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.


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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Individuals and families who receive Services for Mental Health and/or Substance Use Disorders improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.

MHSU 13: Personnel

Personnel are appropriately supervised and qualified by education, training, experience, and licensure to meet the service needs of the target population.

Note: For additional standards guidance on the use of non-employee personnel, please refer to Volunteers, Interns, and Consultants: Applicability of COA Standards to Non-Employee Personnel – Private, Public, Canadian.

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., 
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including: education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised.
    • Supervisors provide additional support and oversight, as needed, to staff without the listed qualifications.
    • Most staff who do not meet educational requirements are seeking to obtain them.
  • With some exceptions staff have received required training, including applicable specialized training.
    • Training curricula are not fully developed or lack depth.
    • A few personnel have not yet received required training.
    • Training documentation is consistently maintained and kept up-to-date with some exceptions.
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies.
    • Supervisors provide structure and support in relation to service outcomes, organizational culture and staff retention.
  • With a few exceptions caseload sizes are consistently maintained as required by the standards.
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services, and are adjusted as necessary in accord with established workload procedures.
    • Procedures need strengthening.
    • With few exceptions procedures are understood by staff and are being used.
  • With a few exceptions specialized staff are retained as required and possess the required qualifications.
  • Specialized services are obtained as required by the standards.
Practice requires significant improvement, as noted in the ratings for the Practice standards.  Service quality or program functioning may be compromised; e.g.,
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
  • A significant number of staff, e.g., direct service providers, supervisors, and program managers, do not possess the required qualifications, including: education, experience, training, skills, temperament, etc.; and as a result the integrity of the service may be compromised.
    • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur.
    • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications.
  • A significant number of staff have not received required training, including applicable specialized training.
    • Training documentation is poorly maintained.
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies.
  • There are numerous instances where caseload sizes exceed the standards' requirements.
  • Workloads are excessive and the integrity of the service may be compromised. 
    • Procedures need significant strengthening; or
    • Procedures are not well-understood or used appropriately; or
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
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., 
For example: 
  • 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
    • Program staffing chart that includes lines of supervision
    • List of program personnel that includes:
      1. name;
      2. title;
      3. degree held and/or other credentials;
      4. FTE or volunteer;
      5. length of service at the organization;
      6. time in current position
    • Table of contents of training curricula
    • Procedures and criteria used for assigning and evaluating workloads
    • Procedures for responding to a crisis or traumatic event 
    • Documentation of training
    • Job descriptions
    • Training curricula
    • Documentation of workload assessment
    • Interview:
      1. Supervisors
      2. Relevant personnel
    • Review personnel files

  • MHSU 13.01

    Supervisors are qualified by:

    1. an advanced degree in a human services field and a minimum of two years professional experience;
    2. specialized training in supervision; and
    3. certification and/or licensure by the designated authority in their state, as appropriate. 

    Interpretation: Supervisor qualifications will vary depending on the services provided and program design. For example, supervisors in substance use treatment programs should have specialized training and experience in alcohol and other drug use, diagnosis, and treatment, and/or certification by the designated authority in their state as approved alcohol and/or drug counseling supervisors.

    Interpretation: Regarding element (a), supervisors in detoxification treatment programs may have an advanced degree in a medical field. 

  • MHSU 13.02

    Supervisors demonstrate a commitment to providing structure and support to direct staff to:

    1. address and reduce stress, anxiety, secondary traumatic stress, and vicarious trauma; 
    2. process and debrief following a crisis or traumatic event;
    3. create an atmosphere of problem-solving and learning;
    4. build and maintain morale;
    5. provide constructive ways to approach difficult situations with service recipients; and 
    6. facilitate regular feedback, growth opportunities, and a structure for ongoing communication and collaboration.

    Interpretation: Supervision is an important determinant of service recipient outcomes, organizational culture, and staff retention. 

    Interpretation: In order to promote workforce well-being, organizations should implement policies that address and help prevent stress-related problems. Strategies to reduce the adverse effects of secondary traumatic stress and vicarious trauma include: helping staff identify and manage the difficulties associated with their respective positions; promoting self-care and well-being through policies and communications with personnel; offering positive coping skills and stress management training; and providing adequate supervision and staff coverage.

    Interpretation: Before a crisis or traumatic event occurs, the organization should establish a coordinated plan detailing its organization-wide response strategy (see also ASE 7), in accordance with all applicable confidentiality laws and regulations. For example, response plans in the event of a suicide can include: procedures for managing information about the death, coordination of internal or external resources, supports for those affected by the death, commemoration of the deceased, and follow-up with anyone at elevated risk for suicide. 

    Interpretation: The suicide attempt or death of a service recipient can be a traumatic experience for staff and appropriate supports and avenues for grief are often not provided. Staff may feel responsible for the individual’s death, professionally inadequate, and ashamed. Individuals exposed to suicide can also be at elevated risk for suicide. To help staff process the loss of a service recipient to suicide, voluntary non-judgmental support services should be made available to help the affected staff and other personnel grieve and prepare for future contact with individuals at risk for suicide. 

