Private Organization Accreditation

HeartShare assist individuals with developmental disabilities through education, day, residential and recreation programs, case management, and health services, and provides foster care/adoption services, counseling, after school and energy assistance programs, and programs for people with HIV/AIDS.


Nicole Deprez-Garrity, M.Ed.

Volunteer Roles: Endorser, Lead Endorser

Nicole Deprez-Garrity is a lead After School Endorser based in Germany.
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Individuals who receive Services for Mental Health and/or Substance Use Disorders improve social, emotional, psychological, cognitive, and family functioning, and attain recovery and wellness.

PA-MHSU 3: Assessment

Service recipients participate in a comprehensive, individualized, trauma-informed, strengths-based, family-focused, culturally and linguistically responsive assessment to determine an appropriate level of service.

Interpretation: For an assessment to be trauma-informed, the agency understands and recognizes the role of traumatic life events in the development of mental health and/or substance use disorders. Personnel should focus on the experiences and strengths of the service recipient rather than personal deficits and weaknesses. Adopting this assumption at all levels of treatment ensures that the agency actively prevents instances that could potentially re-traumatize service recipients.  

Interpretation: For detoxification treatment programs, due to the physical and mental state of the service recipient, family involvement in the assessment process may not be appropriate. Therefore, the assessment will focus on the individual and his or her care 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.

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 and reassessment procedures
    • List of standardized assessment tools used
    • Copies of any standardized assessment tools used 
    • List of identified medical referral sources, if applicable (PA-MHSU 3.07)
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • PA-MHSU 3.01

    The information gathered for assessments is strengths-based, comprehensive, directed at concerns identified in the initial screening, and limited to material pertinent for meeting service requests and objectives.

  • PA-MHSU 3.02

    Assessments are conducted in a culturally and linguistically responsive manner, and:

    1. identify resources that can increase service participation and achievement of agreed-upon goals; and
    2. address issues of special relevance to various groups, such as women, older adults, young children, or adolescents, as applicable.

    Interpretation: Culturally responsive assessments can include attention to geographic location; language of choice;the person’s religious, racial, ethnic, and cultural background; and military status. Other important factors that contribute to a responsive assessment include attention to age, sexual orientation, gender identity, developmental level and level of literacy attainment.

    Interpretation: For agencies serving children, assessments should take into account systems involvement including education, child welfare, and juvenile justice.

    Research Note: Some groups of service recipients may be at higher risk for suicide due to past trauma, compounding risk factors, and/or societal stigma, including individuals with systems involvement (foster care, juvenile justice, criminal justice), military service members, American Indian and Alaska Natives, and individuals who identify as lesbian, gay, bisexual, and transgender (LGBT).

  • PA-MHSU 3.03

    Engagement and assessment are characterized by:

    1. sensitivity to the willingness of the service recipient to be engaged;
    2. a non-threatening manner;
    3. respect for the service recipient’s autonomy and confidentiality;
    4. flexibility; and
    5. persistence.

  • PA-MHSU 3.04

    Each service recipient receives an individualized, comprehensive assessment, which includes a summary of symptoms and diagnoses based on a standardized diagnostic tool.

    Interpretation: The standardized diagnostic tool should be used to match the needs of the service recipient with the appropriate level care. Assessment tools will vary depending on the age and developmental level of the service population. 

    Examples of standardized instruments or protocols include: the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, the International Statistical Classification of Diseases and Related Health Problems (ICD), the Addiction Severity Index, Treatment Services Review, the American Society of Addiction Medicine (ASAM) Patient Placement Criteria, the Institute of Medicine (IOM), the Child and Adolescents Needs and Strengths (CANS), criteria required by federal or state oversight authorities, and criteria required for participation in managed care delivery systems. 

    Interpretation: Assessments are completed within timeframes established by the agency. Organizations should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes.

  • FP
    PA-MHSU 3.05

    The comprehensive assessment includes:

    1. the service recipient’s behavioral health, physical health, and community and social support service needs and goals;
    2. trauma history and recent incidents of trauma;
    3. individual and family strengths, risks, and protective factors; and
    4. natural supports and helping networks.

    Interpretation: In regards to element (a), the comprehensive assessment may include: an evaluation of mental health and/or substance use disorders, a psychiatric history, suicide and self-harm history and current level of risk, a complete alcohol and drug use history, medical history, and evaluation of social support and community support networks.  

    Organizations serving young children should tailor the assessment process to meet the age and developmental level of the service population. Assessments may include an evaluation of factors that impact the child’s social and emotional well-being (e.g., family characteristics), an observation of the child’s behavior, and/or a thorough health and developmental history. 

    Interpretation: A trauma screen is a brief measure or tool that determines whether an individual has experienced specific traumatic events. Trauma screening tools usually detect exposure to potentially traumatic events or experiences or the presence of traumatic stress symptoms and reactions. 

