WHO IS ACCREDITED?

Private Organization Accreditation

Lutheran Social Services of New England is a high-performing nonprofit organization. LSS is a powerful difference maker and go-to resource, driving ourselves to constantly anticipate futures that are different from the past. For 140 years, LSS has been caring for people in need in New England.
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ORGANIZATION TESTIMONIAL

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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Purpose

Residential Treatment Services provide individualized therapeutic interventions and a range of services, including education for residents to increase productive and pro-social behavior, improve functioning and well-being, and return to a stable living arrangement in the community.

PA-RTX 17: Privacy Provisions

The agency provides for resident comfort, dignity, privacy, and safety.

Note: Please see Facility Observation Checklist - Private, Public, Canadian for additional assistance with this standard.

Research Note: Establishing physical and psychological safety has been proven to have a significant impact on residents’ long-term recovery and social and emotional well-being.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Privacy policy and procedures, including protocols on the use of electronics
    • Policy and procedures regarding searches of residents and their property
    • Judicial order, law, or contract, as applicable (PA-RTX 17.02 b.)
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents
    • Observe facility

  • FP
    PA-RTX 17.01

    The agency:
    1. maintains doors on sleeping areas and bathroom enclosures unless there is clear, clinical written justification for their removal;
    2. provides one- or two-person rooms to residents who need extra sleep, protection from sleep disturbance, or extra privacy for clinical reasons; and
    3. requires employees to knock before entering a resident’s room unless there is a safety or clinical concern.

    Interpretation: The agency should provide single rooms for developmentally disabled adults and for others with specialized care issues (e.g., history of being bullied, history of trauma, sexual abuse, sexual orientation or aggressive behavior).

    Interpretation: Regarding element (c), employees should knock before entering a resident’s room unless there is an immediate health or safety concern or a well-documented clinical concern.


  • FP
    PA-RTX 17.02

    The agency:
    1. establishes and implements policies for searches of residents or their property consistent with applicable state and federal law; and
    2. prohibits the use of surveillance cameras or listening devices of persons in their bedrooms, unless required by judicial order, law, or contract.

    Interpretation: Residents should be apprised of the agencies policy regarding room checks and personal searches. 

    Interpretation: When agencies are required by judicial order, law, or contract, documentation must be provided to justify employing this practice which may include the judicial order, contract, or a copy of the state’s safety plan involving the resident. Agencies will need to demonstrate in their privacy policy and procedures that they have taken measures to prevent any unintended violation of an individual’s rights and privacy. Residents must have access to private areas for self-care and the changing of clothing. 

    Sensitivity is taken to ensure that all residents, especially abuse or trauma survivors and the LGBTQ population, feel safe and not violated. 

    Interpretation: The use of surveillance cameras or listening devices should not be used as a supplement to adequate staffing or supervision protocols. 


  • FP
    PA-RTX 17.03

    Searches of residents or their property are conducted in a trauma-informed manner that respects client rights, dignity, and self-determination and include, as appropriate to the frequency and invasiveness of searches:
    1. timely notification of a parent and/or legal guardian;
    2. definition and documentation of reasonable cause and assessed risk of harm to self or others;
    3. trained, qualified staff; and
    4. an administrative review process including documentation, notification, and a timetable for review.

    Interpretation: The invasiveness of the search to be conducted has a direct impact on all aspects of search procedures. Agencies must demonstrate and document that more invasive searches are associated with an increased level of risk, reasonable cause, and level of administrative review. More invasive searches should only be performed by specially trained and qualified staff. FP-PA-RTX 17.04

    The agency respects residents’ privacy by only reviewing mail when a previous incident involving the resident indicates that:
    1. the mail is suspected of containing unauthorized, dangerous, or illegal material or substances, in which case it may be opened by the resident in the presence of designated personnel; or
    2. receipt or sending of unopened mail is contraindicated.
    Interpretation: Mail refers to letters, packages, emails, and other forms of correspondence via electronic messaging. Agencies should have electronic messaging and social networking policies, procedures, and/or protocols for staff and residents and their families.

    Interpretation: Correspondence between residents and their family, friends, and other social supports should be encouraged, and not monitored nor used as a reward or punishment.

    Interpretation: Programs serving individuals with substance use conditions may require personnel to review mail without incident due to the reason for which residents are seeking treatment. If an agency employs this approach, they must provide justification for taking such measures, which may include health, safety, and other security concerns.

    Research Note: Routine activities such as room checks and property searches can trigger traumatic reenactment. Training staff on interventions that help children and youth identify and manage potential triggers supports a trauma-informed living environment.


  • PA-RTX 17.04

    The agency respects residents’ privacy by only reviewing mail when a previous incident involving the resident indicates that:
    1. the mail is suspected of containing unauthorized, dangerous, or illegal material or substances, in which case it may be opened by the resident in the presence of designated personnel; or
    2. receipt or sending of unopened mail is contraindicated.

    Interpretation: Mail refers to letters, packages, emails, and other forms of correspondence via electronic messaging. Agencies should have electronic messaging and social networking policies, procedures, and/or protocols for staff and residents and their families.

    Interpretation: Correspondence between residents and their families, friends, and other social supports should be encouraged, and not monitored nor used as a reward or punishment.

    Interpretation: Programs serving individuals with substance use conditions may require personnel to review mail without incident due to the reason for which residents are seeking treatment. If an agency employs this approach, they must provide justification for taking such measures, which may include health, safety, and other security concerns.


  • FP
    PA-RTX 17.05

    Residents can have private telephone conversations, and any restriction is:
    1. based on contraindications and/or a court order;
    2. approved in advance by the program director or an appropriate designee;
    3. documented in the case record; and
    4. reauthorized weekly by the immediate supervisor of the direct service provider.

    Note: The agency will be responsible for developing protocols addressing the use of cellphones and other types of technology in the program.

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