Private Organization Accreditation

Southeastern Regional Mental Health, Developmental Disabilities and Substance Abuse Services is a Local Management Entity, covering the geographic areas of Bladen, Columbus, Robeson, and Scotland counties. SER ensures continuity of care to consumers through access to a quality of care system available 24/7/365 days a year through management of our network provider services.


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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The agency earns and sustains the public trust through honest, truthful, and responsible transactions, partnerships, and relationships with individuals, communities, providers, businesses, donors, and government entities.

PA-ETH 2: Conflict of Interest

The agency prevents the enrichment of insiders and other abuses through the adoption and enforcement of a conflict of interest policy consistent with state laws and regulations.

Interpretation: COA does not define “conflict of interest,” and expects an agency’s policy to do so.

The Panel on the Nonprofit Sector, Interim Report, Section 4, Conflict of Interest Policy Disclosure contains a useful description of the Conflict of Interest issue. References to the Internal Revenue Code note that the Code defines a conflict of interest and that: “All states mandate that directors and officers owe a duty of loyalty to the organization, and improperly benefiting from a transaction involving a conflict of interest more than likely involves a violation of the duty of loyalty. Some state statutes specifically penalize participation in transactions involving conflicts of interests unless the organization follows certain prescribed procedures.”

Note: Please see Conflict of Interest Policy and Procedure Template - Private, Public, Canadian, Network for additional assistance with this standard.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Conflict of interest policy and procedures
    • Network Management Manual
    • Network utilization data to review referral and utilization patterns
    State Administered Agency (Regional Office)
    • Documentation of policy communication to staff
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Management meeting minutes documenting discussions of potential and apparent conflicts of interest
    • Financial statements/audits
    • Network client files to review reasons for referrals to particular providers
    State Administered Agency (Regional Office)
    • No On-site Evidence
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Interview:
      1. Agency head
      2. Ethics officer/in-house counsel
      3. Oversight Entity/Stakeholder Advisory Panel members
      4. CFO or equivalent
      5. Persons served/community stakeholders
      6. Personnel
    • Network interview:
      1. Network Advisory Body
      2. Directors of agencies that contract with the managing entity
      3. Network personnel involved in assessments and referral
    State Administered Agency (Regional Office)
    • Interview:
      1. Agency leadership
      2. Persons served/community stakeholders
      3. Personnel

  • PA-ETH 2.01

    A conflict of interest policy is tailored to the agency’s specific needs and characteristics, and:

    1. defines conflict of interest;
    2. identifies groups of individuals within the organization covered by the policy;
    3. addresses transactions between oversight entities and the agency;
    4. addresses policy enforcement;
    5. provides a framework for evaluating situations that may constitute a conflict; and
    6. invests management with developing procedures that facilitate disclosure of information to prevent and manage potential and apparent conflicts of interest.

    Interpretation: If an agency has a conflict of interest policy requiring signature of the designated authority, these signed forms should be available with the policy. The conflict of interest policy should ensure, among other things, that advisory members recuse themselves on matters where their objectivity could be compromised.

  • PA-ETH 2.02

    Conflict of interest policies and procedures ensure that contracts and business arrangements serve the agency’s and service recipients’ best interests, not private interests.

  • PA-ETH 2.03

    Advisory group members, personnel, and consultants who in any way have a financial interest in the agency’s assets, business transactions, leases, or professional services:

    1. disclose this information; and
    2. do not participate in any discussion or vote taken with respect to such interests.

  • PA-ETH 2.04

    The network has a process for ensuring that its activities are carried out in an even-handed, principled manner and in the interests of service recipients.

    Interpretation: It is essential that the network guard against any real or perceived conflict of interest in the manner in which it conducts its business, especially with regard to assessment, referral, and utilization management practices.

    NA The agency is not a network management entity.

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