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.


Catholic Charities, Diocese of Covington

Wm. R. (Bill) Jones, ACSW, MDiv, Chief Executive Officer

Catholic Charities in Covington has been COA accredited since 1996. Though the time spent in completing the self study and hosting the site visit can sometimes feel sometimes daunting, the rewards far outweigh the effort. In our agency, the self-study is a group process that involves every member of the staff from the CEO to the building maintenance staff.
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Juvenile Justice Residential Services promote public safety by providing youth with a supportive, structured setting that helps them address their needs and develop the attitudes and skills needed to make responsible choices, avoid negative behaviors, and become productive, connected, and law-abiding citizens.

JJR 7: Mental Health Services

Youth with mental health conditions receive the appropriate level and intensity of treatment needed to address problems and promote rehabilitation.

Research Note: Research indicates that youth in the juvenile justice system are more likely than other youth to have mental health problems, and some literature suggests that these issues may have contributed to youths’ initial delinquency. Accordingly, experts point to the importance of treating these needs and issues in order to help youth rehabilitate and decrease their risk of recidivism.

Research Note: Group treatment has been emphasized in one prominent juvenile justice reform model as an effective method for rehabilitation because it encourages youth to be held accountable for their destructive behavior and be introspective about the cause of such behavior. Utilizing group treatment may reduce recidivism rates, increase security in juvenile justice facilities, and help youth overcome traumatic histories.

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
    • A description of mental health services
    • Mental health related procedures
    • Documentation of residents with co-occurring conditions
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Youth served
    • Verify employment of qualified mental health professional either directly or via contract
    • Review case records

  • FP
    JJR 7.01

    Youth receive a mental health assessment within seven to fourteen days of admission, and youth with mental health conditions receive diagnoses based on standardized diagnostic tools.

    Interpretation: As referenced in JJR 1.04, some organizations may conduct systematic service need screenings to determine when youth are in need of more in-depth assessments. When this is the case these service need screenings should occur within seven to fourteen days, and further evaluation should be conducted if necessary.

    NA The organization provides only detention services.

  • JJR 7.02

    Interventions are appropriate to youths’ needs, and based on evidence or clinical practice guidelines, where they exist.

    Research Note: Research indicates that most evidence-based treatments have been designed for specific disorders. Accordingly, it is critical to conduct assessments that yield an accurate diagnosis.

    NA The organization provides only detention services.

  • FP
    JJR 7.03

    Treatment services are provided by qualified mental health professionals.

    Interpretation: If other personnel provide some aspects of service, they must be trained and supervised by qualified mental health practitioners.

    NA The organization provides only detention services.

  • FP
    JJR 7.04

    When youth receive medications for emotional or behavioral conditions, medication use is:

    1. consistent with the youth’s assessed needs and service plan;
    2. authorized and managed by a board-eligible psychiatrist or another qualified health practitioner; and
    3. monitored for efficacy and side effects.

    Interpretation: It is permissible under the standard to use a consulting psychiatrist or a community mental health center for psychiatric consultation, provided that the organization has a formal agreement.

  • FP
    JJR 7.05

    In case of emergency, youth have access to mental health services 24 hours a day.

    Interpretation: It is permissible to use a local mental health facility for emergency services, provided the organization has a written agreement with the facility.

  • JJR 7.06

    When youth have experienced trauma, the organization provides specialized services and trauma-informed care.

    Research Note: Research suggests that many youth in the juvenile justice system have experienced trauma, especially girls.

  • FP
    JJR 7.07

    To promote the safety of youth at risk of suicide, personnel:

    1. recognize when youth are thinking about suicide;
    2. monitor suicidal youth at a frequency consistent with level of risk;
    3. respond promptly and appropriately to youth who attempt suicide; and
    4. continually supervise youth who attempt suicide until they are assessed by qualified medical and mental health personnel.

  • JJR 7.08

    Youth diagnosed as having co-occurring mental health and substance use conditions receive integrated treatment either directly or through active involvement with a cooperating service provider.

    Note: Collaboration with cooperating service providers is also addressed in JJR 5.02 and 5.03.

    Research Note: Research indicates that the prevalence of co-occurring conditions is high among youth in the juvenile justice system, and suggests that treatment modalities addressing one problem at a time are not likely to be effective. Accordingly, literature points to the importance of providing integrated treatment that addresses needs in a cohesive manner.

    NA The organization provides only detention services.

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