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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VOLUNTEER TESTIMONIAL

Judy Kay, LCSW

Volunteer Roles: Peer Reviewer; Team Leader

In administration for 22 of 24 years at Child Saving Institute, a COA-accredited not-for-profit child welfare agency in Omaha, Nebraska. Retired approximately two years ago, I moved to Tucson, Arizona, where I advocate for children's rights as a Court Appointed Special Advocate (CASA) volunteer to three young children.
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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.

CA-ASE 3: Legal and Regulatory Compliance

The organization’s programs and services are authorized or licenced, and its premises are safe for use by service recipients, personnel, and visitors.

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

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-ASE 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 3 Practice standards.
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 3 Practice standards; and/or
  • CA-ASE 3.02 was rated  3 or 4.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
No Self-Study Evidence
    • Relevant licences
    • Occupancy Permits and other documentation of compliance
    • Interview:
      1. Program director
      2. Facility management

  • CA-ASE 3.01

    The organization has current authorization or licence, as required for all programs and facilities, and displays these documents in an area visible to the public, as applicable.

    Interpretation: This standard requires legal authorization of all facilities, as well as relevant health and safety requirements related to licensure. Examples of physical facilities addressed by this standard include, but are not limited to, child care centres and homes, shelters, group homes, and other residential facilities.

    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., 
    • All licenses are current but are displayed in areas not frequently used by the persons served; or
    • Some licenses have lapsed but the organization is in the process of rectifying the issue, or some licenses are approved but pending receipt.
    3
    Practice requires significant improvement; e.g., 
    • At least one of the organization's programs or sites has been directed to correct minor violations, or has a probationary or provisional status.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • At least one of the organization's programs or sites is operating without approval or current license; or
    • Licenses are not displayed.

  • FP
    CA-ASE 3.02

    The organization complies with all applicable health and safety regulations and codes, including:

    1. occupancy permit requirements;
    2. zoning and building codes;
    3. occupational safety and health administration codes;
    4. health, sanitation, and fire codes;
    5. elevator inspections; and
    6. all other applicable safety codes.

    Interpretation: When codes differ, the stricter code applies. The organization’s ventilation, heating, cooling, electrical work, water supply, plumbing, food service, elevators, and other fixtures conform to all health, sanitation, and safety legislation, regulations, codes, and/or contractual requirements.

    Interpretation: Organizations that rent facilities should obtain relevant documentation from their landlord.  If the organization cannot obtain access to the required documentation from their landlord or from relevant public or private health and safety authorities the organization may also solicit a recognized expert to verify compliance with applicable laws and safety codes. 

    Research Note: The National Fire Protection Association (NFPA) has been an international advocate for fire, building, and life safety issues since 1986. NFPA has published more than 300 codes including NFPA 101®, Life Safety Code®, which establishes minimum design, construction, operation, maintenance, and escape requirements to protect occupants from dangers caused by fire, smoke, and toxic fumes. As of April 2007, the Life Safety Code® was being used in conjunction with the National Building Code of Canada and the National Fire Code of Canada to address issues that aren’t addressed by either of these national codes. Organizations should contact their local fire department to determine which fire codes apply in their area.

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

    The organization including all administrative and service delivery sites complies with all applicable health regulations and codes.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • The organization conforms to all regulations and codes, with minor discrepancies at one or two locations that are being remedied.
    3
    Practice requires significant improvement; e.g.,
    • Some but not all required documentation is kept on file and available for review; or
    • The organization is in the process of remediating deficiencies and has only provisional approval to operate one of its facilities; or
    • The organization has sought review of its compliance by an expert only when forced to do so by an external body and as a result has incurred significant unnecessary costs.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • The organization has a pattern of noncompliance with health regulations and codes.
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