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.


Ulysses Arteaga, L.C.S.W.

Volunteer Roles: Commissioner; EPPA; Marine Reviewer; Military Reviewer; Peer Reviewer; Team Leader

The Consuelo Foundation 2012 Peer Reviewer of the Year, Mr. Arteaga conducts two to three site visits a year, often volunteering for visits that require a Spanish speaking peer.
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Children and youth who participate in Out-of-School Time programs gain the personal, social, emotional, and educational assets needed to support healthy development, increase well-being, and facilitate a successful transition through childhood and adolescence, and into adulthood.

OST 2: Access and Enrollment

The organization recruits and enrolls eligible children and youth.

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
    • Recruitment plan and/or description of outreach and recruitment efforts
    • Policy and/or procedures regarding attendance (OST 2.02)
    • Procedures for registration and orientation (OST 2.03, 2.04)  
    • Sample registration form
    • Policy and procedures for enrolling children and youth with special needs, including for collaboration with families and other providers (OST 2.06)
    • Procedures for file content and maintenance (OST 2.07)
    • Policies and procedures for accessing files (OST 2.08)
    • Informational materials made available to the community
    • Hours of operation
    • Registration/orientation materials, including program handbook
    • Waiting list, if applicable
    • Fee schedule, if applicable
    • Interview:
      1. Program Administrator
      2. Site Director
      3. Program Personnel
      4. Children, youth, and families
    • Review files of children and youth

  • OST 2.01

    The organization develops and implements a recruitment plan that includes:

    1. conducting ongoing outreach to inform the public, including the families of prospective program participants, about the program’s goals, activities, and benefits; and
    2. addressing potential barriers that might prevent children and youth from participating.

    Interpretation:  Potential barriers may include, but are not limited to, factors related to transportation, fees, limited or inconvenient hours, and language spoken.  Given that the nature and quality of the activities offered also impacts attendance, it is also critical that the organization provide high-quality activities relevant to the priorities and interests of children and youth and their families, as addressed thoughout this Service Standard.

    Note: See OST 8 for more information regarding the community partnerships that can help the organization both recruit participants and address potential barriers to service.

  • OST 2.02

    Hours of operation and expectations regarding attendance are based on consideration of community needs, program goals, and the best available evidence of effectiveness.

    Interpretation: Information regarding community needs may be obtained through available data or through assessments, surveys, or focus groups conducted by the organization itself.  While organizations should make an effort to offer programming when children and families need it, COA does recognize that some organizations may face logistical obstacles that they cannot overcome (e.g., if the organization only has access to space during certain hours, and must choose between accommodating those hourly constraints and not operating at all).

    Research Note: While some communities or populations may be in need of informal drop-in programs, it is also important to remember that: (1) children and youth must actually attend programs in order to benefit from them; and (2) level of attendance may impact the type and degree of benefit derived.

  • OST 2.03

    During registration or orientation, children and youth and their families are:

    1. informed about program goals and activities;
    2. provided with a handbook that details program policies and procedures;
    3. offered a tour of the facility; and
    4. introduced to staff and program participants.

    Note: Children, youth, and families should also be informed about program rules and responsibilities, as addressed in CR 1.01.

    Research Note: Research has shown that offering a formal orientation period promotes the development of friendships and ties to the program, which, studies have shown, are critical to sustained involvement with the program over time.  Additionally, involving enrolled youth in orientation helps recruit and retain older youth and helps older youth feel as though they are important members of the community.

  • OST 2.04

    Registration practices:

    1. ensure equitable treatment;
    2. support timely enrollment; and
    3. provide for placement on a waiting list, if desired.

    Interpretation:  Regarding element (a), the organization should ideally consider the demographics of the program population in light of the demographics of the community/school, and strive to encourage diversity and inclusiveness.  If the organization runs a program that is designed to serve a specific population (e.g., girls, low-income children, children of particular racial or ethnic backgrounds, or LGBTQ youth), it should ensure that entry into the program is determined by appropriate criteria rather than by favoritism or discrimination.  

    Children and youth who cannot be served, or cannot be served promptly, should be provided with information about other appropriate programs, if available in the community and desired by the child or youth and family.

