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.


Mike Angstadt

Volunteer Roles: Commissioner; Hague Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

Serving as a Team Leader for COA has been an enriching experience in many ways. Utilizing the Contextual Accreditation process to discern the means in which agencies, offering a variety of services, located throughout the US, Canada ,the Philippines and other countries provide best and most promising practices to their consumers has been particularly rewarding. read more>>


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.

PA-HCS 4: Assessment Based Care Planning and Coordination

Individuals and caregivers 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
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions; exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement. 
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.  
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.  
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.   
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner. 
  • Service quality or agency functioning may be compromised.   
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.  
Please see Rating Guidance for additional rating examples. 

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
    PA-HCS 4.01

    To ensure an appropriate level of care, the agency 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.

  • PA-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.

  • PA-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.

  • PA-HCS 4.04

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

  • PA-HCS 4.05

    Assessments are completed within timeframes established by the agency.

  • PA-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.

  • PA-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.

  • PA-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
    PA-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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