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.


Holy Family Institute

Sister Linda Yankoski, President/CEO

The Council On Accreditation provides all stakeholders involved in the delivery of social services the assurance that the organization is credible, effective, and is committed to quality improvement. The COA process is an important tool for anyone involved in leading an organization to establish best practices and maintaining and updating these practices over time.
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Child Protective Services protect children from abuse and neglect and increase child well-being and family stability.

CA-CPS 10: Removing Children from the Home

When a child cannot safely remain at home, the child is removed from the home, and the child and family are prepared for the transition.

NA The organization only provides Child Protective Case Management Services.

Rating Indicators
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (CA-HR 6.02) and training (CA-TS 2.03); or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • A number of client records are missing important information  or
  • Client participation is inconsistent; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,
  • No written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Procedures for establishing voluntary agreements and submitting court petitions
    • Procedures or protocols for removing a child
    • Domestic violence protocol, if available
    • Interview:
      1. Program director
      2. Supervisors
      3. Relevant personnel
    • Review case records

  • FP
    CA-CPS 10.01

    When a child cannot safely remain at home, the organization collaborates with parents to establish a voluntary agreement, or otherwise petitions a court of proper jurisdiction, to obtain appropriate care.

    Note: The removal of a child can aggravate a domestic violence situation. The service provider should follow the organization’s domestic violence protocol and coordinate the child’s removal with the domestic violence unit or specialist, whenever possible.

  • FP
    CA-CPS 10.02

    A professional with two years of related experience and an advanced degree in social work, or another comparable clinical human services profession, is involved in the decision to remove a child from the home.

  • FP
    CA-CPS 10.03

    The organization minimizes the negative effects removal can have on a child by:

    1. providing age-appropriate information about the removal process;
    2. identifying personal items the child will bring;
    3. collecting information about the child’s daily routine, preferred foods and activities, needed therapeutic or medical care, and education;
    4. discussing how the child can maintain contact with the family; and
    5. discussing separation and loss.

    Interpretation: Personnel should ensure needed medication and medical equipment accompany the child or are obtained. When the child requires medication personnel should follow procedures regarding the storage and administration of medication.

  • CA-CPS 10.04

    The organization minimizes the negative effects a removal can have on the family by:

    1. discussing how the family can maintain contact with the child;
    2. providing information about the removal process;
    3. discussing separation and loss with the parents and siblings remaining in the home; and
    4. addressing needs related to domestic violence, substance use, or mental illness.
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