WHO IS ACCREDITED?

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.
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ORGANIZATION TESTIMONIAL

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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Purpose

Individuals with cognitive, psychiatric, behavioral, and/or substance use conditions and serious emotional disturbances who receive Day Treatment Services improve psychosocial, educational, vocational, and cognitive functioning, and learn to manage their symptoms.

DTX 5: Service Philosophy, Modalities, and Interventions

The service philosophy:

  1. sets forth a logical approach for how program activities and interventions will meet the needs of service recipients;
  2. guides the development and implementation of program activities and services based on the best available evidence of effectiveness; and
  3. outlines the service modalities and interventions that personnel may employ.

Interpretation: A program model or logic model can be a useful tool to help staff think systematically about how the program can make a measureable difference by drawing a clear connection between the service population’s needs, available resources, program activities and interventions, program outputs, and desired outcomes.

Rating Indicators
1
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.
2
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
  • Written service philosophy needs improvement or clarification; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (HR 6.02) and training (TS 2.03); or
  • In a few rare instances required consent was not obtained; or
  • Monitoring procedures need minor clarification; or
  • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
3
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • The written service philosophy needs significant improvement; or
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Documentation is inconsistent or in in some instances is missing and no corrective action has not been initiated; or
  • Required consent is often not obtained; or
  • A few personnel who are employing non-traditional or unconventional interventions have not completed training, as required; or
  • There are gaps in monitoring of interventions, as required; or
  • Policy on prohibited interventions does not include at least one of the required elements; or
  • Service philosophy is not clearly related to expressed mission or programs of the organization; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
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.,
  • There is no written service philosophy; or
  • There are no written policy or 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
    • Include service philosophy in the Narrative
    • Policies for prohibited interventions
    • Procedures for the use of non-traditional or unconventional practices
    • Table of contents of training curricula
    • Documentation of training
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals served

  • DTX 5.01

    The program is guided by a philosophy that provides a logical basis for the services and support to be delivered to individuals based on program goals and the best available evidence of service effectiveness.


  • FP
    DTX 5.02

    If the organization permits the use of service modalities and interventions it defines as non-traditional or unconventional, it:

    1. explains any benefits, risks, side effects, and alternatives to the service recipient or a legal guardian;
    2. obtains the written, informed consent of the individual or his/her legal guardian;
    3. ensures that personnel receive sufficient training, and/or certification when it is available; and
    4. monitors the use and effectiveness of such interventions.

    Interpretation: Examples of non-traditional and unconventional service modalities or