  • FP
    OST 2.05

    The organization collects relevant information from children and youth and their families, including:

    1. identifying information, including name and date of birth;
    2. address;
    3. emergency contact information, including written parental authorization for emergency care;
    4. relevant health information (e.g., records of up-to-date screenings and immunizations);
    5. whether children and youth have any special needs to be accommodated, including needs related to health or mental health;
    6. consent forms or permission slips, as needed, including any consent/authorization forms related to health or other special needs, if applicable;
    7. authorizations for pick-up, if applicable; and
    8. relevant school day data, if applicable.

    Interpretation: Information should be updated at least annually. Regarding element (d), if a child or youth becomes injured the organization may wish to require written authorization from a doctor before allowing the child or youth to resume participation in sports or fitness activities. 

    Note: See OST 2.06 for additional expectations regarding the information to be gathered when children and youth have special needs.

  • OST 2.06

    The organization enrolls children and youth with special needs, and collaborates with their families and other involved providers to learn about:

    1. their strengths and needs; and
    2. strategies for meeting their needs and helping them fully participate in the program.

    Interpretation: Strategies can include efforts currently undertaken to address needs (i.e. at home or in school), as well as ideas for additional accommodations to meet a child or youth’s specific needs.  While some organizations may obtain a copy of a child or youth’s 504 Plan or Individual Education Program, other organizations may work with the family and school to establish other channels for obtaining information about children’s needs.

    Note: See OST 9.06 and 18.08 for additional expectations regarding accommodating children and youth with special needs.  Please also note that the importance of meeting the needs of children and youth with varying needs and abilities is emphasized throughout this section of standards as a whole.  For example, see OST 4 for more information regarding supportive relationships, OST 5 and 6 for more information regarding behavior support, OST 9 for more information regarding programming and activities, and OST 16 for more information regarding program environment and materials.

    Research Note: Title III of the Americans with Disabilities Act (ADA) requires organizations to make “reasonable accommodations” to their policies, procedures, and practices to include persons with disabilities, but families of children with disabilities are frequently discriminated against when they try to access out-of-school time programs. Consequentlly, literature on inclusion emphasizes the importance of: (1) providing individualized support and modifications that allow children to participate in a meaningful way; (2) establishing an inclusive environment where the contributions of each individual are respected and valued; and (3) training staff to ensure they are prepared to accommodate and include all children. It is also important to note that the goal of the ADA is not to put a strain on programs, but rather to prevent discrimination against individuals with disabilities through “reasonable accommodations” that provide opportunities for participation. Accordingly, organizations are expected to accommodate all children and youth unless: (1) an individual poses a safety threat to him/herself or others, (2) the accommodations needed would result in a fundamental alteration to the program, or (3) the accommodations needed would put an undue financial burden on the organization. It is also important to note that accommodations should be based on the individual needs of children and youth, and not on stereotypes about diagnoses or assumptions about needs. 

  • OST 2.07

    The organization maintains files for all children and youth that:

    1. contain relevant information;
    2. are specific, factual, and legible;
    3. are kept up to date;
    4. are signed and dated by authorized personnel, where appropriate;
    5. comply with any applicable legal requirements; and
    6. are maintained and disposed of in a manner that protects privacy and confidentiality.

    Interpretation: Relevant information includes the information specified in OST 2.05 and 2.06, as well as information that would not have been available at the time of registration, such as accident report forms, attendance records, evidence of ongoing communication with parents or other family members, and payment receipts.
    Files and signatures can be paper, electronic, or a combination of paper and electronic.

    Note: In addition to supporting program operations, files are an important risk management tool. Well-maintained files can help shield an organization from allegations of misconduct and negligence, while poorly-maintained files and improper documentation are a known liability. See RPM for more information regarding risk prevention and management.

  • FP
    OST 2.08

    Access to confidential files meets legal requirements, and is limited to:

    1. children and youth and/or, as appropriate, their parents or legal guardians or designated legal representatives;
    2. personnel authorized to access specific information on a “need-to-know” basis;
    3. auditors, contractors, and licensing or accrediting personnel, consistent with the organization’s confidentiality policy; and
    4. others who are permitted access, as applicable.

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