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

Brewer-Porch Children's Center

James W. Thompson, Executive Director

The COA standards as applied to the operations at Brewer-Porch Children’s Center at The University of Alabama has given the administration an opportunity to examine best practice and improve the quality of care provided to clients.
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Purpose

The organization’s administrative and service environments are respectful, caring, safe, and accessible, and contribute to organizational productivity and effective service delivery.

FOC
CA-ASE 1: Promotion of Health and Safety

In its daily operations, the organization ensures the health and safety of its personnel and the individuals and families it serves.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-ASE 1 Practice standards.

Health or safety concerns are promptly addressed.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 1 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 1 Practice standards; and/or
  • One of the CA-ASE 1 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 CA-ASE 1 Practice standards; and/or
  • Two of the CA-ASE 1 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Smoking policy
    • Procedure or checklist for ensuring that facilities not owned or leased by the organization are safe and conducive to effective service delivery (ASE 1.06)
    • Copies of resources and educational materials on healthy living available to service recipients
    • Sample of contracts/agreements (CA-ASE 1.06)
    • A description of how the organization maintains privacy and confidentiality when providing services remotely using technology, as applicable (CA-ASE 1.05)
    • Interview:
      1. Program director
      2. Facility management staff
      3. Personnel
      4. Individuals or families served
    • Observe facility

  • FP
    CA-ASE 1.01

    The organization ensures that its administrative and service environments promote the health and safety of personnel and service recipients.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard. 

    The organization is proactive about health and safety.
    2
    Practices are basically sound but there is room for improvement.
    3
    Practice requires significant improvement; e.g., 
    • Service quality or organizational functioning may be compromised and staff and/or stakeholders may be at risk.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all: e.g.,
    • Staff or stakeholders are at risk due to serious health or safety concerns that remain unaddressed.

  • FP
    CA-ASE 1.02

    The organization develops and implements a policy to prohibit smoking in all areas of its buildings except in specified circumstances and in locations environmentally separate from administrative and service areas.

    Interpretation: In developing its smoking policy, the organization considers fire risks, duration of care, clinical implications, and legal, regulatory, and/or contractual requirements laws governing tobacco use by minors.

    Research Note: Health Canada has concluded that secondhand smoke is an occupational carcinogen containing over 50 cancer-causing chemicals. Smoke-free workplaces are the only effective way to eliminate secondhand smoke exposure in the workplace. Other methods such as separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposure.

    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., 
    • Some aspects of the policy lack clarity or are not fully developed and/or implemented.
    3
    Practice requires significant improvement; e.g., 
    • Smoking policy provides minimal guidance to stakeholders due to lack of specificity, significant missing elements, etc.; or
    • There is a policy, but staff and the public are not aware, e.g., no signs or posters.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • CA-ASE 1.03

    The organization offers information on healthy living choices to service recipients, if desired.

    Interpretation: Information offered may include books, magazines, pamphlets, websites, organization names or phone numbers and addresses, for example, smoking cessation, gambling or other addictions, nutrition, fitness, healthy habits, or stress management.

    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., 
    • The information provided is somewhat limited or outdated, but is generally relevant to the needs of the service population.
    3
    Practice requires significant improvement; e.g., 
    • The information provided is not relevant to the needs of the service population, e.g., no mental health materials at a mental health program.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • CA-ASE 1.04

    The organization takes steps to reduce the environmental impact of its daily operations.

    Interpretation: Examples of standard implementation include, but are not limited to, instituting a recycling program, using environmentally friendly products, and/or reducing water and energy consumption. 

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement.
    3
    Practice requires significant improvement.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • FP
    CA-ASE 1.05

    The organization maintains a work environment for its personnel that is conducive to effectively providing services to individuals and families in a private and confidential manner, as needed.

    Interpretation: Organizations should extend policies and procedures to remote locations as much as feasibly possible and inform service recipients of any limitations on privacy and confidentiality. When providing services remotely using technology, organizations should consider: (1) the location(s) where personnel are providing services, and (2) the location(s) where individuals are receiving services. 

    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., 
    • Some of the organization's facilities are cramped or in need of updating or expansion to better meet the needs of personnel and ensure confidentiality.
    3
    Practice requires significant improvement; e.g.,
    • Some of the organization's facilities lack sufficient space for staff conferences or meetings; or
    • Some service delivery sites lack enough, or sufficiently private, interviewing space at peak periods.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • The work environment in at least one service delivery site is wholly inadequate for effective, confidential service delivery; or
    • No provision for confidential interactions with persons served; or
    • A number of sites lack adequate provisions for privacy for interviewing or for conducting the collective business of the organization such as meetings, case conferences, etc.

  • CA-ASE 1.06

    When services are offered on a regular and ongoing basis in a location that is not owned or leased by the organization, the organization ensures:

    1. the space and required equipment is appropriate to the services being offered, and the ages and abilities of clients;
    2. facilities are clean;
    3. there are no observable safety hazards in the space and required equipment is safe;
    4. fire drills are conducted in accordance with legal requirements; and
    5. smoking is prohibited in all areas of the building except in specified circumstances and in locations environmentally separate from administrative and service areas. 

    Update:

    • Revised Standard - 06/15/17
      The standard was revised to clarify applicability, and some elements were removed. 

    Interpretation: The organization must be able to demonstrate that mechanisms are in place to ensure the safety and appropriateness of facilities prior to their use.  The organization may accomplish this by incorporating requirements into service agreements and/or by visiting the facility to assess the space.  See CA-RPM 9.07 for more information on establishing formal service agreements with the host.

    Interpretation: COA recognizes that, in some locations, hand washing supplies and facilities (e.g., running water, soap) may not be available. When that is the case, hand sanitizer may be an appropriate alternative. 

    Interpretation: When Early Childhood Education (CA-ECE) and Youth Development Services (CA-YD) are being offered, smoking should be prohibited anywhere on the premises.

    Note: This standard is not intended to apply in situations where a location is used intermittently to accommodate the needs of a particular client.

    NA The organization does not offer services at locations it does not own or lease. 

    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.,
    • Monitoring procedures address all health and safety related elements but element (a), (e), or (g) need clarifying.
    3
    Practice requires significant improvement; e.g.,
    • The process for ensuring that outside facilities are safe and conducive to effective service delivery is inadequate; or
    • The process is informal or procedures need strengthening; or
    • The organization does not monitor outside facilities for continuing suitability once use of the facility has been initiated.
    4
    The organization does not evaluate whether outside facilities are safe and conducive to effective service delivery prior to providing services in such locations.
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