WHO IS ACCREDITED?

Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.
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VOLUNTEER TESTIMONIAL

Audrey Coleman, RN-MSN

Volunteer Roles: Military Reviewer; Peer Reviewer; Team Leader

My first experience with COA was in 1999 with what was a NC Area Program. I started as a peer reviewer in 2005, doing two to four site visits a year. I am also a team leader and have recently been approved to be a military reviewer.
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Purpose

A stable, qualified workforce contributes effectively and efficiently to consumer satisfaction and positive service delivery results.

FOC
HR 3: Recruitment, Selection, and Deployment

The organization hires enough qualified personnel to meet the demand for services.

Update:

  • Revised Evidence - 12/15/15
    "Policies and procedures" replaces "copies of attorney, administrative agency, or court opinions" that address organization recruitment practices in the On-Site Evidence. 
  • Revised Evidence - 05/19/16
    Job descriptions were moved to Self-Study Evidence
Rating Indicators
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the HR 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the HR 3 Practice standards.

With few exceptions, personnel possess the requisite qualifications, or there are a few vacancies, but quality of service or organizational performance is not impacted in any observable way.
3
Practice requires significant improvement, as noted in the ratings for the HR 3 Practice standards.

There is a pattern of personnel who lack the requisite qualifications, though few in number in any given service; or 
  • On or more organizational services cannot meet this standard; or 
  • There are significant vacancies in some programs which affect service provision (i.e. high caseloads, or staff unable to meet job expectations); and/or
  • HR 3.03 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 HR 3 Practice standards. 

Personnel consistently do not meet the qualifications for the position and/or for their title.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Recruitment and selection policies/ procedures
    • Policy and procedures regarding background checks
    • Job descriptions (CEO, CFO, Directors and sample of direct service personnel)
    • Network credentialing and verification procedures
    • Personnel records
    • Relevant portion of governing body minute
    • Policies and procedures describing how the organization ensures recruitment practices comply with applicable laws and regulations with regard to protected characteristics
    • Policy and procedures describing the use of volunteers
    • Network Individual provider and contractor files, re: required information and verifications of current licenses or credential
    • Network records of actions to approve practitioners
    • Enabling legislation/ regulations pertaining to background checks
    • Interview:
      1. CEO
      2. HR Director
      3. Senior managers
      4. Supervisory personnel
      5. Direct service personnel
      6. Students, as applicable
      7. Volunteers
      8. Personnel responsible for recruitment and supervision of volunteers
    • Network Interview:
      1. Committee chair or person in charge of the credentialing process
      2. Managing entity staff members responsible for verifications
      3. Clinical supervisors of selected non-accredited contracted providers to verify provision of supervision

  • HR 3.01

    Job descriptions and selection criteria:

    1. state the qualifications, job expectations, essential functions, and responsibilities for each position or group of like positions;
    2. include sensitivity to the service population’s cultural and socioeconomic characteristics; and
    3. are reviewed and updated regularly.
    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., 
    • All but a small percentage of job descriptions comply with the standard, e.g., are comprehensive and up-to-date; or
    • One of the standard's elements is not fully addressed.
    3
    Practice requires significant improvement; e.g.,
    • One of the standard's element has not been implemented at all;
    • In a significant percentage of cases, the organization does not comply with the standard, e.g., job descriptions are incomplete, vague, or omit qualifications; or 
    • Several positions do not have job descriptions.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 3.02

    Recruitment and selection procedures include:

    1. notifying personnel of available positions;
    2. verifying references and credentials of personnel and independent contractors;
    3. providing applicants with a written job description;
    4. giving final candidates the opportunity to speak with currently-employed personnel;
    5. retaining hiring records in accordance with legal requirements; and
    6. using standard interview questions that comply with employment and labor laws.

    Interpretation: Credentials include education, training, relevant experience, competence in required role, recommendations of peers and former employers, and state registration, licensing, or certification for the respective disciplines, if any.

    The retention of hiring records, which can include postings or other advertisements, applications, and interview notes, shows consistency in recruitment and hiring decisions, and protects the organization in the event of an Equal Employment Opportunity Commission (EEOC) or related complaint.

    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., 
    • Procedures need greater clarity; or 
    • One of the standard's elements is not fully addressed.
    3
    Practice requires significant improvement; e.g., 
    • Procedures are very general and/or do not provide useful guidance; or
    • Two elements are not fully addressed or one of the elements is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; or
    • Hiring records do not meet legal requirements.

  • FP
    HR 3.03

    Screening procedures include appropriate, legally permissible, and mandated reviews of state criminal history records and civil child abuse and neglect registries for new employees, consultants, independent contractors, volunteers, and student interns who will:

    1. work in residential programs;
    2. provide direct services to, or be alone with, children, the elderly, or other persons determined by the organization to be vulnerable or at risk; or
    3. work with sensitive or confidential information such as personnel files and case records.

