Private Organization Accreditation

Family Services of Southeast Texas strengthens families through accessible, affordable counseling services and education for issues affecting family life, mental health and employment.  We also provide comprehensive domestic violence shelter and support services.


Judy Kay, LCSW

Volunteer Roles: Peer Reviewer; Team Leader

In administration for 22 of 24 years at Child Saving Institute, a COA-accredited not-for-profit child welfare agency in Omaha, Nebraska. Retired approximately two years ago, I moved to Tucson, Arizona, where I advocate for children's rights as a Court Appointed Special Advocate (CASA) volunteer to three young children.
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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 5: Care Monitoring

Routine care monitoring ensures delivery of appropriate services.

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
    • Care monitoring procedures
No On-Site Evidence
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Individuals or caregivers served
    • Review case records

  • PA-HCS 5.01

    Follow up assessments are based on the physical and cognitive needs of the client and are conducted by a nurse or other qualified professional:

    1. in person at least every 30 days for cognitively impaired clients, or clients with other special needs;
    2. in person at least every 60 days for clients who are not cognitively impaired and are receiving personal care aide services;
    3. in person at least every 90 days for clients receiving homemaker services only; and
    4. by phone, in addition to the in person timeframes listed above, when needed.

    Interpretation: The agency is responsible for determining the necessary qualifications for staff conducting assessments in accordance with state regulations.

  • FP
    PA-HCS 5.02

    Care providers:

    1. document all interventions and how the person responds;
    2. monitor and document changes in physical, mental, and emotional status and gains of the individuals and their care givers;
    3. respect and note service recipient choices;
    4. help individuals make independent choices or assume more responsibility for making decisions;
    5. recognize service gaps and emergency situations and follow procedures to ensure the safety and well being of care recipients; and
    6. report on plan implementation and progress to a supervisor or case manager at least weekly.

    Research Note:Regarding element b.), family service providers who seek to understand the effects of stress on quality of life, point to the importance of helping caregivers appraise stress associated with the care recipient’s behaviors and needs, and to address sufficiency of resources to meet family demands and needs. A related recommendation when caregiver stress is identified is to determine if families require a plan for managing stress.

  • PA-HCS 5.03

    The care provider and person receiving services, or legal guardian, regularly review progress toward achievement of service goals and sign revisions to goals and care plans.

    Interpretation:Multidisciplinary team conferences should include the care recipient, direct care providers, family, and other care givers whenever possible.

  • PA-HCS 5.04

    The worker and a supervisor, or a clinical, service, or peer team review every case quarterly, at a minimum, to assess:

    1. care plan implementation;
    2. progress toward achieving goals and desired outcomes; and
    3. the appropriateness of continuing services and goals.

    Interpretation: Experienced managers may conduct care plan reviews of their own cases. In such cases, the manager’s supervisor reviews a sample of reviewed cases consistent with the requirements of the standard.

    Timeframes for care plan reviews should be adjusted depending upon issues and needs of individuals receiving services, frequency and intensity of services provided, and frequency of contact with informal caregivers and cooperating providers.

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