WHO IS ACCREDITED?

Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.
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ORGANIZATION TESTIMONIAL

The Village for Families & Children, Inc.

Galo A. Rodriguez, M.P.H., President & CEO

COA Peer Reviewers demonstrated their expertise through their knowledge of COA standards as well as experience in the behavioral health field. In addition, COA’s seminars and tools were very helpful in guiding us through the accreditation process.
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Purpose

Youth participating in Psychosocial Services (YPS) receive community based services that facilitate childhood development and resiliency using a holistic approach that improves family functioning and increases child well-being and safety.

YPS 4: Service Plan

Youth participate in the development and ongoing review of a service plan that supports:

  1. the attainment of agreed upon goals;
  2. improvement in the person’s quality of life and ability to manage within the community; and
  3. development of desired skills.

Interpretation: If the person is receiving services from any programs from within the organization or outside organizations, the service plan may be part of the overall service plan.

Interpretation: The six general service sectors accessed by youth are: specialty mental health, substance use treatment, education, child welfare, general medicine, and juvenile justice. Besides the services being provided by the program, there should be documentation of any other service sectors that are being accessed by the youth.

Interpretation: The wraparound approach is a service planning philosophy for youth in need of psychosocial rehabilitation, collaborating with all service providers that touch the youth’s life (educational, justice, family services, etc.) to create a single plan that works with youth and their family to promote positive outcomes. While it is not necessary to use Wraparound services when providing psychosocial rehabilitation to youth, the research supports that participation in Wraparound services sustains youths’ ongoing participation in services.
 

Research Note: The literature on service planning for youth supports the efficacy of a singular plan as promoted by the Wraparound approach.

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 family participation when appropriate
    • Crisis and safety planning procedures
    • Documentation of case review
    • Youth’s signature on the service plan
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review Case Records

  • YPS 4.01

    The service plan is:

    1. based on the strengths and needs identified in the assessment; 
    2. developed in a timely manner with the full participation of the youth and their family/primary caregiver; and
    3. expedited when crisis or urgent need is identified.

    Interpretation: Service planning is conducted so that the youth 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.

    Interpretation: Family members should always be included in the service planning when appropriate, as determined by the youth and primary caregiver. If the youth and primary caregiver agree that it is not appropriate, it should be documented as such.

    Interpretation: If the youth has been identified as a victim of human trafficking, the organization should work with the youth and their primary caregiver to develop a safety plan that focuses on increasing physical safety by securing needed documents, property, and services and linking efficiently to law enforcement, if needed.

    Research Note: The literature supports that the more ‘choice and voice’ the youth feels they have in their service plan, the more likely that they will feel engaged in their treatment resulting in positive outcomes.


  • YPS 4.02

    The youth, family members, and personnel collaboratively develop a written, individualized service plan that is based on the assessment and supports:

    1. attainment of short- and long-term service goals;
    2. improvement in the person’s quality of life and ability to remain within the community; and
    3. development of desired skills.


  • YPS 4.03

    The service plan, 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 youth’s signature.

    Research Note: The resiliency framework suggests that when looking at outcomes and treatment goals, it is important to look at not only emotional or behavioral disturbances, but to also examine strengths and when the youth has used them to protect against adversity.  For example, this is used through the Personal Model of Resilience where therapists and youth identify assets in the individual’s life (such as being good at sports, making friends easily, etc.) and then look at situations in which the strength has been used to overcome an obstacle. 


  • YPS 4.04

    During service planning the organization explains:

    1. available options; and
    2. the benefits, alternatives, and consequences of planned services.


  • YPS 4.05

    The service plan addresses, as appropriate:

    1. services provided by other programs and/or providers; 
    2. unmet service and support needs;
    3. psychological and emotional needs;
    4. educational goals;
    5. cultural interests;
    6. possibilities for maintaining and strengthening family relationships; 
    7. development of life skills, including preparation to work or continuation of schooling; and
    8. the need for support of the youth’s informal social network.

    Interpretation: Experiences with family rejection and capacity for increasing family acceptance and support are a part of the assessment for family relationships. It also includes culturally appropriate education and guidance to help families with LGBTQ youth decrease family rejection and increase family support.

    Research Notes: Youth engagement with positive social and cultural interests through community-based programs is important in the promotion of healthy physical, intellectual, and psychological development. 


  • YPS 4.06

    The worker and a supervisor, or a clinical, service, or peer team, review the service plan at least quarterly, or as frequently as deemed necessary by the service provider and supervisor, to assess:

    1. service plan implementation;
    2. progress toward achieving service goals and desired outcomes; and
    3. the continuing appropriateness of the 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 service plan reviews should be adjusted depending upon: issues and needs of the youth; changes in the youth’s life situations or psychological conditions; and frequency and intensity of services provided.


  • YPS 4.07

    The worker, primary caregiver, and youth regularly review progress toward achievement of agreed upon goals and sign revisions to service goals and plans.


  • YPS 4.08

    Family members, as appropriate, are advised of ongoing progress and invited to participate in case conferences.

    Interpretation: The organization facilitates the participation of family and encourages their role in the service plan when appropriate.

    Research Note: The literature on youth resiliency suggests that service plans that include all adults and family members who play a positive role in youth’s life have a higher likelihood of leading to positive outcomes, reducing familial stress, and decreasing the need for a restrictive setting.
     

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