Private Organization Accreditation

White's Residential & Family Services is Indiana's largest social services agency offering accredited and comprehensive residential, foster care, independent living, adoption, and home-based services.


Rochelle Haimes, ACSW

Volunteer Roles: Commissioner; Peer Reviewer; Standards Panel Member; Team Leader

Rochelle is a Consultant working with a variety of private organizations to become accredited. Her primary area of expertise is in facilitating the development of PQI systems and activities. Her previous experience with both small and large organizations is the cornerstone for her long-standing volunteer activities as a Peer reviewer and as a Team Leader.
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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 4: Service Planning and Monitoring

Service recipients and their families participate in the development and ongoing review of an individualized, person- or family-centered service plan that is the basis for delivery of appropriate services and support.

Interpretation: Family involvement has been emphasized due to the significant impact family engagement can have on resilience and recovery. However, the level of family involvement will vary given the age and expressed wishes of the person and as permitted by law.

Program model and structure can also impact family involvement. For example, detoxification treatment programs are short-term and primarily focused on withdrawal management; therefore, service recipients have limited opportunities to involve family members in the service planning and monitoring process. Furthermore, it may not be appropriate to engage family members due to the service recipient’s physical and mental state and treatment progress. 

Due to the importance of family involvement in achieving positive outcomes for children, all aspects of service delivery should be family-driven when working with this population, accounting for the dynamics of the family as well as the needs of the child. Family should be defined in partnership with the child and can include the child’s birth, foster, adoptive, or kinship caregivers as appropriate.

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

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Service planning and monitoring procedures, including strategies for active family participation when appropriate 
    • Crisis and safety planning procedures
    • Documentation of case review
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • PA-MHSU 4.01

    An individualized, person- or family-centered service plan is developed in a timely manner with the full participation of the service recipient, and expedited service planning is available when crisis or urgent need is identified.

    Interpretation: Service planning is conducted so that the individual retains as much personal responsibility and self-determination as possible and desired. Individuals with limited ability in making independent choices receive help with making or learning to make decisions. 

    When the service recipient is a minor, or an adult under the care of a guardian, the agency should follow applicable state laws or regulations requiring involvement or consent of service recipients’ legal guardians.

    Note: Agencies should review state Medicaid plans or other third party reimbursement requirements to ensure they are meeting required timeframes for completing service plans.

    Research Note: Literature suggests that service recipient involvement should support active communication of ideas, goals, and feelings so individuals can be successful and satisfied in their chosen environment. When service recipients feel empowered to make choices, positive outcomes increase. Individuals build self-esteem and experience greater independence and self-mastery.

  • PA-MHSU 4.02

    The service plan is based on the assessment, and includes:

    1. agreed upon goals, desired outcomes, and timeframes for achieving them;
    2. services and supports to be provided, and by whom; and 
    3. the service recipient or legal guardian’s signature.

    Interpretation: Treatment outcomes for adults may include the ability to live independently or obtain employment, while outcomes for children and youth may focus on school performance and social and emotional well-being.

    Note: For service members, veterans, and their families, the service plan should also clearly outline which services will be provided on the installation or Veterans Affairs facility, when appropriate to the needs and wishes of the service recipient. Research has shown that this population is often unsure of which services they are entitled to and how to navigate military care systems. The clinician should take an active role in navigating these care systems when possible.

  • PA-MHSU 4.03

    During service planning, the agency explains:

    1. available options;
    2. how the agency can support the achievement of desired outcomes; and
    3. the benefits, alternatives, and risks or consequences of planned services.

  • PA-MHSU 4.04

    The service plan addresses, as appropriate:

    1. unmet service and support needs;
    2. possibilities for maintaining and strengthening family relationships; and
    3. the need for support of the service recipient’s informal social network.

    Note: While the involvement of family and significant others can support the development of an effective, individualized service plan, Medicaid requires that all goals, services and interventions be for the exclusive benefit of the service recipient. 

  • FP
    PA-MHSU 4.05

    The agency engages service recipients and involved family members in crisis and/or safety planning, as appropriate to individual needs. 

    Interpretation: While each individual service recipient may not require a crisis plan, the agency should have a process in place for determining whether or not a crisis plan is necessary.

    The crisis plan should identify individualized warning signs of a crisis, and should specify interventions that may or may not be implemented by personnel in order to help the individual de-escalate and promote stabilization. The plan can be part of, and reviewed with, the service recipient’s overall service or treatment plan. 

    Depending on the needs of the individual, crisis plans may reference an advanced mental health directive, also known as advanced psychiatric directive, which enables a person to make decisions about the care they want to receive when they may be incapacitated. Advanced directives go into effect if the person is unable to make decisions for him/herself, and are revocable. They frequently address preference for hospitals, medications, specific interventions, and designation of a person to make decisions about their care. 

    Agencies may also provide family members with information on crisis prevention. For example, Mental Health First Aid is a one-day training that can prepare someone to recognize, understand, and respond to a service recipient’s mental health crisis.

    Interpretation: A safety plan is a prioritized written list of coping strategies and sources of support that individuals who have been deemed to be at high risk for suicide can use. Individuals can implement these strategies before or during a suicidal crisis. A personalized safety plan and appropriate follow-up can help suicidal individuals cope with suicidal feelings in order to prevent a suicide attempt or possibly death. The safety plan should be developed once it has been determined that no immediate emergency intervention is required. Components of a safety plan include: recognition of warning signs, internal coping strategies, socialization strategies for distraction and support, family and social contacts for assistance, professional and agency contacts, and lethal means restriction. 

    “No-suicide contracts,” also known as “no-harm contracts” and other similar terms, should never be used. No-suicide contracts are based on a verbal or written agreement by the service recipient to not engage in self-harm or suicidal acts during a specific timeframe. Research does not support this practice or show that these agreements are effective at preventing suicides, nor have they been found to provide protection against malpractice lawsuits.

  • PA-MHSU 4.06

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

    1. service plan implementation;
    2. progress toward achieving service goals and desired outcomes; and
    3. the continuing appropriateness of the agreed upon service goals.

    Interpretation: Experienced workers may conduct reviews of their own cases. In such cases, the worker’s supervisor reviews a sample of the worker’s evaluations as per the requirements of the standard.

    Interpretation: Timeframes for review should be adjusted depending upon the issues and needs of persons receiving services and the frequency and intensity of the services being provided. Individuals with higher level of care needs require frequent review. For example, weekly review is recommended for service recipients with substance use disorders at high risk for relapse. Individuals with acute or complex needs (e.g., service recipients receiving medications for diagnosed symptoms and conditions) may require that their service plan be reviewed and updated every 30 days. 

    NA The agency provides detoxification treatment only. 

  • PA-MHSU 4.07

    The worker and service recipient or legal guardian regularly review progress toward achievement of agreed upon goals and document revisions to service goals and plans.

    Interpretation: In regards to documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the service recipient, or a legal guardian when the service recipient is a minor, or otherwise documented in a manner that is consistent with the agency’s service planning and monitoring procedures.

    NA The agency provides detoxification treatment only. 

  • PA-MHSU 4.08

    Family members and significant others, as appropriate, and with the consent of the service recipient, are advised of ongoing progress and invited to participate in case conferences.

    Interpretation: The agency facilitates the participation of family and significant others by, for example, helping arrange transportation, and including them in scheduling decisions.

    NA The agency provides detoxification treatment only. 

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