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.


Judy Kay, LCSW

Volunteer Roles: Peer Reviewer; Team Leader

In administration for 22 of 24 years at Child Saving Institute, a COA-accredited not-for-profit child welfare agency in Omaha, Nebraska. Retired approximately two years ago, I moved to Tucson, Arizona, where I advocate for children's rights as a Court Appointed Special Advocate (CASA) volunteer to three young children.
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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.

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 t