Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.


Orange County Government, Youth & Family Services Division

Rodney J. Hrobar Sr., LMHC, CPP, Quality Assurance Manager

As the lead agency in Orange County, providing the safety net for children and families, it is reassuring that our clients can be confident that their needs will be addressed in accordance with the most stringent standards of public, as well as private, accountability as monitored and reviewed by the Council on Accreditation. 
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Residential Treatment Services provide individualized therapeutic interventions and a range of services, including education for residents to increase productive and pro-social behavior, improve functioning and well-being, and return to a stable living arrangement in the community.

CA-RTX 17: Privacy Provisions

The organization provides for resident comfort, dignity, privacy, and safety.

Research Note: Establishing physical and psychological safety has been proven to have a significant impact on residents’ long-term recovery and social and emotional well-being.  

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
    • Privacy policy and procedures, including protocols on the use of electronics
    • Policy and procedures regarding searches of residents and their property
    • Judicial order, law, or contract, as applicable (CA-RTX 17.02 b.) 
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents
    • Observe facility

  • FP
    CA-RTX 17.01

    The organization:

    1. maintains doors on sleeping areas and bathroom enclosures unless there is clear, clinical written justification for their removal;
    2. provides one- or two-person rooms to residents who need extra sleep, protection from sleep disturbance, or extra privacy for clinical reasons; and
    3. requires employees to knock before entering a resident’s room unless there is a safety or clinical concern.

    Interpretation: The organization should provide single rooms for developmentally disabled adults and for others with specialized care issues (e.g., history of being bullied, history of trauma, sexual abuse, sexual orientation or aggressive behavior).

  • FP
    CA-RTX 17.02

    The organization:

    1. establishes and implements policies for searches of residents or their property consistent with applicable legislation, regulations, and/or contractual requirements; and
    2. prohibits the use of surveillance cameras or listening devices of persons in their bedrooms, unless required by judicial order, law, regulations, and/or contracts.

    Interpretation: Residents should be apprised of the organizations policy regarding room checks and personal searches. 

    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 a 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. Residents must have access to private areas for self-care and the changing of clothing. 

    Sensitivity is taken to ensure that all residents, 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. 

  • FP
    CA-RTX 17.03

    Searches of residents or their property are conducted in a trauma-informed manner that respects client rights, dignity, and self-determination and include, as appropriate to the frequency and invasiveness of searches:

    1. timely notification of a parent and/or legal guardian;
    2. definition and documentation of reasonable cause and assessed risk of harm to self or others;
    3. trained, qualified staff; and
    4. an administrative review process including documentation, notification, and a timetable for review.

    Interpretation: The invasiveness of the search to be conducted has a direct impact on all aspects of search procedures. Organizations must demonstrate and document that more invasive searches are associated with an increased level of risk, reasonable cause, and level of administrative review. More invasive searches should only be performed by specially trained and qualified staff. 

    Research Note: Routine activities such as room checks and property searches can trigger traumatic reenactment. Training staff on interventions that help children and youth identify and manage potential triggers supports a trauma-informed living environment. 

  • FP
    CA-RTX 17.04

    The organization respects residents’ privacy by only reviewing mail when a previous incident involving the resident indicates that:

    1. the mail is suspected of containing unauthorized, dangerous, or illegal material or substances, in which case it may be opened by the resident in the presence of designated personnel; or
    2. receipt or sending of unopened mail is contraindicated.

    Interpretation: Mail refers to letters, packages, emails, and other forms of correspondence via electronic messaging. Organizations should have electronic messaging and social networking policies, procedures, and/or protocols for staff and residents and their families.

    Interpretation: Correspondence between residents and their families, friends, and other social supports should be encouraged, and not monitored nor used as a reward or punishment.

    Interpretation: Programs serving individuals with substance use conditions may require personnel to review mail without incident due to the reason for which residents are seeking treatment. If an organization employs this approach, they must provide justification for taking such measures, which may include health, safety, and other security concerns. 

  • FP
    CA-RTX 17.05

    Residents can have private telephone conversations, and any restriction is:

    1. based on contraindications and/or a court order;
    2. approved in advance by the program director or an appropriate designee;
    3. documented in the case record; and
    4. reauthorized weekly by the immediate supervisor of the direct service provider.

    Note: The organization will be responsible for developing protocols addressing the use of cellphones and other types of technology in the program.

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