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.


Ulysses Arteaga, L.C.S.W.

Volunteer Roles: Commissioner; EPPA; Marine Reviewer; Military Reviewer; Peer Reviewer; Team Leader

The Consuelo Foundation 2012 Peer Reviewer of the Year, Mr. Arteaga conducts two to three site visits a year, often volunteering for visits that require a Spanish speaking peer.
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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.

CA-ASE 4: Facility Maintenance

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

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

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: The organization should have procedures to ensure vehicles are in proper working condition. Procedures should address periodic visual inspections conducted by the organization or other documentation indicating mechanical soundness from a certified mechanic minimally once a year. Procedures should also address the need for repair.

Interpretation: "Emergency maintenance issues" include: overflowing toilets, flooded basements, defective heating systems, and other situations that can damage property, post 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, and radios and unsafe use of objects by those who may be vulnerable.

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.

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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