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.


Orange County Government, Youth & Family Services Division

Rodney J. Hrobar Sr., LMHC, CPP, Quality Assurance Manager

As the lead agency in Orange County, providing the safety net for children and families, it is reassuring that our clients can be confident that their needs will be addressed in accordance with the most stringent standards of public, as well as private, accountability as monitored and reviewed by the Council on Accreditation. 
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Residential Treatment Services provide individualized therapeutic interventions and a range of services, including education for residents to increase productive and pro-social behavior, improve functioning and well-being, and return to a stable living arrangement in the community.

PA-RTX 5: Service Planning and Monitoring

Residents and their families participate in the development and ongoing review of a comprehensive service plan that is the basis for delivery of appropriate services and supports.

Interpretation: While a service plan may conform to a uniform format, plan content will be individualized through collaboration with the resident and, as appropriate, a parent, guardian, and/or legal advocate. Level of family involvement in the service planning process will vary by resident and/or program model. 

Interpretation: When the agency is working with Indian children and families, tribal or local Indian representatives must be included in the service planning process and culturally relevant resources available through or recommended by the tribe or local Indian agencies should be considered when developing the service plan.

Note: When services are provided as part of a Medicaid contract, the service plan should be client-centered with all goals, services, and interventions being for the exclusive benefit of the client.

Research Note: Working collaboratively with residents and soliciting their perspective on service planning is critical to ensuring services are provided in a trauma-informed and culturally-sensitive manner. 

Research Note: Research suggests that the development of a comprehensive family-driven service plan, which addresses family relationships, decision-making, goal setting, and communications can improve recovery outcomes for those receiving services in a residential program. 

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
    • Service planning and monitoring procedures, including strategies for active resident and family participation in service planning
    • Service plan form/template
    • Documentation of case review
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents and their families
    • Review case records

  • PA-RTX 5.01

    Residents participate in the development of an initial service plan within one week of admission and a comprehensive service plan within 30 days.

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

    Note: Service planning timeframes for crisis stabilization units are addressed in PA-RTX 12.04. Agencies that only operate a crisis stabilization unit will complete all other applicable service planning and monitoring standards. 

    NA The agency only operates a crisis stabilization unit or short-term diagnostic center. 

  • FP
    PA-RTX 5.02

    The comprehensive service plan is based on the assessment and includes:
    1. measurable service goals and objectives, strengths, desired outcomes, and timeframes for achieving them;
    2. services and supports to be provided, and by whom; and
    3. the resident’s and/or legal guardian’s signature.

    Interpretation: Service planning is conducted so the resident retains as much personal responsibility and self-determination as possible. Individuals with limited ability in making independent choices due to developmental age or other circumstances receive assistance in learning how to make decisions consistent with healthy activities and goal achievement. When the resident is a minor, or an adult under the care of a guardian, the agency should follow applicable state laws or regulations requiring involvement of resident’s legal guardian.
    Interpretation: Engagement strategies, including building rapport, establishing trust, and promoting physical and psychological safety are critical when working with victims of trauma to facilitate the development of realistic goals in an empowering and trauma-informed manner. 

    Research Note: Research suggests that when residents receive information about their mental health diagnoses and are provided an opportunity to participate in their own treatment decisions, they are more likely to continue treatment once leaving the residential program leading to more positive long-term outcomes. 

  • PA-RTX 5.03

    The service plan also includes diagnoses made using standardized diagnostic tools and contains:
    1. a diagnostic summary;
    2. intended treatment outcomes;
    3. specific treatment modalities to be used, appropriate to the cultural perspective and competencies of the individual; and
    4. the estimated length of treatments and stay.

    Interpretation: Standardized diagnostic tools may include the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (DSM), the International Statistical Classification of Diseases and Related Health Problems (ICD), or another comparable standardized diagnostic tool. Individuals in diagnostic settings may receive a working diagnosis while completing a full assessment.

    Research Note: To better address the needs of girls and women, residential treatment programs can offer gender-responsive programming and treatment which emphasizes physical and psychological safety, empowerment, and encourages relationship building with other women.

  • PA-RTX 5.04

    A family-driven service plan is developed with the participation of the resident’s family and/or significant others as agreed to by:
    1. a legal guardian when the resident is a minor;
    2. the person being served when the resident is an adult not under the care of a guardian.

    Interpretation: The service plan addresses, as appropriate, matters that have a direct bearing on safety, a permanent living arrangement, and well-being, including:
    1. the family strengths;
    2. unmet family service and support needs, family relationships, siblings, other family members in care, and
    3. the person’s need for family and other informal network support in their community.
    Interpretation: Safety concerns for victims of human trafficking often do not end when they are admitted to residential settings. The agency should work with the victim to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services; maintaining the residence’s location in confidence or restricting access by certain individuals; and linking efficiently to law enforcement, if needed. Psychological safety should also be prioritized as the emotional effects of trauma – mistrust, anxiety, and depression – can be persistent and overwhelming for victims.

  • PA-RTX 5.05

    The treatment team, resident and, when appropriate, his or her family participates in a documented quarterly review of the service plan to assess: 
    1. service plan implementation;
    2. progress toward achieving service goals and desired outcomes; 
    3. the continuing appropriateness of the service goals; and 
    4. the need to revise, cancel, or add new goals and/or objectives.

    Interpretation: Regarding documentation, any revisions to the service plan or service goals should be signed by a member of the treatment team and the resident or a parent and/or legal guardian when the resident is a minor.

    Interpretation: Service plans are reviewed more frequently for young children, individuals with specialized care needs, and as acute needs and contractual requirements dictate. Timeframes for service plan reviews should be adjusted depending upon: issues and needs of persons receiving services; changes in residents’ life situations or psychological conditions; frequency and intensity of services provided; and frequency of contact with informal caregivers and cooperating providers.

    NA The agency only operates a crisis stabilization unit or short-term diagnostic center.

  • PA-RTX 5.06

    Extended family members, significant others, and other supportive individuals, as appropriate and with the consent of the resident, may be invited to participate in case conferences and advised of ongoing progress.

    Interpretation: For children and youth, family members and/or legal guardians should always be involved in case conferences and advised of ongoing progress. 

    Interpretation: The agency facilitates the participation of extended family and significant others by, for example, helping arrange transportation, including them in scheduling decisions or utilizing web-based technologies and other electronic communications.

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