Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.


Ulysses Arteaga, L.C.S.W.

Volunteer Roles: Commissioner; EPPA; Marine Reviewer; Military Reviewer; Peer Reviewer; Team Leader

The Consuelo Foundation 2012 Peer Reviewer of the Year, Mr. Arteaga conducts two to three site visits a year, often volunteering for visits that require a Spanish speaking peer.
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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.

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.

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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