    Interpretation: The organization should not use criminal history records to deny employment to qualified individuals unless the nature of the conviction is related to the job duties. The organization should consult with legal counsel about any concerns regarding the appropriate use of background information.

    The organization is not required to conduct background checks for licensed staff if the organization has verified that background checks are conducted as part of the licensing process. The organization should assess whether there is any risk associated with not conducting background checks on staff not expressly addressed in the standard and consult with legal counsel, as appropriate. The requirements do not apply to current employees and contractors or to agencies with which the organization contracts for services.

    Interpretation: Due to the nature of services provided, credit counseling organizations are required to conduct criminal history record checks on all staff and volunteers. The child abuse and registry checks are not applicable.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.

    Practice reflects that the organization has a thorough knowledge of the legal requirements regarding criminal records checks and review of civil child abuse and neglect registries, accordingly, the organization conducts legally permissible reviews at the federal and state or provincial level.
    2
    Practices are basically sound but there is room for improvement; e.g.,
    • Procedures for verifying background checks for licensed personnel need strengthening.
    3
    Practice requires significant improvement; e.g., 
    • In some cases background checks are not completed prior to personnel beginning work. 
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
    • The organization consistently does not screen personnel per the requirements of the standard; or
    • Screening procedures violate applicable law; or
    • Procedures are vague or non-existent.

  • HR 3.04

    An organization that recruits and selects personnel with specific cultural traits or other characteristics establishes that such selectivity is:

    1. legally permissible;
    2. reviewed and approved by the organization’s governing body, as applicable; and
    3. appropriately considered a bona fide occupational qualification.

    Interpretation: When recruitment and hiring criteria include consideration of specific protected characteristics, such as gender, religion, and national origin, the organization should seek legal advice as to whether these characteristics are bona fide occupational qualifications that are critical to the organization’s normal operation.

    In addition, an organization under religious auspices should seek legal advice to confirm that it may require employees to belong to a specific religious affiliation if knowledge of and commitment to the values of the religious tradition are necessary to accomplish the activities of the organization.

    NA The organization does not recruit and select personnel with specific cultural traits or other characteristics.

    Rating Indicators
    1
    The organization's practices reflect full implementation of the standard.
    2
    Practices are basically sound but there is room for improvement.
    3
    Practice requires significant improvement; e.g., 
    • The organization has not verified that practices are legally permissible, e.g.,
      • Bona fide occupational qualification; and/or
      • Criteria based on religious affiliation.
    • Selection criteria have not been reviewed and approved by the organization’s governing body.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 3.05

    Organizations that deploy volunteers to provide direct services specify their roles and responsibilities.

    NA The organization does not use volunteers to provide direct 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.,
    • Job descriptions or other documentation specifying roles and responsibilities require greater clarity.
    3
    Practice requires significant improvement; e.g., 
    • For some positions roles and responsibilities are only communicated verbally.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 3.06

    The network has a uniform and fairly applied credentialing process that assesses and confirms the qualifications of licensed independent contractors/providers who provide network services and are not employed by a member or community partner that includes:

    1. verification of licensure, education and other relevant training and board certification, where applicable;
    2. experience delivering services to the populations served by the network;
    3. the professional judgment of at least three peer professional references with regard to competence and prior satisfactory levels of performance;
    4. information about pending challenges, provisional status, or previous suspensions or denials of licenses to practice;
    5. publicly available information or official information regarding professional liability actions and litigation relevant to the provision of network services; and
    6. information about prior involuntary termination, reduction of professional staff privileges, or discharge from professional employment obtained from prior staff affiliations or employers.

    NA The organization is not a network management entity.

    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.,
    • Procedures for verifying credentials need clarifying; or 
    • One of the standard's elements is not fully addressed.
    3
    Practice requires significant improvement; e.g., 
    • Procedures are not well-understood or used appropriately; or
    • Two of the standard's element are not fully addressed or one element is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.

  • HR 3.07

    The network verifies that personnel of network partners and network provider organizations who provide clinical services to network clients:

    1. possess relevant licenses and/or credentials; and
    2. are receiving appropriate supervision.

    NA All partner and subcontracting provider organizations are accredited by COA or a COA-recognized accrediting body.

    NA The organization is not a network management entity.

    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.,
    • Procedures related to one of the standard's elements need clarifying. 
    3
    Practice requires significant improvement; e.g., 
    • One of the standard's element's is not addressed at all.
    4
    Implementation of the standard is minimal or there is no evidence of implementation at all.
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