Private Organization Accreditation

As one of the largest family services agencies in the country, Child & Family Services has dedicated its resources to meet the needs of the community since 1873.


Family Services of the North Shore

Kathleen Whyte, Manager of Human Resources / Accreditation Coordinator

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency.
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Individuals who receive Services for Mental Health and/or Substance Use Disorders improve social, emotional, psychological, cognitive, and family functioning, and attain recovery and wellness.

CA-MHSU 7: Medical Care and Clinical Support Team

Treatment decisions are guided by a qualified clinical team and are made in collaboration with the service recipient. 

Interpretation: A formal written agreement, as referenced in this section, refers to a non-legally binding document in which organizations collaborate with other providers to deliver specific services. Also known as a non-contractual service agreement or Memorandum of Understanding (MOU), formal written agreements specify mutually-accepted expectations between two or more parties as they work together toward a common objective. Please refer to CA-RPM 9.04 for further guidance on formal written agreements. 

Note: Medical care includes psychiatric care and treatment. 

NA The organization provides Diagnosis, Assessment, and Referral Services only.

NA The organization provides Clinical Counseling services only. 

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
    • A description of services provided by the clinical care team 
    • Job description and resumé of physician or qualified health professional and/or formal agreement with psychiatrist or a community mental health center 
    • Interview:
      1. Clinical or program director
      2. Physician or qualified health professional
      3. Relevant personnel
      4. Individuals or families served
    • Review case records
    • Review physician or qualified health professional's personnel record or the formal consulting agreement, as appropriate

  • FP
    CA-MHSU 7.01

    A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment. 

    Interpretation: Medical aspects can include:

    1. prescribing medication and medication management; 
    2. providing or reviewing diagnostic, toxicological, and other health related examinations of persons not currently under medical care and supervision; 
    3. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect; 
    4. seizure disorders;
    5. psychosomatic disorders; and
    6. other medical and psychiatric related issues such as traumatic brain injury.
    The organization ensures that medication management includes appropriate monitoring and administration of pharmacotherapy for individuals with co-occurring health, mental health, and substance use conditions.

    Interpretation: The qualifications and training of the physician should be appropriate to the program. 

    For example, organizations that provide mental health services should have a psychiatrist who is responsible for the medical aspects of treatment or a qualified health professional with the appropriate training, licensure, and/or credentials. 

    Examples of qualified health professionals include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by legislation, regulations, and/or contracts to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.

    Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement or contract. 

  • FP
    CA-MHSU 7.02

    In collaboration with the service recipient, a clinical team and a licensed physician, or other qualified health professional, make decisions about level of care, treatment, and aftercare or discharge planning. 

    Interpretation: When not employed by the organization, medical, psychological, and psychiatric consultants with specialized training participate in the clinical team as needed, through formal agreements or contracts. 

    Interpretation: Organizations that employ or have formal agreements with telemedicine practitioners, or individuals that provide telehealth services, must develop protocols and procedures for monitoring and sharing internal review information to ensure privacy and security of confidential information.

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