Private Organization Accreditation

Lutheran Social Services of New England is a high-performing nonprofit organization. LSS is a powerful difference maker and go-to resource, driving ourselves to constantly anticipate futures that are different from the past. For 140 years, LSS has been caring for people in need in New England.


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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The rights and dignity of clients are respected throughout the organization.

CR 3: Grievance Procedures

The organization maintains a formal mechanism through which applicants, clients, and other stakeholders can express and resolve grievances, including denial of service, which includes:

  1. the right to file a grievance without interference or retaliation;
  2. timely written notification of the resolution and an explanation of any further appeal, rights or recourse; and
  3. at least one level of review that does not involve the person about whom the complaint has been made or the person who reached the decision under review.

Interpretation: Organizations providing Adult Guardianship should ensure that an advocate is appointed to assist the individual in navigating the grievance process.

Interpretation: For networks, grievance procedures for persons served by the network include provisions for filing and appealing grievances related to the network management entity, owner and provider organizations, and independent practitioners.

Note: For networks, appeals or denials of service authorizations are addressed in Utilization Management standards NET 7.08 and NET 7.09. An appeal of a denial of service authorization is, in effect, a request for a second opinion, and as such, does not imply that a person’s rights were denied. However, if the appeal is denied, the person making the appeal might file a complaint or grievance if they believe the network’s procedures or criteria for placement were not followed. For example, if the appeal was not addressed within the network’s time requirements, or if the person believes that the criteria were misapplied, then the person may resort to the complaint or grievance process.

Rating Indicators
The organization's practices reflect full implementation of the standard.
Practices are basically sound but there is room for improvement; e.g., 
  • Procedure or documentation related to one of the elements needs strengthening.
Practice requires significant improvement; e.g.,
  • Procedure or documentation related to two of the elements needs strengthening.
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • One of the elements is not addressed; or
  • The only option for filing a grievance is referral to an external body such as a funder.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Grievance policy
    • Grievance procedures for individuals and families served
    • Grievance reports for the last two quarters (see RPM 2.02)
No On-Site Evidence
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
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