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.


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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The agency’s human resources practices attract and retain a competent and qualified workforce that is capable of supporting the agency’s mission and strategic goals. 

PA-HR 4: Satisfaction and Retention

The agency promotes a high level of personnel satisfaction and retention.

Note: Please see Staff Turnover Rate Worksheet - Private, Public, Canadian for additional assistance with this standard.

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 administration and management 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
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Policies and/or procedures for:
      1. Personnel recognition (PA-HR 4.01)
      2. Personnel grievance
      3. Exit interviews
    • Description of work-related stress awareness and prevention efforts (PA-HR 4.02)
    • Aggregate personnel satisfaction and retention information (PA-HR 4.03)
    • Documentation of actions taken to address personnel satisfaction and retention concerns (PA-HR 4.04)
    State Administered Agency (Regional Office)
    • Documentation of regional personnel recognition activities (PA-HR 4.01)
    • Description of regional work-related stress awareness and prevention efforts (PA-HR 4.02)
    • Documentation of regional actions taken to address staff satisfaction and retention concerns (PA-HR 4.04)
    All Agencies
    • Grievance reports for the most recent review period (PA-HR 4.05)
    • Training files, database or personnel files that demonstrate attendance at training on the personnel grievance procedure (PA-HR 4.05)
    • Exit interview documentation from personnel records (PA-HR 4.06)
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Interview:
      1. Agency head
      2. HR director
      3. PQI manager
      4. Personnel at all levels
    State Administered Agency (Regional Office)
    • Interview:
      1. Regional Director
      2. Agency leadership
      3. Regional HR personnel
      4. Personnel at all levels

  • PA-HR 4.01

    The agency recognizes and rewards the contributions of personnel. 

  • FP
    PA-HR 4.02

    The agency integrates work-related stress awareness and prevention efforts into its human resources practices. 

    Interpretation: Awareness and prevention efforts can include, but are not limited to: supervision and training, access to employment assistance programs, vacation and flex time policies, and peer support opportunities. 

  • PA-HR 4.03

    The agency establishes annual personnel satisfaction and retention goals, and measures:

    1. rate of personnel turnover; and
    2. personnel satisfaction.

  • PA-HR 4.04

    The agency address identified personnel satisfaction and retention concerns. 

    Research Note: Factors that have been associated with personnel satisfaction and retention include: role clarity, recognition of employee contributions, satisfaction with salary and benefits, reasonable workload, quality supervision and strong supervisory relationships, autonomy, opportunities for advancement, career development, and work/life balance (e.g. flexible work options, personal and family support). 

  • PA-HR 4.05

    The agency follows personnel grievance procedures that include:

    1. the right to file a grievance without interference or retaliation;
    2. a description of how grievances are filed and to whom, including who will make a final determination; 
    3. timely written notification of the resolution and an explanation of any further appeal, rights or recourse;
    4. processes for review, including a third-party review of the final determination;
    5. documenting responses and actions taken; and
    6. maintaining a copy of the notification of resolution in the personnel record.

    Interpretation: Regarding element (d), the third-party review refers to at least one level of review that does not involve the person about whom the complaint has been made or the person who reached the decision under review. 

  • PA-HR 4.06

    The agency provides all departing personnel with an opportunity to participate in an exit interview and documents the interview feedback or exit interview declination in the personnel record.

    Interpretation: This interview enables exiting personnel to provide feedback on the agency’s strengths and weaknesses, including any administrative challenges related to their transition.

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