Private Organization Accreditation

Family Services of Southeast Texas strengthens families through accessible, affordable counseling services and education for issues affecting family life, mental health and employment.  We also provide comprehensive domestic violence shelter and support services.


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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The rights and dignity of clients are respected throughout the organization.

CR 3: Grievance Procedures

The organization maintains a formal mechanism through which applicants, clients, and other stakeholders can express and resolve grievances, including denial of service, which includes:

  1. the right to file a grievance without interference or retaliation;
  2. timely written notification of the resolution and an explanation of any further appeal, rights or recourse; and
  3. at least one level of review that does not involve the person about whom the complaint has been made or the person who reached the decision under review.

Interpretation: Organizations providing Adult Guardianship should ensure that an advocate is appointed to assist the individual in navigating the grievance process.

Interpretation: For networks, grievance procedures for persons served by the network include provisions for filing and appealing grievances related to the network management entity, owner and provider organizations, and independent practitioners.

Note: For networks, appeals or denials of service authorizations are addressed in Utilization Management standards NET 7.08 and NET 7.09. An appeal of a denial of service authorization is, in effect, a request for a second opinion, and as such, does not imply that a person’s rights were denied. However, if the appeal is denied, the person making the appeal might file a complaint or grievance if they believe the network’s procedures or criteria for placement were not followed. For example, if the appeal was not addressed within the network’s time requirements, or if the person believes that the criteria were misapplied, then the person may resort to the complaint or grievance process.

Rating Indicators
The organization's practices reflect full implementation of the standard.
Practices are basically sound but there is room for improvement; e.g., 
  • Procedure or documentation related to one of the elements needs strengthening.
Practice requires significant improvement; e.g.,
  • Procedure or documentation related to two of the elements needs strengthening.
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed; or
  • The only option for filing a grievance is referral to an external body such as a funder.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Grievance policy
    • Grievance procedures for individuals and families served
    • Grievance reports for the last two quarters (see RPM 2.02)
No On-Site Evidence
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
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