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.


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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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.

PA-DDS 5: Service Philosophy and Intervention

The program is guided by a service philosophy that:

  1. serves as the basis for how the program will meet the needs of individuals and their families; and
  2. guides the development and implementation of services, interventions, and activities based on the program goals and the best available evidence of service effectiveness.

Interpretation: A program model or logic model can be a useful tool to help staff think systematically about how the program can make a measureable difference by drawing a clear connection between the service population’s needs, available resources, program activities and interventions, program outputs, and desired outcomes.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Include service philosophy in the Narrative
    • Policies for prohibited interventions
    • Procedures for use of non-traditional or unconventional practices
    • Table of contents of training curricula
    • Procedures for use of interventions that limit movement, diminish sensory experience, limit personal freedom, or cause personal discomfort
    • Documentation of training
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Individuals served
    • Review case records

  • PA-DDS 5.01

    The service philosophy:

    1. promotes meaningful participation, inclusion, and self-determination;
    2. provides a basis for the implementation of strengths-based, person-centered activities and interventions; and
    3. safeguards the emotional, physical, and psychological well-being of the individual.

  • FP
    PA-DDS 5.02

    If the agency permits the use of service modalities and interventions it defines as non-traditional or unconventional, it:

    1. explains any benefits, risks, side effects, and alternatives to the individual;
    2. obtains the written, informed consent of the individual;
    3. ensures that personnel receive sufficient training and/or obtain certification when it is available; and
    4. monitors the use and effectiveness of such interventions.

    Interpretation: Examples of non-traditional and unconventional service modalities or interventions include, but are not limited to: hypnosis, acupuncture, and modalities or interventions that involve physical contact, such as massage therapy.

    NA The agency does not permit non-traditional or unconventional modalities or interventions.

  • FP
    PA-DDS 5.03

    Agency policy prohibits:

    1. corporal punishment;
    2. the use of aversive stimuli;
    3. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain;
    4. the use of demeaning, shaming or degrading language or activities;
    5. unnecessarily punitive restrictions including cancellation of visits as a disciplinary action;
    6. forced physical exercise to eliminate behaviors;
    7. punitive work assignments;
    8. punishment by peers;
    9. group punishment or discipline for individual behavior; and
    10. unwarranted use of invasive procedures or activities as a disciplinary action.

  • FP
    PA-DDS 5.04

    If the agency uses interventions that limit physical movement, diminish sensory experience, restrict personal freedoms, or cause personal discomfort, such interventions are implemented only when:

    1. the agency can document its reasons for believing that the intervention will be beneficial to the individual;
    2. the individual or his or her guardian has been fully informed about the risks and benefits of the intervention and has consented to it;
    3. the intervention is prescribed by a qualified medial practitioner or recommended by an interdisciplinary team;
    4. the agency periodically reviews the continued need for and effectiveness of the treatment or intervention; and
    5. the intervention is not used as a substitute for appropriate staffing patterns, for the convenience of staff, or as punishment.

    Interpretation: Examples of such treatments and interventions are use of splints or poseys to prevent self-injury, use of visual or auditory screens to reduce stimulation, use of distasteful substances, textures, or activities as a consequence for behavior.

    NA The agency does not use interventions that limit physical movement, diminish sensory experience, restrict personal freedoms, or cause personal discomfort.

  • FP
    PA-DDS 5.05

    An intervention is discontinued immediately if it produces adverse side effects, or is deemed unacceptable according to prevailing professional standards.

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