WHO IS ACCREDITED?

Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.
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VOLUNTEER TESTIMONIAL

Mike Angstadt

Volunteer Roles: Commissioner; Hague Evaluator; Lead Evaluator; Peer Reviewer; Team Leader

Serving as a Team Leader for COA has been an enriching experience in many ways. Utilizing the Contextual Accreditation process to discern the means in which agencies, offering a variety of services, located throughout the US, Canada ,the Philippines and other countries provide best and most promising practices to their consumers has been particularly rewarding. read more>>

Purpose

Group Living Services allow individuals who need additional support to regain, maintain, and improve life skills and functioning in a safe, stable, community-based living arrangement.

GLS 12: Privacy Provisions

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

Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

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
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
  • 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 (HR 6.02) and training (TS 2.03); or
  • Active client participation occurs to a considerable extent.
3
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.
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 the use of electronics
    • Policy and procedures regarding searches of residents and their property
    • Judicial order, law, or contract, as applicable (GLS 12.02 b.)
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents
    • Observe facility

  • FP
    GLS 12.01

    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 ideally 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). However, COA recognizes that this can be difficult for organizations to achieve. Factors to be considered when assigning a rating for this standard include: what portion of developmentally disabled adults have private rooms, whether shared rooms are a temporary placement, whether a shared room is the preference of the resident, and whether the group living facility is the resident’s permanent home.

    Interpretation: Regarding element (c), employees should knock before entering a resident’s room unless there is an immediate health or safety concern or a well-documented clinical concern.


  • FP
    GLS 12.02

    The organization:
    1. follows procedures for legal searches of residents or their property consistent with applicable state and federal law; and
    2. prohibits the use of surveillance cameras or listening devices in residents’ bedrooms unless required by judicial order, law, or contract.

    Interpretation: Residents should be apprised of the organization’s policy regarding personal or room 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 the state’s 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 dressing. 

    Sensitivity is taken to ensure that residents, especially 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
    GLS 12.03

    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 the 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 that more invasive searches are associated with an increased level of risk, reasonable cause, staff competence, and level of administrative review. More invasive searches should only be performed only 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
    GLS 12.04

    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
    GLS 12.05

    All 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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