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.


Anita Paukovits

Volunteer Roles: Peer Reviewer

Being a COA peer reviewer has clearly played a role in my professional development and has made me a better administrator at my own agency as a result!  To be part of a professional network that is on the cutting edge of program, practice, fiscal responsibility, and insuring Best Practice across the field is an amazing opportunity.
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Individuals who receive Home Care and Support Services obtain a maximum level of independence, functioning, and health, and extend the time it is possible to live safely at home and in the community.

HCS 4: Assessment Based Care Planning and Coordination

Individuals and care givers participate in a comprehensive, individualized, strengths-based, family-focused assessment as the basis for a care plan that specifies the coordinated services needed to promote independent functioning at home and in the community.

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
  • Culturally responsive assessments are the norm and any issues with individual staff members are being addressed through performance evaluations (HR 6.02) and training (TS 2.05); or
  • Active client participation occurs to a considerable extent; or
  • Diagnostic tests are consistently and appropriately used, but interviews with staff indicate a need for more training (TS 2.08).
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
  • Assessment and reassessment timeframes are often missed; or
  • Assessment are sometimes not sufficiently individualized;
  • Culturally responsive assessments are not the norm and this is not being addressed in supervision or training; or
  • Staff are not competent to administer diagnostic tests , or tests are not being used when clinically indicated; or
  • Client participation is inconsistent; 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.,
  • There are 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
    • Assessment procedures
    • Assessment tools and/or criteria including caregiver assessment
    • Service planning procedures
    • Job descriptions
    • Program and staff guidelines that address unique home care and service delivery issues
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Individuals or caregivers served
    • Review case records

  • FP
    HCS 4.01

    To ensure an appropriate level of care, the organization completes, or receives within a reasonable period of time from start of service:

    1. a current, comprehensive individualized assessment, including the individual’s view of his or her current health and functioning;
    2. baseline functional, mental, emotional, and physical status information, including prescription medication use and recent or progressive functioning to confirm capacity, decline, or progress;
    3. a caregiver assessment including level of caregiver burden, caregiver health, choice in serving in the caregiver role, and presence of informal support;
    4. a plan delineating specific services to be delivered by the care provider; and
    5. a plan for coordinating services with other providers including nurses, physicians, rehabilitative personnel, or mental health providers, as needed.

    Interpretation: All service providers, including those who may not have responsibility for the comprehensive assessment and determination of appropriate level of care, should obtain, at a minimum, information regarding an individual’s and/or family’s special needs.

    Interpretation: The Assessment Matrix - Private, Public, Canadian, Network determines which level of assessment is required for COA’s Service Sections. The assessment elements of the Matrix can be tailored according to the needs of specific individuals or service design.

    Research Note: Resources are now available that provide broad assessment parameters and recommendations for this population. Professional literature recommends standardized instruments selected to assess function should be efficient to administer, easy to interpret, able to provide useful practical information for clinicians, and part of routine history taking and daily assessments.

  • HCS 4.02

    The individual or a legal guardian is the primary source of information about the need for service.

    Interpretation: Additional sources of information should be sought to confirm or enhance assessments as appropriate, for example, physical and occupational therapy services may be involved to determine how to manage or prevent further decline.

  • HCS 4.03

    The information gathered for assessments is directed at concerns identified in initial screenings and is limited to material pertinent for meeting service requests and objectives.

  • HCS 4.04

    Personnel who conduct assessments are qualified by training, skill, and experience, and can recognize individuals and families with special needs.

  • HCS 4.05

    Assessments are completed within timeframes established by the organization.

  • HCS 4.06

    Assessments are conducted in a culturally responsive manner and identify resources to increase service participation and success.

    Interpretation: Culturally responsive assessments can include geographic location, language of choice, and the person’s religious, racial, ethnic, and cultural background. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, and developmental level.

  • HCS 4.07

    Health and/or social service professionals:

    1. develop the care plan in cooperation with consumers and care team;
    2. link interventions to service recipient goals;
    3. assess service appropriateness;
    4. approve service plans prior to implementation; and
    5. assist the care provider with plan implementation, as necessary.

  • HCS 4.08

    Prior to beginning services, the individual meets with professional personnel and caregivers in the home to review:

    1. the role of family members in caretaking and related needs;
    2. any current concerns, including household and community safety;
    3. specific services to be provided by the care provider;
    4. limits of services provided;
    5. preferences and choices of service recipients that can affect service delivery;
    6. coordination of services with other providers, as appropriate;
    7. client rights and responsibilities, including how to report complaints or concerns;
    8. information about advanced directives, and crisis planning as appropriate; and
    9. guidelines for resolving differences between service recipient and care providers, including the role of supervisors.

  • FP
    HCS 4.09

    Written guidelines that address issues unique to in-home care and service delivery include:

    1. off-site supervision;
    2. safety of personnel;
    3. timely communication and record keeping; and
    4. other prescribed health and safety related procedures.
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