Private Organization Accreditation

Germaine Lawrence is a residential treatment center for girls ages 12-18 with complex behavioral, psychological and learning challenges.   Girls live at our programs while receiving special education, individual, family and group therapy; psychiatric and primary medical care; and a wide variety of therapeutic activities and interventions.


Advantage Credit Counseling Service

Mary Loftus, VP, Agency Service

Our agency is preparing for reaccreditation under the Eighth Edition Standards. The COA site is well organized and very easy to use. Our team of employees working on the reaccreditation process has found the tools index to be very helpful, particularly some of the templates.
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Youth who participate in Wilderness and Adventure-based Therapeutic Outdoor Services expand individual capabilities, develop self-confidence and insight, ameliorate symptoms, and improve interpersonal skills and relationships.

CA-WT 11: Safety Review and Risk Prevention

The organization ensures safe practice through advanced planning, safety procedures, and personnel and participant training.

Note: See CA-WT 21 Staff Training and Development.
Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

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
    • Safety procedures that address standards in this section
    • Three trip or activity plans
    • The table of contents for safety training curricula
    • Procedures for maintaining medication and first aid supplies
    • Procedures for vehicle use, inspection, maintenance, and operation
    • Contracts, including safety expectations, with any outside transportation providers
    • Safety committee meeting minutes
    • Interview:
      1. Program director
      2. Relevant personnel
    • Review medical clearance records

  • FP
    CA-WT 11.01

    A safety review committee, supervisory personnel, or external advisors:

    1. conduct ongoing safety reviews;
    2. promptly review incidents when emergency procedures are invoked; and
    3. recommend corrective action.

  • FP
    CA-WT 11.02

    Safety procedures include:

    1. use of a written safety manual or equivalent safety plan for each type of activity offered;
    2. completion of a safety or risk-management plan before each trip or activity that contains safety preparations and other emergency planning information;
    3. a mechanism for bringing a participant’s relevant health and medical information into the field;
    4. providing trip leaders with funds or other means for obtaining emergency resources during trips or programs held outside the organization’s immediate vicinity;
    5. filing incident reports for any accidents or incidents in which personnel or participants were injured or at risk; and
    6. notifying the chief executive officer or his/her designee if emergency procedures are invoked or an unanticipated problem or incident occurs.

  • FP
    CA-WT 11.03

    When conducting trips or outdoor activities in remote areas, the organization:

    1. develops written evacuation and search and rescue procedures;
    2. trains staff on protocols for conducting medical evacuation; and
    3. provides appropriate equipment for emergency communication links from field personnel to outside medical and other resources.

  • FP
    CA-WT 11.04

    When conducting offsite activities, the trip or activity plan includes:

    1. an itinerary maintained at the organizations central location;
    2. weather conditions under which evacuation may be warranted;
    3. detailed information regarding contact with the service director, or a designee, and parks staff when appropriate;
    4. means of contacting rescue resources, medical facilities, and law enforcement; and
    5. any public or private entity notified of the itinerary.

  • FP
    CA-WT 11.05

    Safety training related to missing persons addresses:

    1. search and rescue procedures;
    2. public-safety agency involvement; and
    3. notification of all relevant personnel.

  • FP
    CA-WT 11.06

    The organization trains all participants in planned trips or adventure based activities about the prevention of risks that may include:

    1. sunstroke, sunburn, hyperthermia, dehydration, frostbite, and snow blindness as appropriate to the type of activity and weather conditions;
    2. dangerous plants, animals, situations, and other hazards that may be associated with adventure-based activities or locations; and
    3. allergic and anaphylactic reactions.

  • FP
    CA-WT 11.07

    First aid, emergency response kits and emergency supplies, and medications needed by participants are available and under the control of the senior trip leader or other designated group leader at all times.

  • FP
    CA-WT 11.08

    An organization that provides transportation in agency-owned vehicles, or in vehicles owned by personnel or contractors, requires:

    1. vehicles be equipped with standard safety equipment and passenger restraint mechanisms;
    2. access to emergency roadside repair tools, spare tires and parts, and other equipment required by law;
    3. pre-trip vehicle checks and regular vehicle maintenance;
    4. advance planning for supervision of participants during travel and during scheduled stops; and
    5. advance planning for appropriate breaks and rest stops, with a full day of rest scheduled following four consecutive days of vehicular travel.

    NA The organization does not provide transportation directly or by contract.

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