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.


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 agency’s behavior support and management policies and practices promote positive behavior and protect the safety of service recipients and staff.

PA-BSM 6: Documentation and Debriefing

The agency assesses restrictive behavior management incidents and effects to reduce future preventable occurrences and untoward consequences.

NA The agency prohibits the use of restrictive behavior management interventions.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Debriefing procedures
    • Documentation of behavior management/incident reviews
    State Administered Agency (Regional Office)
    • Documentation of behavior management/incident reviews
    All Agencies
    • Documentation of debriefing
    • Behavior management logs
    All Agencies
    • Interview:
      1. Agency Leadership
      2. Supervisory/management personnel
      3. Persons served
      4. Parents/legal guardians
    • Case record review

  • PA-BSM 6.01

    The use of restrictive behavior management interventions is documented, including:

    1. the justification, use, circumstances, and length of application in the individual’s case record; and
    2. names of the service recipient and personnel involved, reasons for the intervention, length of intervention, and verification of continuous visual observation in a log.

  • FP
    PA-BSM 6.02

    Debriefing occurs in a safe, confidential setting within 24 hours of the incident and includes the service recipient, appropriate personnel, the foster parents, and parents or legal guardian to:

    1. evaluate physical and emotional well-being;
    2. identify the need for counseling, medical care, or other services related to the incident;
    3. identify antecedent behaviors and modify the service plan as appropriate; and
    4. facilitate the person’s reentry into routine activities.

    Interpretation: When agencies serving youth in the juvenile justice system use mechanical restraints to prevent escape during transport, rather than in response to an incident, it may not be relevant to identify antecedent behaviors and modify the service plan, as referenced in element (c) of the standard. However, elements (a), (b), and (d) are still relevant.

    Interpretation: The agency ensures the service recipient’s participation in the debriefing process.  In situations where the service recipient initially refuses to participate, the agency should make continued attempts to involve the individual.

    Note: Agencies serving youth involved with the juvenile justice system should refer to the Interpretation to PA-BSM 2.01 regarding the involvement of youths’ parents or legal guardians.

    Note: Following each incident of restrictive intervention, Medicaid requires that a physician or other qualified clinician conducts and documents an initial face-to-face assessment and summary review within one hour of the intervention to evaluate the health and safety of client, the appropriateness of the intervention, and necessary changes to the treatment plan.  Agencies should review state Medicaid plans for their state’s definition of a qualified clinician and a list of specific elements to be included as part of the assessment.

  • FP
    PA-BSM 6.03

    Personnel and foster parents involved in the incident are debriefed to assess:

    1. their current physical and emotional status;
    2. the precipitating events; and
    3. how the incident was handled and necessary changes to procedures and/or training to avoid future incidents.

    Interpretation: When agencies serving youth in the juvenile justice system routinely use mechanical restraints to prevent escape during transport, rather than in response to an incident, it may not be relevant to assess precipitating events or address how future incidents might be avoided, as referenced in elements (b) and (c) of the standard.

  • FP
    PA-BSM 6.04

    Any other person involved in or witness to the incident is debriefed to identify possible injuries and emotional reactions.

    Interpretation: Debriefing can include a discussion of factors that led up to the incident and other appropriate responses for future situations. Emphasis should be placed on returning the environment to pre-incident condition and resuming the normal program routine.

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