    Research Note: Secondary traumatic stress (STS) – distress that results from being exposed to the traumatic stories of others, and vicarious trauma (VT) – internal changes in the perception of self due to chronic exposure to traumatic material, have a significant impact on direct care workers and supervisors. STS has been linked to increased absenteeism among employees, high staff turnover, and decreased compliance with organizational requirements. The impact of VT can impede organizational function and negatively influence an individual’s sense of trust, safety, control, and esteem. 

  • MHSU 13.03

    Clinical personnel and personnel who conduct assessments are competent; qualified by education, training, supervised experience, licensure or the equivalent; and able to recognize individuals and families with special needs.

    Interpretation: Clinical personnel qualifications will vary depending on the services provided and program design. Clinical personnel may also include individuals who are license-eligible and supervised by experienced, licensed staff. 

  • MHSU 13.04

    Clinical personnel receive ongoing training and education in the following areas:

    1. delivering culturally and linguistically responsive care ; 
    2. evidence-based practices and other relevant emerging bodies of knowledge;
    3. psychosocial and ecological or person-in-environment perspectives;
    4. methods of engagement, including establishing rapport and building trust;
    5. assessing for signs and symptoms of trauma and risk, and implementing trauma-informed care practices;
    6. assessing for and responding to signs of suicide risk; and
    7. health information technology and electronic interventions, including mobile and web-based technologies, as appropriate.   

    Interpretation: Ecological or person-in-environment perspectives view social, economic, and environmental factors as critical in the development and resolution of personal and family problems. Factors may include:

    1. poverty and lack of employment opportunities;
    2. local mores;
    3. language and cultural differences; and
    4. alternative medicine and traditional healing processes.

  • MHSU 13.05

    Clinical personnel demonstrate competency in:

    1. methods of crisis prevention and intervention; 
    2. identifying the needs of exploited, abused, and neglected children and adults;
    3. understanding child development and individual and family functioning;
    4. working with difficult to reach, traumatized, or disengaged individuals and families;
    5. criteria to determine the need for more intensive services;
    6. recognizing and working with individuals with co-occurring physical health, mental health, and substance use conditions; and
    7. collaborating with other disciplines and services.

    Interpretation: When the organization serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, co-occurring conditions, effective and evidence-based interventions, applicable regulations, benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. 

    Signature injuries and co-occurring conditions include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance abuse, and intimate partner violence, which could subsequently increase the risk for suicide. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions.

    Interpretation: In addition to having the knowledge and skills to identify co-occurring mental health and substance use disorders, clinical personnel should also be able to recognize physical health issues commonly associated with mental health or substance use disorders. 

    Note: Element (c) is not applicable to detoxification treatment programs. 

  • MHSU 13.06

    Clinical personnel receive training and demonstrate knowledge of the latest information, theories, and proven practices related to the treatment of alcohol and other drug use disorders, including:

    1. the signs and symptoms of withdrawal;
    2. addiction as a disease;
    3. relapse prevention; and
    4. interventions that demonstrate respect for sociocultural values, personal goals, life style choices, and complex family interactions.

    Research Note: The importance of the client-therapist relationship has been established by research across many fields. Literature regarding substance use disorders suggests that counselors and therapists can be a powerful motivating influence for individuals and a strong therapeutic relationship is associated with engagement in treatment for longer durations and positive recovery outcomes.

    NA The organization provides mental health services only. 

  • MHSU 13.07

    Individuals who provide peer support must:

    1. obtain formal training and certification, as appropriate; 
    2. be willing to share their personal recovery stories; and
    3. have adequate support and appropriate supervision.

    Interpretation: Peer support workers must complete training and certification as defined by their state. 

    NA The organization does not utilize peer support workers.

  • MHSU 13.08

    Individuals who provide peer support receive pre- and in-service training on:

    1. how to recognize the need for more intensive services and how to make an appropriate referral;
    2. established ethical guidelines including setting appropriate boundaries; and
    3. skills, concepts, and philosophies related to recovery and peer support.

    Interpretation: Peer support workers should receive ongoing education to remain current on wellness support methods, trauma-informed care practices, and recovery resources as the field of recovery and peer support is rapidly evolving.  

    Interpretation: Peer support workers establish relationships with service recipients that are based on mutual respect and trust and support bidirectional learning and reciprocity. One of the greatest perceived challenges of delivering peer support services is peers’ ability to handle confidentiality and boundaries. Clearly defining and communicating the roles of the peer worker is critical when establishing the peer-to-peer relationship. 

    Research Note: A national network of researchers, health care professionals, behavioral health experts, and individuals in recovery developed a set of universal recovery principles. The ten guiding principles of recovery include: 

    1. hope;
    2. person-centered/self-directed;
    3. individualized/many pathways;
    4. holistic;
    5. peer support;
    6. relational;
    7. cultural competence;
    8. trauma-informed;
    9. strengths-based/responsibility; and
    10. respect.

    NA The organization does not utilize peer support workers.

  • MHSU 13.09

    Personnel workloads support the achievement of service recipient outcomes, are regularly reviewed, and are based on an assessment of the following:

    1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
    2. the work and time required to accomplish assigned tasks and job responsibilities; and
    3. service volume, accounting for assessed level of needs of new and current service recipients and referrals.

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