. all attempts made prior ro the use of a restrictive behavior management intervention in order to preempt it, including the strategies identified in the individual’s behavior management plan; and
    3. names of the service recipient and personnel involved, reasons for the intervention, length of intervention, and verification of continuous visual observation in a log.

    Update:

    • Revised Standard - 05/07/18

    Research Note: For organizations using Root Cause Analyses, documentation could include the “5 Whys” of the incident (asking why an incident happened and then asking why 4 more times) and can be helpful in understanding the reasons why a restrictive intervention was necessitated thus allowing for a more in-depth analysis of all contributing factors and identifying changes needed.

    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; or
    • In a few instances documentation was not complete.
    3
    Practice requires significant improvement; e.g.,
    • Procedures are inadequate; or
    • Documentation problems are common but corrective action is being taken.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    BSM 6.02

    Debriefing occurs in a safe, confidential setting within 24 hours of the incident and includes the service recipient, appropriate personnel, and parents or legal guardian, when possible, to:

    1. evaluate physical and emotional well-being;
    2. identify the need for counseling, medical care, or other services related to the incident;
    3. identify antecedent behaviors and modify the service plan as appropriate; and
    4. facilitate the person’s reentry into routine activities.

    Update:

    • Revised Standard - 05/07/18

    Interpretation: When organizations serving youth in the juvenile justice system use mechanical restraints to prevent escape during transport, rather than in response to an incident, it may not be relevant to identify antecedent behaviors and modify the service plan, as referenced in element (c) of the standard. However, elements (a), (b), and (d) are still relevant.

    Interpretation: The organization ensures the service recipient’s participation in the debriefing process. In situations where the service recipient initially refuses to participate, the organization should make continued attempts to involve the individual.

    Interpretation: If the parent or legal guardian is unable to be reached within the 24 hour period, all attempts to reach them should be document and there should be continued outreach attempts past the 24 hour period to notify them of the incident.

    Interpretation: Appropriate personnel includes frontline and clinical staff so that both perspectives are represented in any modifications made to the service plan.

    Note: Organizations serving youth involved with the juvenile justice system should refer to the Interpretation to BSM 2.01 regarding the involvement of youths’ parents or legal guardians.

    Note:  Following each incident of restrictive intervention, Medicaid requires that a physician or other qualified clinician conducts and documents an initial face-to-face assessment and summary review within one hour of the intervention to evaluate the health and safety of client, the appropriateness of the intervention, and necessary changes to the treatment plan.  Organizations should review state Medicaid plans for their state’s definition of a qualified clinician and a list of specific elements to be included as part of the assessment.

    Research Note: Structured debriefing, with a standard set of questions, can be beneficial in gathering data on restrictive behavior management incidents for future review.

    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 is not regularly addressed; or
    • In a few instances:
      • Debriefing occurred after 24 hours; or
      • One of the required attendees was absent.
    3
    Practice requires significant improvement; e.g.,
    • Two of the elements are not regularly addressed; or
    • In several instances:
      • Debriefing occurred after 24 hours; or
      • One or two of the required attendees was absent.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all;
    • One of the elements is not addressed at all; or
    • Timeframes are routinely exceeded; or
    • One of the required attendees is routinely excluded.

  • FP
    BSM 6.03

    Personnel involved in the incident are debriefed to assess:

    1. their current physical and emotional status;
    2. the precipitating events; and
    3. how the incident was handled and necessary changes to procedures and/or training to avoid future incidents

    Interpretation: When organizations serving youth in the juvenile justice system routinely use mechanical restraints to prevent escape during transport, rather than in response to an incident, it may not be relevant to assess precipitating events or address how future incidents might be avoided, as referenced in elements (b) and (c) of the standard.

    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 instances one of the elements was not addressed.
    3
    Practice requires significant improvement; e.g.,
    • In several instances one of the elements was not addressed; or
    • In a few instances staff were not debriefed.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all;
    • One of the elements is not addressed at all; or
    • Staff are frequently not debriefed.

  • FP
    BSM 6.04

    Any other person involved in or witness to the incident is debriefed to identify possible injuries and emotional reactions.

    Interpretation: Debriefing can include a discussion of factors that led up to the incident and other appropriate responses for future situations. Emphasis should be placed on returning the environment to pre-incident condition and resuming the normal program routine.

    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 instances the debriefing did not occur.
    3
    Practice requires significant improvement; e.g.,
    • In several instances debriefing did not occur.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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