WHO IS ACCREDITED?

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.
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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 

The organization earns and sustains the public trust through honest, truthful, and responsible transactions, partnerships, and relationships with individuals, communities, providers, businesses, donors, and government entities.

FOC
ETH 5: Professional Conduct

The organization conducts business and delivers services in an honest, ethical, objective manner and is guided in making decisions by professional responsibility.

Note: Please see Conflict of Interest Policy and Procedure Template - Private, Public, Canadian, Network for additional assistance with this standard.

Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the ETH 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the ETH 5 Practice Standards.
3
Practice requires significant improvement, as noted in the ratings for the ETH 5 Practice Standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at al, as noted in the ratings for the ETH 5 Practice Standards.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Policy regarding ethical referral practices (ETH 5.02) 
    • Policy prohibiting preferential treatment
    • A written statement provided to persons served that clarifies the relationship between the private practitioner and the organization
    • Review service-related referral procedures
    • Network client files to review reasons for referrals to particular providers
    • Network Management Manual
    • Network utilization data regarding referral and utilization patterns
    • Interview:
      1. CEO
      2. Direct service personnel
      3. Persons served/community stakeholders
    • Network Interview:
      1. Management Entity CEO
      2. Network Advisory/Governing Body
      3. Directors of organizations that contract with the managing entity
      4. Network personnel involved in assessments and referral

  • ETH 5.01

    Personnel know and follow the code of ethics of their respective professions, and of the organization, as applicable.

    Rating Indicators
    1
    The standard has been fully implemented.  The organization requires its professional personnel to become familiar with and abide by the code of ethics of their respective professions.  This requirement is reinforced through supervision and in-service training.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • Expectations about codes of ethics are not consistently communicated across all programs and services or for all professional staff.
    3
    Practice requires significant improvement; e.g., 
    • The organization does not have a formal requirement regarding professional codes of ethics, but does so informally.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • Staff report conflicts between professional ethics and organizational practices.

  • ETH 5.02

    The organization prohibits:

    1. making or accepting payment or other consideration in exchange for referrals;
    2. steering, directing referrals to, or giving preference to clients easier or less costly to serve for the organization and practitioners within the organization;
    3. unfairly steering or directing referrals to, or "creaming" clients for specific network service provider organizations, such as network owners, or individual practitioners within the network, as applicable to networks; and
    4. steering or directing referrals to private practices in which personnel, consultants, or the immediate families of personnel and consultants are engaged.

    Interpretation: It is permissible to include on referral lists personnel and consultants with private practices, or family members of personnel and consultants, but the organization may not actively direct service recipients to the practices of these individuals.

    Note: Element (c) only applies to network management entities.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Some aspects of the policy are vaguely written, but there have been no ethical violations of the principles outlined in the standard.
    3
    Practice requires significant improvement, e.g., 
    • Significant aspects of the policy are vaguely written or confusing; or
    • The policy does not address at least one of the standards elements; or
    • The policy exists but enforcement is lax and there have been a few instances where it has been violated; or
    • The policy generally is understood but it is an unwritten expectation.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all: e.g.,
    • No policy exists; or
    • Policy is not enforced or is ignored in practice.

  • ETH 5.03

    The organization prohibits preferential treatment of organization members, community partners, members of the organization’s governing body, advisory groups, personnel, or consultants applying for and receiving the organization’s services.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • The organization, in practice, does not give preferential treatment and this expectation is well understood, but a few staff members are not aware of it.
    3
    Practice requires significant improvement, e.g., 
    • The policy is vaguely written policy or confusing; or
    • The policy does not address at least one of the groups listed in the standard; or
    • The policy exists but enforcement is lax and there have been a few violations noted, or staff unaware of the policy; or
    • The policy generally is understood but it is an unwritten expectation.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • No policy exists; or
    • Policy is not enforced or is ignored in practice.

  • ETH 5.04

    An organization requires practitioners with a private practice on its premises to provide their clients with a written statement that clarifies the relationship between the private practitioner and the organization.

    Interpretation: As an example, the statement would make it known if a practitioner is also an employee of the organization, and clearly indicate that the client is not being served by the organization.

    NA Private practice is not permitted on the organization’s premises.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement; e.g., 
    • The written statement is vaguely written or confusing.
    3
    Practice requires significant improvement; e.g., 
    • The requirement exists but enforcement is lax and there have been a few instances where it has been violated.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g., 
    • The written statement does not exist or the requirement is not enforced or is ignored in practice.
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