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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ORGANIZATION TESTIMONIAL

Nuevo Amanecer Latino Children's Services

Galo A. Rodriguez, M.P.H., President & CEO

Since Nuevo Amanecer Latino Children’s Services pursued its COA accreditation on October 14, 2004, this corporation has sustained a continuous quality improvement process by not looking whom to blame among the involved parties but improving what we have already done well… because good enough is not good enough.
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Purpose

Through sound administration and effective management, the MFR program achieves its vision, mission and strategic goals; assures appropriate use of resources for the good of customers; and remains responsive to the needs of the military community.

MIL-AM 1: MFR Program Operation

A system is in place to provide effective management and oversight of MFR program operations. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Risk prevention and management plan (MIL-AM 1.02) 
    • Long-term or strategic plan (MIL-AM 1.04)
    • Description of outreach strategies (MIL-AM 1.05, MIL-AM 1.06)
    • Description of customer involvement in program development and activities (MIL-AM 1.06)
    • Documentation of regular communication with staff and oversight entities (e.g. staff meeting minutes, memos, trainings, reports, etc.) (MIL-AM 1.01)
    • Documentation of risk reviews that include analysis and evidence of corrective action as needed (MIL-AM 1.02)
    • Reports of incidents, accidents, and grievances for the previous year (MIL-AM 1.02)
    • Documentation supporting MFR program offerings and/or resource allocation decisions (e.g. customer satisfaction surveys, service utilization data, research, etc.) (MIL-AM 1.03)
    • A representative sample of publicly available documents, publications, or websites containing MFR program information (MIL-AM 1.05, MIL-AM 1.07)
    • Interview:
      1. MFR program director
      2. Staff at all levels

  • MIL-AM 1.01

    The MFR program has a communication system is in place that:

    1. provides all relevant parties with timely information needed to operate effectively; and
    2. spells out mutual expectations for all parties.

    Interpretation: Examples of relevant parties for element (a) include MFR program staff, MFR program directors, installation commanding officers, regional coordinators, and community partners.


  • MIL-AM 1.02

    The MFR program implements a risk prevention and management plan that outlines its risk management structure and activities, including mechanisms for:

    1. annually reviewing and responding to areas of potential risks;
    2. quarterly reviewing and responding to aggregate reports of local risks associated with incidents, accidents, and customer complaints;
    3. reporting all incidents, accidents, and customer complaints to oversight entities; and
    4. training staff on their risk management responsibilities.

    Interpretation: The MFR program is responsible for determining what areas of potential risks are most applicable to the program and will have the greatest impact on operations and service delivery. Examples of relevant areas to consider when annually reviewing risks (element a) include: compliance with legal or regulatory requirements; health and safety of persons who are in the MFR program’s facilities, on its grounds, or working off-site; human resources practices at the local level; customer rights and confidentiality issues; fiscal accountability; conflicts of interest; service modalities or other MFR program practices; situations where a person was determined to be a danger to him or herself or others; and injuries and deaths.


  • MIL-AM 1.03

    While maintaining compliance with applicable regulation, the MFR program adapts the services it offers in response to changes in the needs and desired outcomes of customers.

    Interpretation: While mandated MFR services are defined by DoD regulation, implementation of MIL-AM 1.03 requires that local MFR programs take responsibility for identifying needs at the local level and managing resources as needed to meet those needs within the confines of applicable regulation and funding limitations.


  • MIL-AM 1.04

    The MFR program conducts long-term planning every three to five years that involves relevant staff and other stakeholders and includes:

    1. envisioning and setting the MFR program’s direction;
    2. a review of the MFR program’s mission, values, and mandates;
    3. an assessment of strengths and weaknesses;
    4. measurable goals and objectives that flow from the MFR program’s mission and mandated responsibilities; and
    5. appropriate strategies for meeting identified goals.

    Interpretation: While the MFR program’s strategic plan will likely flow from the strategic goals set by oversight entities, implementation of MIL-AM 1.04 requires that the local MFR program tailor the strategic plan according to the needs of its customers and community. The specific timeline for long-term planning may vary depending on the timeline set by oversight entities.


  • MIL-AM 1.05

    The MFR program uses a variety of culturally and geographically appropriate, non-stigmatizing outreach strategies to inform military units, Service members and their families, other service providers, and military and community organizations about:

    1. the needs of Service members and their families, including those with special needs;
    2. the services the MFR program provides;
    3. hours of operation; and
    4. how to access the MFR program’s services.

    Interpretation: Examples of outreach activities include on- and off-installation publicity such as posters, pamphlets, mailings, information packets, public service announcements or awareness briefings, multi-media publications and communications methods, communication with those who come into contact with the target population, announcements at local MFR programs and events, individual outreach, the MFR program’s website, and outreach to other providers. Culturally and geographically appropriate strategies are defined as those practices that take into consideration geographic location, language of choice, age, developmental level, and religious, racial, ethnic, and cultural background.
     

    Research Note: Barriers to accessing services for customers with special needs include: transportation, location, language, physical and architectural barriers, and societal attitudes.


  • MIL-AM 1.06

    The MFR program encourages Service members and their families to participate in its services by:

    1. minimizing barriers that may prevent prospective customers from seeking or obtaining services;
    2. understanding and reducing the stigma, shame, or denial associated with accessing services;
    3. encouraging customer involvement in MFR program development, service delivery activities, and community building efforts, as appropriate;
    4. targeting geographically dispersed Service members and their families; and
    5. coordinating service delivery with its community partners to develop a comprehensive system of care that increases the likelihood that needed supports and services are available and will be used.

    Interpretation: Examples of factors that may impact whether prospective customers will seek or obtain services can include: disabilities, behavioral health conditions, cultural differences, lack of English proficiency, age, hours of operation, location, physical and architectural barriers, the lack of complete confidentiality, fear of career consequences, lack of financial resources, and lack of transportation.
     

    Interpretation: Examples of ways that MFR programs can involve customers in MFR program development and decision making include inviting them to participate in advisory committees, regularly sending out MFR program evaluations and soliciting feedback, and informing them of volunteer opportunities within the MFR program.

    Research Note: Research suggests that individuals find services more useful when there is greater coordination among the providers that deliver them.
     

    Research Note: Research suggests that there is often a stigma attached to accessing more formal support services. As such, MFR programs may be able to encourage customers to seek out services by establishing or encouraging less-formal peer support or self-help groups and mentoring relationships, in addition to its more formal MFR programs and supports.


  • MIL-AM 1.07

    Publicly available MFR program information is clear, timely, and accurate.

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