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.


Holy Family Institute

Sister Linda Yankoski, President/CEO

The Council On Accreditation provides all stakeholders involved in the delivery of social services the assurance that the organization is credible, effective, and is committed to quality improvement. The COA process is an important tool for anyone involved in leading an organization to establish best practices and maintaining and updating these practices over time.
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Child and Family Services promote child and family well-being, protect children’s safety, stablilize and strengthen families, and ensure permanency.

PA-CFS 9: Ongoing Assessment and Case Review

Ongoing assessments and evaluations of progress enable the agency to protect children’s safety, meet children’s and families’ needs, and determine when cases can be closed. 

Interpretation: When the agency is working with American Indian or Alaska Native children and families, the tribe or local Indian organization must receive timely notification of case reviews to ensure their involvement, especially when any changes are made to the plan. Phone and video conferencing can be used to facilitate tribal participation.The case review should include an assessment for compliance with the Indian Child Welfare Act.

Note: See PA-CFS 14 for more information regarding permanency planning, including evaluations of progress toward permanency and the appropriateness of the permanency goal.

Rating Indicators
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions; exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement. 
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented.  
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.  
Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  
  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.   
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner. 
  • Service quality or agency functioning may be compromised.   
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.  
Please see Rating Guidance for additional rating examples. 

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Procedures for:
      1. Ongoing assessment
      2. Case review
    • Regulatory or administrative requirements that define intervals for safety assessments, if applicable
    • Interview:
      1. Agency leadership
      2. Relevant personnel
      3. Children and families served
      4. Resource parents
    • Review case records

  • FP
    PA-CFS 9.01

    Assessment is ongoing and formal re-assessments of strengths, needs, risk, and safety are conducted with families periodically, including: 

    1. as part of case reviews;
    2. for decision making processes; and
    3. when children’s or families’ circumstances change.

    Interpretation: The agency should be in compliance with any regulatory or administrative requirements that define intervals for safety assessments.

  • FP
    PA-CFS 9.02

    Workers and families regularly: 

    1. review and document progress toward the achievement of goals, including family members’ perspectives on progress and concerns regarding the case; 
    2. identify any barriers to meeting goals; and
    3. make adjustments to service plans as needed, and sign updated plans.

    Interpretation: In addition to involving all immediate family members, children and families should be given the opportunity to include other supportive people of their choice, such as extended family, friends, and community members, in progress reviews. When children are in out-of-home care resource families or residential treatment providers should be involved in progress reviews and sign updated service plans, with the parent’s consent when possible, unless parental rights have been terminated. 

    Research Note: Using a solution-focused approach when monitoring and adjusting plans with families supports positive engagement through acknowledging and building on successes, and working from a shared vision, so families can experience monitoring as a mutual process intended to ensure that their goals are met.

  • FP
    PA-CFS 9.03

    Workers and families regularly:

    1. review any safety concerns that threaten children; and
    2. develop or revise safety plans, as needed.

    Interpretation: Depending on safety threats and family circumstances it may be appropriate to develop or revise an in-home safety plan, or to place a child in out-of-home care.  It is also important to note that in-home safety plans are not only useful in preventing the need to separate children from their homes and families – they can also be implemented to allow children in out-of-home care to return to their families when safety concerns can be managed with an in-home plan, even if ongoing services to reduce risk remain necessary.  In addition to involving all immediate family members, children and families should be given the opportunity to include other supportive people of their choice, such as extended family, friends, and community members, in reviewing and revising safety plans.

    Note: See PA-CFS 6 for more information and requirements related to safety planning.

  • FP
    PA-CFS 9.04

    Workers and supervisors, or case review teams, regularly review cases to assess:

    1. safety concerns and the appropriateness of safety plans;
    2. service plan implementation; 
    3. progress toward goals, including permanency goals; 
    4. the continuing appropriateness of goals, including permanency goals; and 
    5. visitation/family time plans, as applicable.

    Interpretation: Cases should be reviewed quarterly, or more frequently as needed. For example, more frequent review may be necessary because of decision-making milestones, the involvement of other systems, the frequency and intensity of service provision, or other case-specific factors. When arranging an adoption or guardianship, review should occur weekly for infants and monthly for all other children awaiting adoption or transfer of custody. 

    Note: Workers are also expected to collaborate with other involved service providers to obtain their input regarding service participation and progress, as addressed in PA-CFS 2.02.  While communication with providers is always important, it will be especially critical when providers work with family members regarding specific issues that may impact safety, such as substance use, mental health, and domestic violence. 

  • FP
    PA-CFS 9.05

    The agency considers safety, risk, and progress toward goals in making decisions regarding the status of the case, including in determining whether a case can be closed. 

    Interpretation: When the permanency goal has been changed to adoption or guardianship, the case will be closed once permanency has been achieved or the youth has transitioned from the system, rather than based on an evaluation of risk and safety.

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