Private Organization Accreditation

HeartShare assist individuals with developmental disabilities through education, day, residential and recreation programs, case management, and health services, and provides foster care/adoption services, counseling, after school and energy assistance programs, and programs for people with HIV/AIDS.


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 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 5: Human Resource Practices

Human resource practices are equitable, consistently applied, and in compliance with applicable laws and regulations. 

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
    • Procedures for conducting an annual audit of human resource practices (PA-HR 5.01, PA-HR 5.04)
    • Reports from the most recent HR audit, including documentation of corrective action, as needed (PA-HR 5.01, PA-HR 5.04)
    • Table of Contents for Personnel Manual (PA-HR 5.02)
    • Most recent biennial review of compensation and benefits, including plans for corrective actions, as needed (PA-HR 5.03)
    State Administered Agency (Regional Office)
    • No Self-Study Evidence
    All Agencies
    • Personnel Manual (PA-HR 5.02)
    • Personnel records (PA-HR 5.02)
    • State/civil service title compensation scale and rules (PA-HR 5.03)
    County/Municipality Administered Agency, State Administered Agency (Central Office), or other Public Entity
    • Interview:
      1. Agency head
      2. HR director
      3. Supervisory personnel
      4. Personnel at all levels
    State Administered Agency (Regional Office)
    • Interview:
      1. Regional Director
      2. Agency leadership
      3. Regional HR personnel
      4. Supervisory personnel
      5. Personnel at all levels

  • FP
    PA-HR 5.01

    The agency conducts an annual audit of its human resource practices to verify compliance with applicable: 

    1. employment and labor laws at the local, state, and federal level;
    2. civil service rules and regulations; and
    3. union contracts. 

    Interpretation: Agencies must be prepared to justify how the audit process ensures compliance with applicable employment and labor laws, civil service rules and regulations, and union contracts. Applicable employment and labor laws include, but are not limited to: those governing fair employment practices, use of contingent workers, compensation and benefits, maintenance of personnel records, retention of hiring records, background checks, and collective bargaining.  

    NA State-administered agency regional office

  • PA-HR 5.02

    All personnel receive, and confirm in writing, receipt of an up-to-date employee policies and procedures manual that articulates current:

    1. conditions of employment;
    2. benefits;
    3. rights and responsibilities of employees; and
    4. other important employment-related information.

    Interpretation: Policies and procedures can be written or electronic, and address:

    1. conditions and procedures for layoffs;
    2. safety procedures and protocols (PA-ASE 6);
    3. emergency response procedures (PA-ASE 7);
    4. non-discrimination/EEO and anti-harassment policies and reporting procedures (PA-HR 1);
    5. conflict of interest policies including nepotism policy (PA-ETH 2, PA-HR 1);
    6. personnel grievance procedures (PA-HR 4);
    7. insurance protections including unemployment, disability, medical care, and malpractice liability;
    8. policies and procedures governing access to free legal counsel;
    9. performance review procedures (PA-HR 6);
    10. whistle-blower protections (PA-ETH 4);
    11. promotions;
    12. professional development;
    13. standards of conduct;
    14. time-off policies;
    15. wage policy; 
    16. working conditions; and
    17. policies and guidelines on the use of social media, electronic communications, and mobile devices (PA-RPM 6).

  • PA-HR 5.03

    Compensation and benefits are reviewed biennially in relation to industry practices.

    Interpretation: When comparing total compensation and benefits to industry practices, the agency should focus its comparison on public agencies providing a comparable service array in states of a similar size and demographic makeup.

    NA State-administered regional office. 

  • PA-HR 5.04

    The agency annually reviews its use of independent contractors, leased workers, volunteers, and temporary employees, with respect to tax law, wage and hour laws, and other applicable employment and labor laws. 

    Interpretation: See PA-HR 5.01 for more information on ensuring compliance with applicable laws.

    NA The agency does not use contingent workers, including independent contractors, leased workers, volunteers, and temporary employees.

    NA State-administered agency regional office. 

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