WHO IS ACCREDITED?

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.
read more >>

ORGANIZATION TESTIMONIAL

Nuevo Amanecer Latino Children's Services

Galo A. Rodriguez, M.P.H., President & CEO

Since Nuevo Amanecer Latino Children’s Services pursued its COA accreditation on October 14, 2004, this corporation has sustained a continuous quality improvement process by not looking whom to blame among the involved parties but improving what we have already done well… because good enough is not good enough.
read more>>

Purpose

Adults with serious and persistent mental illness who participate in Psychiatric Rehabilitation Services achieve their highest level of self-sufficiency and recovery through gains in personal empowerment, hopefulness, and competency.

PA-PSR 1: Service Philosophy, Modalities, and Interventions

The service philosophy:

  1. sets forth a logical approach for how program activities and interventions will meet the needs of service recipients;
  2. values consumer choice and promotes the individual’s and family member’s, as appropriate, participation and autonomy in the service design and implementation;
  3. ensures that services are strengths-based, culturally and linguistically responsive, and trauma-informed;
  4. guides the implementation and development of program activities and services based on the best available evidence of effectiveness; and
  5. outlines the service modalities and interventions that personnel may employ.

Update:

  • Revised Standard - 02/07/18

Interpretation: A functional philosophy, logic model, or similar framework, guides program development and implementation by linking the organization’s mission or purpose with strategies, practices, or tools needed to integreate these into daily work. A well-defined and visible practice model will help staff and stakeholders think systematically about how the program can make a measureable difference by drawing a clear connection between the service population’s needs, available resources, program activities and interventions, program outputs, and desired outcomes.

Interpretation: Being culturally and linguistically responsive includes attention to geographic, language of choice, mode of communication, and the person’s racial, ethnic, cultural background, age, sexual orientation, gender identity, gender expression, and developmental level. Variations of this phrase are used throughout the standards and relate to this definition.

Research Note: A trauma-informed approach is one that involves recognizing the signs and symptoms of trauma, and responding by emphasizing/considering the following during service delivery:

  • safety;
  • trustworthiness and transparency;
  • peer support;
  • collaboration and mutuality;
  • empowerment, voice and choice; and
  • cultural, historical, and gender issues.

Rating Indicators
1
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. 
2
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.  
3
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.
4
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
    • Service philosophy
    • Policies for prohibited interventions
    • Procedures for the use of therapeutic interventions
    • Procedures for the use of non-traditional or unconventional practices
    • Table of contents of training curricula
    • Documentation of training
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • PA-PSR 1.01

    The program is guided by a philosophy that provides a logical basis for the services and support to be delivered to individuals, based on program goals and the best available evidence of service effectiveness.


  • FP
    PA-PSR 1.02

    If the agency permits the use of service modalities and interventions it defines as non-traditional or unconventional, it:

    1. explains any benefits, risks, side effects, and alternatives to the service recipient or a legal guardian;
    2. obtains the written, informed consent of the individual or his/her legal guardian;
    3. ensures that personnel receive sufficient training, and/or certification when it is available; and
    4. monitors the use and effectiveness of such interventions.

    Update:

    • Revised Interpretation - 02/07/18

    Interpretation: Agencies that choose to engage in modalities or interventions that do not have an established evidence base should ensure that practices do not cause physical or psychological harm by demonstrating in their procedures that they have acknowledged the potential risks of implementing such methods and subsequently taken appropriate measures to minimize risks.

    NA The agency does not permit non-traditional or unconventional modalities or interventions.


  • FP
    PA-PSR 1.03

    Agency policy prohibits:

    1. corporal punishment;
    2. the use of aversive stimuli;
    3. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain;
    4. the use of demeaning, shaming, or degrading language or activities;
    5. forced physical exercise to eliminate behaviors;
    6. unwarranted use of invasive procedures or activities as a disciplinary action;
    7. punitive work assignments;
    8. punishment by peers; and
    9. group punishment or discipline for individual behavior.

  • FP
    PA-PSR 1.04

    An intervention is discontinued immediately if it produces adverse side effects or is deemed unacceptable according to prevailing professional standards.

Copyright © 2018 Council on Accreditation. All Rights Reserved.  Privacy Policy and Terms of Use