Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.


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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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 14: Residential Facilities

Residential facilities contribute to a physically and psychologically safe, healthy, non-institutional, homelike environment.

Interpretation: “Homelike” settings are assessed within the context of organizations location and environment.

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

Research Note: Physical environments convey symbolic and concrete messages. The way in which organizations maintain, design, and decorate their residential facilities can greatly impact residents’ perception of safety and security. For example, facilities that are warm and inviting, and incorporate age, developmentally, and culturally appropriate decor into the aesthetic impart a sense of belonging to residents.

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 (HR 6.02) and training (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
    • Procedures for establishing a homelike environment 
    • Procedures for maintaining a clean and safe environment
No On-Site Evidence
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents
    • Observe facility and outdoor area/grounds

  • GLS 14.01

    Living quarters are age, developmentally, gender, and culturally appropriate and consist of separate cottages or units in a residential building that include:
    1. a common room, dining and/or kitchen area, and space for indoor recreation;
    2. private areas where residents can meet with family and friends;
    3. private facilities for bathing, toileting, and personal hygiene; and
    4. ready access to a telephone and other technology, as permitted, for use by residents and personnel.

    Interpretation: Programs must have gender-specific sleeping areas and facilities for bathing, toileting, and personal hygiene to ensure a residents’ privacy from residents of the opposite gender.
    Programs serving children should have facilities that are developmentally appropriate and culturally responsive, including separate bathrooms and shower areas, and outdoor and indoor play spaces with adequate toys, books, and other recreational supplies. 

    Interpretation: The organization is responsible for developing policies or procedures addressing the use of cellphones and types of technology in the program. See evidence at GLS 12. 

    Research Note: Literature emphasizes the importance of creating a sensitive and nonjudgmental service environment for LGBTQ individuals. Organizations can create and maintain a safe environment by posting a nondiscrimination policy that explicitly includes sexual orientation and gender identity, and by allowing transgender residents to use bathrooms and showers based on their gender self-identity and gender role.

  • GLS 14.02

    Personal accommodations for residents are age, developmentally, gender, and culturally appropriate and include:
    1. adequately and attractively furnished rooms with a separate bed for each resident, including a clean, comfortable, covered mattress, pillow, sufficient linens, and blankets; 
    2. a non-stacking crib for each infant and toddler that is 24 months or younger that meets federal safety regulations; and
    3. a safe place such as a locker to keep personal belongings and valuables.

    Interpretation: Bedroom space should, at a minimum, meet state requirements and accommodate the basic furnishings the standard mentions. National advocacy standards suggest that single rooms have at least 100 square feet of floor space and rooms housing more than one individual have at least 80 square feet per person. Group assignments and room accommodations may be adjusted as appropriate to the service provided, therapeutic considerations, level of risk, or developmental appropriateness.

    Interpretation: All cribs, including portable cribs that can be folded or collapsed without being disassembled, must meet current Consumer Product Safety Commission (CPSC) full-size and non-full size crib standards per Sections 1219 and 1220 of Title 16 of the Code of Federal Regulations to ensure safety for children.
    The American Academy of Pediatrics recommends that cribs are used by children under 90 centimeters (35 inches) tall.

    Note: Element (b) will not apply to organizations that do not allow residents to bring their children to the treatment program.

  • GLS 14.03

    Organizations that serve families house families as a unit and keep sibling or family groups together, when possible.

    NA The program does not serve family units, or housing families as a unit is not possible or prohibited by law.

  • GLS 14.04

    Residents participate actively in:
    1. decorating and personalizing their sleeping area; 
    2. choosing clothing preferences; 
    3. food preparation and meal planning; and
    4. contributing to decisions about how to make living areas inviting, comfortable, and reflective of the their interests and diversity.

  • GLS 14.05

    Residential facilities provide:
    1. adequate space for storage and maintenance needs;
    2. sufficient and culturally appropriate supplies and equipment to meet residents’ needs;
    3. access to a computer and the internet;
    4. rooms for providing on-site services, as applicable;
    5. accommodations for informal gathering of residents including during inclement weather;
    6. at least one room suitably furnished for the use of on-duty personnel; and
    7. private sleeping accommodations for personnel who sleep at the facility, if applicable.

  • GLS 14.06

    The organization has adequate facilities for administrative support functions, food preparation, housekeeping, laundry, maintenance, and storage.

  • GLS 14.07

    The residential facility and outdoor space should be clean and maintained in good condition to promote the health and safety of personnel and residents.

    Interpretation: The facility’s outdoor area should be inviting and contain sufficient space for recreational activities. Outdoor equipment must meet all playground equipment safety standards and be appropriate for the number, age, and developmental level of residents.

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