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

Family Services of the North Shore

Kathleen Whyte, Manager of Human Resources / Accreditation Coordinator

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency.
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Purpose

Children, youth, and adults who participate in Services for Individuals with Developmental Disabilities achieve full integration and inclusion in the mainstream, make choices, exert control over their lives, and fully participate in, and contribute to, their communities.

DDS 9: Residential Services

The organization protects the rights, and provides for the comfort of individuals using residential services.

NA The organization does not provide residential services.

Rating Indicators
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (HR 6.02) and training (TS 2.03); or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • A number of client records are missing important information  or
  • Client participation is inconsistent; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Family visitation procedures
    • Policy regarding the right to make telephone calls
    • Description of opportunities and support for the exercise of religious beliefs and practices
No On-Site Evidence
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Individuals served
    • Review case records
    • Facility observation

  • FP
    DDS 9.01

    The organization provides a living environment that:

    1. is home-like;
    2. provides the individual the opportunity to design or personalize his or her space;
    3. respects the person’s right to privacy; and
    4. provides the individual with enough space to spend time alone.

  • DDS 9.02

    Individuals receiving residential services have the opportunity to visit and receive visits from family and friends, and the organization assists with travel arrangements, as necessary.


  • FP
    DDS 9.03

    Individuals receiving residential services have the right to make private telephone calls at any time.

    Interpretation: Any restrictions on the right to make private phone calls are:

    1. based on contraindications in the service plan;
    2. approved in advance by the program director or an appropriate designee;
    3. documented in the case record; and
    4. reauthorized weekly by the immediate supervisor of the direct support provider.

  • FP
    DDS 9.04

    Individuals served are free to express and practice their religious or spiritual beliefs, and the organization provides:

    1. appropriate opportunities for religious or spiritual practice; and
    2. support, including transportation and schedule adjustments, as necessary.
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