Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.


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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Individuals with cognitive, psychiatric, behavioral, and/or substance use conditions and serious emotional disturbances who receive Day Treatment Services improve psychosocial, educational, vocational, and cognitive functioning, and learn to manage their symptoms.

DTX 4: Service Planning and Monitoring

Each person participates in the development and ongoing review of a service plan that is the basis for delivery of appropriate services and support.

Rating Indicators
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.
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
  • In a few instances client or staff signatures are missing and/or not dated; or
  • Active client participation occurs to a considerable extent.
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
  • In a number of instances client or staff signatures are missing and/or not dated (RPM 7.04); or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or
  • Documentation is routinely incomplete and/or missing; or
  • Assessments are done by referral source and no documentation and/or summary of required information present in case record; or
  • One of the Fundamental Practice Standards received a rating of 3 or 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
    • Service planning and monitoring procedures
    • Documentation of case review
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals served
    • Review case records

  • DTX 4.01

    A service plan is developed in a timely manner with the full participation of the individual and expedited service-planning is available when crisis or urgent need is identified.

    Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. When the service recipient is a minor, or an adult under the care of a guardian, the organization should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians.

  • DTX 4.02

    A family-centered service plan is developed with the participation of the individual’s family or significant others as agreed to by:

    1. a legal guardian, when the service recipient is a minor; or
    2. the person, when an adult not under the care of a guardian.

  • DTX 4.03

    The service plan is based on the assessment, and includes:

    1. agreed upon goals, desired outcomes, and timeframes for achieving them;
    2. services and supports to be provided, and by whom; and
    3. the individual’s signature.

  • DTX 4.04

    During service planning the organization explains:

    1. available options;
    2. how the organization can support the achievement of desired outcomes; and
    3. the benefits, alternatives, and consequences of planned services.

  • DTX 4.05

    The service plan addresses:

    1. psychological and emotional needs;
    2. educational and vocational goals;
    3. social and cultural interests;
    4. substance use treatment needs; and
    5. physical health needs.

  • DTX 4.06

    The service plan addresses, as appropriate and with the consent of the individual:

    1. the family’s unmet service and support needs;
    2. possibilities for maintaining and strengthening family relationships; and
    3. the need for support from the individual’s informal social network.

  • DTX 4.07

    Service planning identifies internal and external service providers, and includes specific referrals to be made during treatment and aftercare.

  • DTX 4.08

    The worker and a supervisor, or a clinical, service, or peer team, review the case quarterly to assess:

    1. service plan implementation;
    2. progress toward achieving service goals and desired outcomes; and
    3. the continuing appropriateness of the agreed upon service goals.

    Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard. Timeframes for review should be adjusted depending upon issues and needs of persons receiving services and frequency and intensity of services provided.

  • DTX 4.09

    The worker and individual or legal guardian regularly review progress toward achievement of agreed upon service goals and sign revisions to service goals and plans.

  • DTX 4.10

    Extended family members and significant others, as appropriate and with the consent of the individual, may be invited to participate in case conferences and advised of ongoing progress.

    Interpretation: The organization facilitates the participation of family and significant others by, for example, helping arrange transportation, or including them in scheduling decisions.

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