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

Nuevo Amanecer Latino Children's Services

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

Since Nuevo Amanecer Latino Children’s Services pursued its COA accreditation on October 14, 2004, this corporation has sustained a continuous quality improvement process by not looking whom to blame among the involved parties but improving what we have already done well… because good enough is not good enough.
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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 7: Emergency Response Preparedness

The organization plans for and coordinates emergency response preparedness.

Rating Indicators
1
The organization's practices fully meet the standard as indicated by full implementation of the practices outlined in the CA-ASE 7 Practice standards; 
  • Ongoing training addresses CA-ASE 7.01, CA-ASE 7.02, CA-ASE 7.03, and CA-ASE 7.04.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-ASE 7 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-ASE 7 Practice standards; and/or
  • One of the CA-ASE 7 Fundamental Practice Standards received a 3 or 4 rating; or
  • Emergency plans/procedures are not appropriately tailored to specific locations.
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 7 Practice standards; and/or
  • At least two of the CA-ASE 7 Fundamental Practice Standards received a 3 or 4 rating.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Emergency Response Plan/Emergency Preparedness Procedures
    • Protocols for treating injuries and responding to medical emergencies (including overdose treatment procedures, if applicable)
    • Emergency preparedness training materials
    • Documentation of staff training
    • Documentation of training of residents in residential settings, as appropriate
    • Interview:
      1. Relevant personnel
    • Observe facility

  • FP
    CA-ASE 7.01

    The organization develops an emergency response plan that addresses:

    1. coordination with appropriate local, provincial, and federal governmental authorities;
    2. coordination with emergency responders;
    3. coordination and communication with service recipients;
    4. evacuation of persons with mobility challenges and other special needs;
    5. accounting for the whereabouts of staff and service recipients;
    6. options for relocating service recipients; and
    7. situations involving harm or violence, or the threat of harm or violence.

    Interpretation: Emergency response planning must address:

    • medical emergencies such as accidents, illness, and death;
    • facility and security-related emergencies such as fire, hostage situations, bomb threats, unlawful intrusion, physical assault, and other life threatening situations; and
    • natural disasters such as hurricanes, earthquakes, etc. 
    Interpretation: When organizations provide services remotely using technology, emergency response planning addresses the organization’s capacity to respond to emergency and crisis situations. 
    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.,
    • Plans or procedures related to one of the standard's elements: 
      • Could be more explicit or detailed, or
      • Have not been reviewed recently.
    3
    Practice requires significant improvement; e.g.,
    • Plans or procedures related to at least one of the standard's elements:
      • Are vague and/or confusing and as a result may pose a risk; or
      •  Are outdated or have not been reviewed in more than two years; or
      •  Do not designate responsibility for coordinating a response, or for taking actions identified as being critical; or
      • Are not readily available to staff who may need them immediately in the event of an emergency.
    • Emergency response plans or procedures are "one-size-fits-all" and are not appropriately tailored to:
      • The specific needs of different geographic locations or jurisdictions; or
      • The needs of different populations (e.g., foster children or the elderly) at different programs.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • One of the elements is not addressed at all.

  • FP
    CA-ASE 7.02

    The organization is prepared to treat injuries and respond to medical emergencies by:

    1. maintaining a readily available communication device, poison control information, and first aid supplies and manuals at all program sites;
    2. consulting with a health professional, as necessary, to develop procedures for such situations; and
    3. maintaining emergency contact information for personnel and service recipients.

    Interpretation: Organizations that maintain Naloxone or opioid antagonist kits to treat opioid overdose cases:

    1. ensure authorized and properly trained staff are available to administer these treatments; and
    2. have procedures and appropriate training in place to get affected individuals to urgent care or an emergency department immediately following overdose treatment to preempt the reoccurrence or worsening of symptoms. 

    Interpretation: When conducting off-grounds outdoor activities such as overnight camping, the standard requires first-aid supplies, emergency response kits, and other emergency supplies and medications needed by participants to be under the control of the senior trip leader or other designated group leader at all times.

    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., 
    • First aid supplies at one site were outdated.
    3
    Practice requires significant improvement; e.g., 
    • One or more of the following was not readily available at one of the organization's program sites:
      • A telephone or other communication device; or
      • Poison control information; or
      • First aid supplies and manuals.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • One of the elements is not addressed at all.

  • CA-ASE 7.03

    The emergency response plan includes arrangements for:

    1. a temporary work site in the event of facility closure;
    2. communicating with the governing body, personnel, service recipients, the public, and the media; and
    3. notifying parents, legal guardians, and/or authorities as appropriate.

    Interpretation: To ensure preparedness in the event of an emergency, communication with service recipients in residential settings should include training service recipients about the organization’s emergency response plan, including evacuation procedures, and conducting emergency preparedness drills related to different types of emergencies identified in CA-ASE 7.01.

    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.
    • Arrangements for a temporary work site have not been completed for one of the organization's administrative or service-delivery sites; or
    • Procedures or responsibility for communicating with one of the listed stakeholder groups is unclear; or
    • Procedures or responsibility at one program site for communicating with parents is unclear.
    3
    Practice requires significant improvement; e.g.,
    • Arrangements for a temporary work site have not been completed for at least two of the organization's administrative or service-delivery sites; or
    • Procedures or responsibility for communicating with at least two of the listed stakeholder groups is unclear; or
    • Procedures or responsibility at two or more program sites for communicating with parents or one of the listed stakeholder groups is unclear.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • One of the elements is not addressed at all.

  • FP
    CA-ASE 7.04

    All personnel receive ongoing training on:

    1. assessing risk and safety; and
    2. implementing the organization’s emergency response plan and procedures.

    Interpretation: Training is tailored, as appropriate to:

    • the specific types of emergencies faced by the organization;
    • level of responsibility;
    • needs of service recipients;
    • program type; and
    • geographic location.
    Interpretation: All staff should receive basic training on the organization’s health and safety procedures and understand how to respond to emergency situations, as appropriate to their position and the services provided. For example, staff could receive “gatekeeper training” on how to recognize, interpret, and respond to signs of suicide risk, and/or Mental Health First Aid Canada training for recognizing and responding to signs of a mental health crisis.

    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., 
    • Training is inconsistent across program sites; or
    • The curriculum related to one of the elements is not fully developed or lacks depth; or
    •  A few personnel have not been trained.
    3
    Practice requires significant improvement; e.g.,
    • Training is not provided at some programs; or
    • Training addresses some but not all of the types of potential emergencies likely to be encountered; or
    • A significant number of staff have not been trained.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • One of the elements is not addressed at all.
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