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.


Family Services of the North Shore

Kathleen Whyte, Manager of Human Resources / Accreditation Coordinator

Family Services of the North Shore is about to enter our third accreditation cycle with COA. Accreditation has provided us with a framework that enables us to demonstrate accountability to our clients, our funders and our donors. There is no question that the accreditation process and COA have benefited our agency.
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The MFR program’s administrative and service environments contribute to program effectiveness and are respectful, safe, and accessible. 

MIL-ASE 1: Promotion of Health and Safety

The MFR program works with responsible parties to promote the health and safey of its staff and customers in its administrative facilities and wherever services are provided. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Procedures for vehicle use when transporting children and youth (MIL-ASE 1.04)
    • Facility maintenance procedures (MIL-ASE 1.06)
    • Medication management procedures/protocols (MIL-ASE 1.08)
    • Local-level documentation tracking completion of required safety training (MIL-ASE 1.01)
    • Smoking policy (MIL-ASE 1.02)
    • Copies of MOUs or contracts with host sites, if applicable (MIL-ASE 1.05)
    • Maintenance inspection reports and/or evidence of reports made for follow-up/corrective action regarding facility safety concerns (MIL-ASE 1.06)
    • Logs of medication administration (MIL-ASE 1.08)
    • Interview:
      1. MFR program director
      2. Relevant staff
    • Observe facility (MIL-ASE 1.02, MIL-ASE 1.03, MIL-ASE 1.06, MIL-ASE 1.07) 
    • Observe restraint systems in government vehicles (MIL-ASE 1.04)
    • Observe medication storage, when available (MIL-ASE 1.08)

  • MIL-ASE 1.01

    The MFR program informs staff of the strategies used to maintain a safe environment. 

  • FP
    MIL-ASE 1.02

    The MFR program adheres to a policy that prohibits smoking in all areas of its buildings and within 20 feet of entrances, operable windows, and the ventilation systems of enclosed areas. 

    Note: If the installation’s smoking policy differs from this standard, the stricter requirement applies.

  • MIL-ASE 1.03

    When computer access is offered to customers, the MFR program posts signage informing customers of any usage restrictions or monitoring that may be in place. 

    NA Computer access is not offered to customers.

  • FP
    MIL-ASE 1.04

    MFR programs that permit or require the use of government-owned vehicles to transport children and youth require:

    1. the use of age-appropriate passenger restraint systems; and
    2. adequate passenger supervision, as mandated by statute or regulation.

    NA The MFR program does not serve children or youth without a parent or legal guardian present or the MFR program’s child and youth programming is not being included in this accreditation review. 

    NA The MFR program does not permit or require the use of government-owned vehicles to transport children and youth.

  • MIL-ASE 1.05

    When services are offered in a location that is not owned or leased by a DoD organization or entity, the MFR program develops a memorandum of understanding (MOU) or contractual agreement with the host that includes:

    1. space and equipment needs;
    2. health and safety expectations; and
    3. each group’s responsibility for cleaning, maintenance, liability risk, and other costs (e.g., utilities, insurance, and repairs). 

    Note: See MIL-AM 3.03 for more information on the content of MOUs.

    NA The MFR program does not offer services at locations that are not owned or leased by a DoD organization or entity.

  • FP
    MIL-ASE 1.06

    The MFR program ensures its facilities and equipment are properly maintained in a safe, hygienic manner by:

    1. immediately reporting emergency maintenance issues and potentially hazardous conditions according to established reporting procedures; and
    2. following-up on corrective action as needed.

    Interpretation: While outside agencies are responsible for conducting regular inspections and managing corrective action, standard implementation requires that the MFR program be able to demonstrate that it reports concerns in a timely manner (a) and makes reasonable efforts to follow-up until corrective action is taken (b).
    Examples of “emergency maintenance issues” include: overflowing toilets, flooded basements, defective heating systems, and other situations that can damage property, pose a threat to customers, or interfere with service delivery.
    Examples of “hazardous conditions” include: uncovered electrical outlets; improper storage of cleaning supplies and other hazardous materials; unsecured floor coverings or equipment; stairs without handrails; harmful water temperatures; inadequate lighting, ventilation and temperature; unscreened areas or unmarked glass doors; and broken or malfunctioning electrical appliances, space heaters, kitchen appliances, and radios.

  • MIL-ASE 1.07

    Safety procedures governing customers’ use of equipment, tools, and/or appliances with the potential to cause harm if used inappropriately are posted in applicable areas at the MFR program’s facilities. 

    Interpretation: Examples of “equipment, tools, and appliances” include appliances such as microwaves or coffee makers that could be found in a kitchen that is accessible to customers.

    NA Customers do not have access to equipment, tools, and/or appliances with the potential to cause harm if used inappropriately.

  • FP
    MIL-ASE 1.08

    When the MFR program serves children and youth without a parent or legal guardian present, protocols and controls governing the proper administration and storage of medication include:
    1. locked, supervised storage with access limited to authorized staff and in accordance with law, regulation, and manufacturer’s instruction;
    2. maintaining medication in its original packaging;
    3. labeling medication with the name of the child or youth, medication name, dosage, prescribing physician name, and number or code identifying the written order;
    4. procedures for returning out-of-date or unused medication to the parent or legal guardian, and arranging for appropriate disposal when needed;
    5. protocols for the administration of over-the-counter medications;
    6. a record of who received medications, what medications were administered, how medications were administered and at what dosage, and when and by whom medications were administered; and
    7. protocols for documenting adverse effects of medications, notifying the parent or legal guardian, and calling emergency responders if needed.

    NA The program is not authorized to administer or store medication.

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