WHO IS ACCREDITED?

Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.
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VOLUNTEER TESTIMONIAL

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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Purpose

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.

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 organization 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 organizations 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
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,  
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (HR 6.02) and training (TS 2.03); or
  • In a few instances client or staff signatures are missing and/or not dated; or
  • Active client participation occurs to a considerable extent.
3
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • In a number of instances client or staff signatures are missing and/or not dated (RPM 7.04); or
  • Quarterly reviews are not being done consistently; or
  • Level of care for some clients is inappropriate; or
  • Service planning is often done without full client participation; or
  • Appropriate family involvement is not documented; or
  • Documentation is routinely incomplete and/or missing; or
  • Assessments are done by referral source and no documentation and/or summary of required information present in case record; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

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

  • 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.

    Update:

    • Revised NA - 03/15/17
      The NA was expanded to include short-term diagnostic centers.

    Note: Organizations 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 RTX 12.04. Organizations that only operate a crisis stabilization unit will complete all other applicable service planning and monitoring standards.

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


  • FP
    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 organization 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. 


  • 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.


  • 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 organization 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.


  • 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 organization only operates a crisis stabilization unit or short-term diagnostic center. 


  • 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 organization 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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