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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VOLUNTEER TESTIMONIAL

Rochelle Haimes, ACSW

Volunteer Roles: Commissioner; Peer Reviewer; Standards Panel Member; Team Leader

Rochelle is a Consultant working with a variety of private organizations to become accredited. Her primary area of expertise is in facilitating the development of PQI systems and activities. Her previous experience with both small and large organizations is the cornerstone for her long-standing volunteer activities as a Peer reviewer and as a Team Leader.
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Purpose

Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.

FOC
CA-RPM 8: Access to Case Records

Service recipients or designated legal representatives can access their case records, consistent with legal, regulatory, and/or contractual requirements.

Interpretation: Organizations are expected to have policies and procedures that address access to case records by service recipients.

Note: See CA-DV 17 for further guidance about the information to be included in case records for Domestic Violence Services (CA-DV).

Note: If the organization operates a program that qualifies for an NA but also provides other types of services, the standards should be implemented in all programs aside from those that qualify for the NA.

NA The organization provides only Community Change Initiatives (CA-CCI), Social Advocacy (CA-SOC), and/or Youth Development (CA-YD) Services.

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-RPM 8 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the CA-RPM 8 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the CA-RPM 8 Practice standards; and/or
  • At least one of the 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 CA-RPM 8 Practice standards; and/or
  • At least two of the Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Case record access policies and procedures
No On-Site Evidence
    • Interview:
      1. MIS Manager
      2. Case record clerk
      3. Program directors
      4. Direct service personnel
      5. Persons served
    • Case record room/ files and MIS accessibility observation

  • FP
    CA-RPM 8.01

    Access to confidential case records meets legal, regulatory, and/or contractual requirements, and is limited to:

    1. the service recipient or, as appropriate, a parent or legal guardian;
    2. personnel authorized to access specific information on a “need-to-know” basis;
    3. others who are permitted access;
    4. former service recipients;
    5. requests for records of deceased service recipients; and
    6. auditors, contractors, and licensing or accrediting personnel consistent with the organization’s confidentiality policy.

    Interpretation: Case records should not be left in public areas such as on carts in hallways, on desks, or in non-secured areas. When not being used by authorized staff, files should be returned to a secure area.

    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., 
    • Record access policy or procedure needs strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Record access policy or procedure needs significant strengthening; or
    • In a few instances the organization does not comply with the standard.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • CA-RPM 8.02

    Reviews of case records by service recipients are:

    1. conducted in the presence of professional personnel on the organization’s premises, when feasible; and
    2. carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record.

    Interpretation: For organizations using electronic record systems, allowing the service recipient to directly access the case record through a staff account represents a security risk. Access for service recipients may be provided, for example, through a separate user portal or by printing the case record.  

    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., 
    • Record access policy or procedure needs strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Record access policy or procedure needs significant strengthening; or
    • In a few instances the organization does not comply with the standard.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-RPM 8.03

    If the organization determines that it would be harmful for a service recipient to review his/her case record, and applicable law, regulations, and/or contracts provides no guidance on case record access, then:

    1. senior management reviews, approves in writing, and enters into the case record the reasons for refusal; and
    2. procedures permit a qualified professional to review records on behalf of the service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.

    Interpretation: An individual’s right to review his/her care or treatment may be denied, or otherwise limited, only in the most extreme circumstances where serious harm is likely to ensue. In such cases, objective criteria must guide decisions to deny access. In all cases, the organization must operate in accord with applicable law, regulations, and/or contracts.

    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., 
    • Record access policy or procedure needs strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Record access policy or procedure needs significant strengthening; or
    • In a few instances the organization does not comply with the standard.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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