Private Organization Accreditation

CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.


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.
read more>>


The agency supports personnel and promotes personnel competence, satisfaction, and retention by providing initial and ongoing competency-based training; a variety of personnel development opportunities; and regular, supportive supervision. 

PA-PDS 1: Personnel Development

The agency supports effective service delivery through a structured personnel development program that provides personnel with the knowledge, skills, and abilities needed to promote positive outcomes.

Research Note: Research suggests that inadequate personnel development programs can cause retention challenges for agencies as workers may choose to leave an agency when they have not been adequately prepared and supported for the position they have been hired to fill.

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 administration and management 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
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Outline of competency expectations for personnel in all core positions or specific job categories, i.e. caseworkers, front-line supervisors, program managers, program directors (PA-PDS 1.01) 
    • Leadership development activities for the previous and current calendar years (PA-PDS 1.02)
    • See personnel development activities in the implementation plan for the most recent agency-wide initiative in PA-AM 2 (PA-PDS 1.03)
    • Training evaluation procedures  (PA-PDS 1.04)
    State Administered Agency (Regional Office)
    • Regional training evaluation procedures (PA-PDS 1.04)
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Documentation of improvements made based on results of training evaluation efforts (PA-PDS 1.04)
    State Administered Agency (Regional Office)
    • Documentation of regional improvements made based on training evaluation efforts (PA-PDS 1.04)
    All Agencies
    • Interview: 
      1. Clinical or program director
      2. Agency field personnel
      3. Volunteers

  • PA-PDS 1.01

    The personnel development program:

    1. incorporates a variety of educational methods;
    2. is responsive to the history, cultural backgrounds, and related needs of personnel;
    3. outlines specific competency expectations for personnel in core  positions or specific job categories; and
    4. provides the opportunity for personnel to fulfill the continuing education requirements of their respective professions.

    Interpretation: Educational methods include, but are not limited to:

    1. interactive classroom trainings; 
    2. webinars, self-paced trainings, or other computer-assisted training models; 
    3. coaching; 
    4. conferences; 
    5. degree or certificate programs; 
    6. workshops; and 
    7. structured peer support opportunities. 
    The agency may also support personnel development by encouraging personnel to join and participate in professional organizations; helping personnel to identify training and educational experiences that are credit bearing; and offering tuition reimbursement or financial assistance, whenever possible.

    Interpretation: Training, particularly around trauma-informed care, can act as a trigger to personnel with their own personal history of trauma.  As such, implementation of element (b) includes ensuring that the agency is aware of and responsive to the potential for re-traumatization when designing and executing training activities.

  • PA-PDS 1.02

    The agency supports advancement within the agency and profession by offering, or providing access to, a competency-based leadership development program that:

    1. is aligned with the agency’s strategic and human resource planning; 
    2. identifies desired leadership competencies that support achievement of the agency’s vision, mission, and strategic goals;
    3. outlines the initiatives or activities that will assist eligible personnel in developing those competencies;
    4. establishes performance-driven, objective criteria for eligibility to participate; and
    5. is visible across the agency to promote participation.

    Interpretation: Standard implementation can be demonstrated through access to a state-wide leadership development program that meets elements (a) through (e) of the standard.  When an adequate program is not available, the standard requires that the agency implement its own leadership development program that meets the requirements of the standard.

    Interpretation: Criteria for eligibility can include factors such as data on performance over time, assessments of competencies and skills, previous experience, time in current position, etc.

    Interpretation: Leadership development programming can include, but is not limited to: trainings, degree or certificate programs, review of relevant professional literature or research, shadowing, additional assignments to develop new skills, leadership mentoring, and exposure to functions outside the individual’s current role. 

    Research Note: Leadership development programs are not designed to give preference to participants when filling vacancies. The intent is to promote the continuous development of a talented pool of internal candidates that possess the leadership competencies necessary for the agency to achieve its mission and vision for the future. 

    NA State-administered agency regional office

  • PA-PDS 1.03

    The personnel development program supports implementation of agency-wide practice changes through training, coaching, and supervision designed to provide relevant personnel with the knowledge and skills needed to effectively implement the new practice with fidelity.

  • PA-PDS 1.04

    The agency’s training evaluation practices are incorporated into the agency’s overall performance and quality improvement initiatives and:

    1. include methods for assessing knowledge and skill acquisition such as pre- and post-testing and direct practitioner observation;
    2. are data-driven;
    3. include mechanisms to identify trends and make improvements at regular intervals; and
    4. are continuously evolving to include greater focus on knowledge transfer and quality improvement.   

    Interpretation: Training evaluation exists on a continuum ranging from personnel surveys that look only at satisfaction and perceived competence following training to evaluating the impact of training on positive outcomes.  While agencies will fall at various stages along this continuum, every agency should be actively working towards developing more sophisticated systems for evaluating the delivery and effectiveness of their training activities.

    In regards to element (a), data from assessments should be used to inform the individual’s ongoing professional development and, in the aggregate, should inform improvements to recruitment, selection, professional development, and supervision activities. 


    Research Note: Agencies with more sophisticated training evaluation systems consistently cite partnerships with universities or other external experts as key to their success in this area.

Copyright © 2019 Council on Accreditation. All Rights Reserved.  Privacy Policy and Terms of Use