Private Organization Accreditation

White's Residential & Family Services is Indiana's largest social services agency offering accredited and comprehensive residential, foster care, independent living, adoption, and home-based 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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Individuals who participate in Opioid Treatment Programs improve social, emotional, and vocational functioning, achieve optimal productivity, and attain the recovery they seek.

CA-OTP 12: Detoxification Treatment

Detoxification treatment is provided based on the needs of the individual.

Interpretation: In these standards, the term “detoxification” refers to detoxification from opioid drugs and not medical or administrative withdrawal from opioid treatment medication, which is addressed in OTP 15.

NA The organization does not provide detoxification treatment.

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 the detoxification process
    • Procedures related to detoxification
    • Service recipient/ personnel care and supervision ratios and scheduling criteria (residential detoxification programs only)
    • Privacy policy and procedures (residential detoxification programs only)
No On-Site Evidence
    • Interview:
      1. Medical director
      2. Relevant personnel
    • Review: 
      1. Case records
      2. Service recipient/personnel care and supervision coverage schedule for the past year (residential detoxification programs only)

  • CA-OTP 12.01

    Qualified personnel determine if short- or long-term detoxification treatment is appropriate for the individual using diagnostic criteria according to the Diagnostic and Statistical Manual for Mental Disorders.

  • CA-OTP 12.02

    Individuals are placed in the appropriate level of care and have access to all components of the detoxification process, including: 

    1. evaluation;
    2. stabilization; and
    3. preparation for entry into substance use treatment. 

    Interpretation: Organizations should conduct a multidimensional assessment and utilize standard criteria to determine the appropriate level of care. The multidimensional assessment is strengths-based and addresses the service recipient’s needs and challenges, as well as his or her strengths, assets, resources, and supports. 

    Research Note: A consensus panel of physicians, psychologists, counselors, nurses, and social workers established guiding principles in detoxification and substance use treatment. According to the principles, the detoxification process must consist of three sequential and essential components: a) evaluation, 2) stabilization, and 3) fostering patient readiness for and entry into treatment. Evaluation includes a comprehensive assessment and serves as the basis of the initial treatment plan. Stabilization is the process of helping individuals through acute intoxication and withdrawal to achieve a substance-free state. After the individual is stabilized, he or she should then be encouraged to enter into a substance treatment program to promote a continuum of substance use treatment and care. 

  • CA-OTP 12.03

    The organization conducts an initial drug test for individuals in short-and long-term detoxification treatment and monthly random tests for individuals receiving long-term detoxification treatment.

  • CA-OTP 12.04

    The organization limits individuals to two detoxification treatment episodes per year.

  • FP
    CA-OTP 12.05

    Individuals who have had two or more unsuccessful detoxification episodes are assessed by a physician to determine the need for other forms of treatment.

  • CA-OTP 12.06

    The organization provides 24-hour-a-day supervision, observation, and care tailored to meet the individual’s assessed needs and goals.

    Interpretation: Service recipients’ basic daily living requirements should be met in a culturally responsive manner. 

    Interpretation: Staffing requirements and care ratios can vary depending on the age, developmental level, and service needs of the population. 

    Note: Organizations must also meet provincial licensing requirements and provide scheduling criteria as justification for their service recipient/personnel care and supervision ratios. 

    NA The organization does not provide detoxification treatment in a residential setting. 

  • CA-OTP 12.07

    Residential facilities contribute to a physically and psychologically safe, healthy, non-institutional environment by:

    1. providing personal accommodations for individuals that are age, developmentally, gender, and culturally appropriate; 
    2. providing private areas for bathing, toileting, and personal hygiene;
    3. allocating rooms for occasional on-site services, as needed;
    4. ensuring accommodations for informal gathering of service recipients, including during inclement weather;
    5. having adequate space for administrative support functions, food preparation, housekeeping, laundry, maintenance, and storage; and
    6. being maintained in good, clean condition.

    Interpretation: Bedroom space should, at a minimum, meet provincial requirements and accommodate basic furnishings.

    Interpretation: Accommodations may be adjusted as appropriate to the service provided, therapeutic considerations, level of risk, or developmental appropriateness. 

    NA The organization does not provide detoxification treatment in a residential setting.

  • CA-OTP 12.08

    The organization ensures service recipients’ comfort, dignity, privacy, and safety by:

    1. establishing and implementing policies for searches of individuals or their property consistent with applicable provincial and federal law; 
    2. prohibiting the use of surveillance cameras or listening devices of persons in bedrooms, unless required by judicial order, law, or contract; 
    3. maintaining doors on sleeping areas and bathroom enclosures unless there is clear, clinical written justification for their removal; 
    4. providing one- or two-person rooms to individuals who need extra sleep, protection from sleep disturbance, or extra privacy for clinical reasons;  and
    5. requiring employees to knock before entering a service recipient’s room unless there is a safety or clinical concern.

    Interpretation: Individuals should be apprised of the organization’s policy regarding room checks and personal searches.

    Interpretation: Regarding element (e), employees should knock before entering a service recipient’s room unless there is an immediate health or safety concern or a well-documented clinical concern. 

    Interpretation: When organizations are required by judicial order, law, or contract, documentation must be provided to justify employing this practice which may include the judicial order, contract, or a copy of the province’s safety plan involving the resident. Organizations will need to demonstrate in their privacy policy and procedures that they have taken measures to prevent any unintended violation of an individual’s rights and privacy. Service recipients must have access to private areas for self-care and the changing of clothing. 

    Sensitivity is taken to ensure that all service recipients, especially abuse or trauma survivors and the LGBTQ population, feel safe and not violated. 

    Interpretation: The use of surveillance cameras or listening devices should not be used as a supplement to adequate staffing or supervision protocols. 

    NA The organization does not provide detoxification treatment in a residential setting.

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