WHO IS ACCREDITED?

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.
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ORGANIZATION TESTIMONIAL

Family Services of the North Shore

Kathleen Whyte, Manager of Human Resources / Accreditation Coordinator

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency.
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Purpose

Comprehensive, systematic, and effective risk prevention and management practices reduce the organization’s risk, loss, and liability exposure.

FOC
RPM 8: Access to Case Records

Service recipients or designated legal representatives can access their case records, consistent with legal requirements.

Interpretation: Organizations are expected to have policies and procedures that address access to case records by service recipients.

Interpretation: For networks, RPM 8 applies to case records and case information that is maintained by the network management entity, as well as records maintained by members of organizations or subcontracted providers.

Note: See DV 17 for further guidance about the information to be included in case records for Domestic Violence Services (DV).

Note: If the organization operates a program that qualifies for an NA but also provides other types of services, the standards should be implemented in all programs aside from those that qualify for the NA.

NA The organization provides only Community Change Initiatives (CCI), Early Childhood Education (ECE), Social Advocacy (SOC), and/or Youth Development (YD) Services.

NA The organization provides only non-clinical group, crisis intervention, and/or information and referral services.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the RPM 8 Practice standards.
2
Practices are basically sound but there is room for improvement as noted in the ratings for the RPM 8 Practice standards.
3
Practice requires significant improvement as noted in the ratings for the RPM 8 Practice standards; and/or
  • At least one of the Fundamental Practice Standards received a 3 or 4 rating.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the RPM 8 Practice standards; and/or
  • At least two of the Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Case record access policies and procedures
No On-Site Evidence
    • Interview:
      1. MIS Manager
      2. Case record clerk
      3. Program directors
      4. Direct service personnel
      5. Persons served
    • Observe case record room/ files and MIS accessibility observation

  • FP
    RPM 8.01

    Access to confidential case records meets legal requirements, and is limited to:

    1. the service recipient or, as appropriate, a parent or legal guardian;
    2. personnel authorized to access specific information on a “need-to-know” basis;
    3. others who are permitted access;
    4. former service recipients;
    5. requests for records of deceased service recipients; and
    6. auditors, contractors, and licensing or accrediting personnel consistent with the organization’s confidentiality policy.

    Interpretation: Case records should not be left in public areas such as on carts in hallways, on desks, or in non-secured areas. When not being used by authorized staff, files should be returned to a secure area.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Record access policy or procedure needs strengthening.
    3
    Practice requires significant improvement; e.g.,
    • Record access policy or procedure needs significant strengthening; or
    • In a few instances the organization does not comply with the standard.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • RPM 8.02

    Reviews of case records by service recipients are:

    1. conducted in the presence of professional personnel on the organization’s premises; and
    2. carried out in a manner that protects the confidentiality of family members and others whose information may be contained in the record.

    Interpretation: For organizations using electronic record systems, allowing the service recipient to directly access the case record through a staff account represents a security risk. Access for service recipients may be provided, for example, through a separate user portal or by printing the case record. 

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Record access policy or procedure needs strengthening.
    3
    Practice requires significant improvement; e.g.,
      •  Record access policy or procedure needs significant strengthening; or
      •  In a few instances the organization does not comply with the standard.
      4
      Implementation of the standard is minimal or there is no evidence of implementation at all.

    • FP
      RPM 8.03

      If the organization determines that it would be harmful for a service recipient to review his/her case record, and applicable law provides no guidance on case record access, then:

      1. senior management reviews, approves in writing, and enters into the case record the reasons for refusal; and
      2. procedures permit a qualified professional to review records on behalf of service recipients, provided the professional signs a statement that information determined to be harmful will be withheld.

      Interpretation: An individual’s right to review his or her care or treatment may be denied, or otherwise limited, only in the most extreme circumstances where serious harm is likely to ensue. In such cases, objective criteria must guide decisions to deny access. In all cases, the organization must operate in accord with applicable law.

      Rating Indicators
      1
      The organization's practices reflect full implementation of the standard.
      2
      Practices are basically sound but there is room for improvement; e.g., 
      • Record access policy or procedure needs strengthening.
      3
      Practice requires significant improvement; e.g.,
      • Record access policy or procedure needs significant strengthening; or
      • In a few instances the organization does not comply with the standard.
      4
      Implementation of the standard is minimal or there is no evidence of implementation at all.

    • RPM 8.04

      Contracts with subcontracted provider organizations and independent practitioners ensure that the network management entity has access to the case records of persons and families receiving network services.

      Interpretation: Network management entities require access to case information in order to conduct utilization management activities, verify billing, provide care coordination, and other network management activities.

      NA The organization is not a network management entity.

      Rating Indicators
      1
      The organization's practices reflect full implementation of the standard.
      2
      Practices are basically sound but there is room for improvement; e.g., 
      • Record access policy or procedure needs strengthening.
      3
      Practice requires significant improvement; e.g.,
      • Record access policy or procedure needs significant strengthening; or
      • In a few instances the organization does not comply with the standard.
      4
      Implementation of the standard is minimal or there is no evidence of implementation at all.