Private Organization Accreditation

Germaine Lawrence is a residential treatment center for girls ages 12-18 with complex behavioral, psychological and learning challenges.   Girls live at our programs while receiving special education, individual, family and group therapy; psychiatric and primary medical care; and a wide variety of therapeutic activities and interventions.


Barry Gourley

Volunteer Roles: Endorser; Peer Reviewer

It is an honor to be a COA volunteer. I’ve had a great opportunity to work with fabulous COA volunteers, I’ve grown professionally in the COA accreditation process and I’ve met some wonderful people across this nation who are working hard to help and support children and families.
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The organization’s administrative and service environments are respectful, caring, safe, and accessible, and contribute to organizational productivity and effective service delivery.

ASE 4: Facility Maintenance

All facilities in which the organization operates are properly maintained through:

  1. regular inspections;
  2. preventive maintenance by a qualified professional;
  3. a monthly review of the physical plant’s heating, fire extinguishers, fire safety, lighting, and other systems;
  4. a review of vehicle safety inspections;
  5. installation of window guards, where necessary; and
  6. quick responses to emergency maintenance issues and potentially hazardous conditions.

Interpretation: “Emergency maintenance issues” include: overflowing toilets, flooded basements, defective heating systems, and other situations that can damage property, pose a threat to clients, or interfere with service delivery.

Interpretation: “Hazardous conditions” include: uncovered electrical outlets, improper storage of cleaning supplies and other hazardous materials, unsecured floor coverings or equipment, stairs without handrails, harmful water temperatures, inadequate lighting, ventilation and temperature, unscreened areas or unmarked glass doors, and broken or malfunctioning electrical appliances, space heaters, kitchen appliances, and radios, and unsafe use of objects by those who may be vulnerable.

Interpretation: The monthly review is typically a facility walk-through with a check list to verify that systems are functional, fire extinguishers are charged, etc.

Interpretation: Some or all of the above activities may be conducted by the landlord if the organization is a tenant in all its facilities. In such instances, the organization must be able to demonstrate that it monitors and documents the completion of elements (a) through (f) to provide a safe environment for people to work and receive services.

Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

Rating Indicators
The organization's practices reflect full implementation of the standard.

All administrative and service-delivery facilities are safe and well-maintained in accordance with comprehensive maintenance procedures as per the requirements of the standard.
Practices are basically sound and facilities are generally safe and well-maintained, but there is room for improvement; e.g.,
  • Inspections are conducted regularly on a timeframe established in procedures at all administrative and program sites, but non-emergency or non-hazardous issues identified as needing maintenance are not always resolved in a timely manner; or
  • The organization rarely reviews the need for, or conducts, preventive maintenance, instead making repairs on an "as needed" basis; or
  • Review of the physical plant at some programs or sites is conducted less than monthly but at least quarterly; or
  • Maintenance records are not always up-to-date at rented facilities.
Practice requires significant improvement and potentially unsafe conditions exist at at least one administrative or service-delivery site; e.g.,
  • One of the standard's elements is not addressed at all; or
  • Poorly written or incomplete maintenance procedures, or use of unqualified staff have resulted in the failure to recognize critical problems needing attention; or
  • Maintenance procedures are implemented in a cursory or haphazard manner; or
  • Needed repairs are typically not made in a timely manner; or
  • There are ongoing problems with critical systems, like the hot water supply or heat, that the organization is attempting to remediate, thus far unsuccessfully; or
  • There are deficiencies in regard to health, sanitation, and safety codes and regulations, and remedial action is being taken under direction from authorities; or
  • Maintenance at rented facilities is not routinely monitored and/or documented.
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • At least two of the standard's elements have not been addressed at all; or
  • Staff and/or clients are at risk due to the organization's failure to conduct routine inspections or maintenance, make critical repairs of emergency issues or hazardous conditions, or otherwise properly maintain at least one of its owned or rented facilities; or
  • Licensure or certification has been denied or revoked due to failure to meet applicable health and safety codes and regulations.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Facility Maintenance procedures
    • Maintenance inspection reports
    • Interview:
      1. Facility management
    • Observe facility
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