    If there is an indication of trauma during the trauma screen then the individual should also receive a comprehensive, evidence-based trauma assessment. The trauma assessment is a diagnostic process that is conducted by a clinician or trained mental health professional and determines whether clinical symptoms of traumatic stress are present as well as the severity of symptoms that impact the individual’s level of functioning and treatment options. 

    Personnel with specialized trauma-related education, skills, and training, or a qualified cooperating service provider, screen and assess individuals for trauma symptoms.

    Interpretation: Due to the short-term nature and focus of detoxification treatment programs, individuals seeking treatment may not have the opportunity to address trauma history and/or recent incidents of trauma during the assessment process. Similarly, it may not be appropriate to involve family members in the assessment process or assess family strengths, risks, and protective factors due to the service recipient’s physical and mental state at the time of the assessment. 

  • FP
    PA-MHSU 3.06

    The agency engages service recipients in a risk assessment to assess their risk of suicide, self-injury, neglect, exploitation, and violence towards others.  

    Interpretation: Personnel that conduct evaluations should be aware of the indicators of a potential trafficking victim, including, but not limited to, evidence of mental, physical, or sexual abuse; physical exhaustion; working long hours; living with employer or many people in confined area; unclear family relationships; heightened sense of fear or distrust of authority; presence of older significant other or pimp; loyalty or positive feelings towards an abuser; inability or fear of making eye contact; chronic running away or homelessness; possession of excess amounts of cash or hotel keys; and inability to provide a local address or information about parents.

    Interpretation: All programs should maintain an evidence-based suicide risk assessment protocol. All suicide risk assessment tools are required to include information related to the four core principles of: suicidal desire, capability, intent, and buffers/protective factors.

    Research Note: The field of suicide prevention and research has grown dramatically in recent years. Research shows that behavioral health conditions, such as mental illness and/or substance use disorders, and traumatic or violent life events can heighten an individual’s subsequent suicide risk. Identifying risks, warning signs, and protective factors during the assessment process can facilitate prompt access to necessary services and interventions. 

  • FP
    PA-MHSU 3.07

    Unmet medical needs identified in the assessment are addressed directly, or through an established referral relationship, and can include:

    1. medication monitoring and management;
    2. physical examinations or other physical health services;
    3. medical detoxification;
    4. laboratory testing and toxicology screens; or
    5. other diagnostic procedures.

    Interpretation: The nature of problems resulting from mental health and/or substance use disorders may require medical services to be available. The agency is not required to provide services directly, but the results of medical screens, tests, and services should be documented in the case record when available and incorporated into service planning and monitoring.

    Interpretation: Organizations providing treatment services for mental health and/or substance use disorders are expected to have a licensed physician or other qualified health professional with appropriate training and experience on staff or available through a contract or formal arrangement.  All other services must have, at minimum, an established referral relationship with a licensed physician or other qualified health professional.

    Interpretation: Clinical personnel coordinate services when an individual receives medical treatment from a private physician. For example, a physician may refer the individual to the agency for counseling or prevention. In such cases, the agency is not responsible for addressing the medical aspects of treatment, but must coordinate services with the physician.

  • PA-MHSU 3.08

    Reassessments are conducted as necessary, according to the needs of the service recipient.

    Interpretation: Reassessments are completed within timeframes established by the agency depending on the service population and length of treatment. Timeframes may also be delineated by regulatory requirements. The agency may conduct a reassessment during specific milestones in the treatment process, including:

    1. after significant treatment progress;
    2. after a lack of significant treatment progress;
    3. after new symptoms are identified;
    4. after changes in treatment strategy and/or medication;
    5. when significant behavioral changes are observed; 
    6. when there are changes to a family situation; or
    7. when significant environmental changes or external stressors occur. 
    Interpretation: The events listed in elements (c) through (g) may heighten or trigger suicide risk, as could a new physical or mental health diagnosis, and should therefore prompt a new suicide risk assessment. Once any potential suicide risk is identified, reassessments should occur regularly even if these trigger events are not observed. 

    Research Note: Service recipients may not be able or willing to reveal traumatic life events during the initial, comprehensive assessment process. Reassessments allow for personnel to gather new trauma-related information that can inform service delivery as well as treatment objectives and goals.

    Similarly, individuals at risk for suicide may not be identified unless reassessed as they often do not disclose their thoughts or plans due to stigma and discrimination, or may be in denial. Additionally, suicide risk is not a constant state, instead, individuals move between various stages of risk or between passive and active ideation.

    Research Note: Research shows that children involved in the child welfare system, particularly children in foster care, experience high rates of mental illness, which can often be difficult to detect. Due to the many life changes they experience, multiple, ongoing assessments may be necessary as they adjust to a new situation.

    NA The agency provides Diagnosis, Assessment, and Referral Services only.

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