Private Organization Accreditation

Debt Education and Certification Foundation (DECAF), a private non-profit 501(c)(3) organization, provides high-quality financial education and counseling, with nationwide outreach throughout the U.S. DECAF is HUD-approved, and recognized as one of the 100 Best Companies to Work for in Texas.


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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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 22: Personnel

Personnel have the education, training, experience, skills, and supervision that are needed to meet the needs of residents and their families.

Note: For additional standards guidance on the use of non-employee personnel, please refer to Volunteers, Interns, and Consultants: Applicability of COA Standards to Non-Employee Personnel – Private, Public, Canadian.

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 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
    • Program staffing chart that includes lines of supervision
    • Job descriptions
    • List of program personnel that includes:
      1. name;
      2. title;
      3. degree held and/or other credentials;
      4. FTE or volunteer;
      5. length of service at the agency;
      6. time in current position
    • Table of contents of training curricula
    • Documentation of training
    • Information and/or data describing staff turnover
    • Interview:
      1. Supervisors
      2. Personnel
    • Review personnel files
    • Verify employment or contract with psychiatrist, psychologist, and other professionals

  • PA-RTX 22.01

    Residential counselors, youth workers, adult care, and child care workers have:
    1. a bachelor’s degree or are actively, continuously pursuing the degree;
    2. knowledge and understanding of organizational mission and values; 
    3. the personal characteristics and experience to collaborate with and provide appropriate care to residents, gain their respect, guide their development, and participate in their overall treatment program;
    4. the ability to support constructive resident-family visitation and resident involvement in community activities;
    5. the ability to provide services in a culturally and linguistically competent manner;
    6. the temperament to work with and care for children, youth, adults, or families with special needs, as appropriate; 
    7. the ability to work effectively with the treatment team and other internal and external stakeholders; 
    8. up-to-date certification in first aid and CPR; and
    9. adequate and continuous ongoing training and supervision.

    Interpretation: Competency can be demonstrated through education, training, or experience. The elements of the standard will be considered together to assess implementation. Recruitment of staff with demonstrated competence in elements (b), (c), and (d), and with appropriate supervision and specialized training – sometimes available through national certification programs – can compensate for a lack of a bachelor’s degree.

    Interpretation: Experience per element (c) can include lived experience as residential programs can have peer support specialists, youth advocates, mentors, and/or family advocates on staff. 

  • FP
    PA-RTX 22.02

    Depending on the residents’ needs, qualified professionals and specialists provide services and support related to the following:
    1. mental health; 
    2. substance use;
    3. crisis intervention;
    4. medicine and dentistry;
    5. prenatal and postnatal care, and the developmental needs of children;
    6. prenatal and postpartum depression screenings and care; 
    7. nursing;
    8. education and vocational skill development;
    9. physical and developmental disabilities;
    10. speech, occupational and physical therapy;
    11. recreation and expressive therapy;
    12. nutrition; and/or
    13. religion and spirituality.

  • PA-RTX 22.03

    Direct service personnel demonstrate experience or receive training and education on:
    1. engagement with residents, including building trust and establishing rapport;
    2. partnering and engaging with families and significant others;
    3. accessing culturally-relevant community services;
    4. recognizing trauma and coping mechanisms, and providing trauma-informed care;
    5. the definitions of human trafficking (both labor and sex trafficking) and sexual exploitation, and identifying potential victims;
    6. protocols for responding to residents who run away;
    7. interventions for addressing the acute needs of victims of trauma; and
    8. collaborating with local law enforcement.

    Interpretation: In relation to element (d), direct service personnel should be trained to recognize and respond therapeutically to manifestations of trauma, such as mood instability, acting out behaviors, and hyper-vigilance.

  • PA-RTX 22.04

    Personnel who conduct assessments are qualified by training, skill, and experience and are able to recognize individuals and families with special needs.

  • FP
    PA-RTX 22.05

    A licensed psychiatrist with experience appropriate to the level and intensity of service and the population served assumes responsibility for the psychiatric elements of the program, develops guidelines for participation, and provides full-time coverage on an on-call basis.

    Interpretation: A psychiatrist with the required qualifications assumes psychiatric responsibility for residents and provides service on a full-time basis as an employee, contractor, or through another formal arrangement, such as an on-call arrangement which ensures coverage 24 hours a day, seven days a week. There may be more than one psychiatrist fulfilling the duties outlined. Residential treatment programs whose primary service is residential substance use treatment are not required to have full-time psychiatric coverage but may provide psychiatric services though a formal referral arrangement on an as-needed basis. Certification in child psychiatry is not applicable to programs serving adults only.

    Note: In situations where a psychiatrist is not available to assume psychiatric responsibility for residents, the agency can receive a rating of 2 if they have an advanced practice registered nurse (APRN) supervised by a physician.

  • PA-RTX 22.06

    A psychologist with appropriate credentials and experience is available to provide testing and psychological services, as necessary.

  • PA-RTX 22.07

    Supervisors of direct personnel are qualified by: 
    1. an advanced degree in social work or a comparable human service field and two years of relevant experience; or
    2. a bachelor’s degree in social work or a comparable human service field and four or more years of relevant experience.  

  • PA-RTX 22.08

    Supervisors demonstrate a commitment to providing structure and support to direct staff to:
    1. address and reduce stress, anxiety, secondary traumatic stress, and vicarious trauma; 
    2. create an atmosphere of problem-solving and learning;
    3. build and maintain morale;
    4. reinforce the organizational values and clinical practices in family-based treatment; 
    5. provide constructive ways to approach difficult situations with clients; and 
    6. facilitate regular feedback, growth opportunities, and a structure for ongoing communication and collaboration.

    Interpretation: Supervision is an important determinant of child and family outcomes, organizational culture, and staff retention.

    Research Note: Secondary traumatic stress (STS) – distress that results from being exposed to the traumatic stories of others – and vicarious trauma (VT) – internal changes in the perception of self due to chronic exposure to traumatic material – have a significant impact on direct care workers and supervisors.  STS has been linked to increased absenteeism among employees, high staff turnover, and decreased compliance with organizational requirements. The impact of VT can exceed organizational function and negatively influence an individual’s sense of trust, safety, control, and esteem. 

    In order to promote workforce well-being, agencies should implement policies that address and help prevent stress-related problems. Strategies to reduce the adverse effects of STS and VT include: helping staff identify and manage the difficulties associated with their respective positions; promoting self-care and well-being through policies and communications with personnel; offering positive coping skills and stress management training; and providing adequate supervision and staff coverage. 

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