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.


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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Youth who participate in Wilderness and Adventure-based Therapeutic Outdoor Services expand individual capabilities, develop self-confidence and insight, ameliorate symptoms, and improve interpersonal skills and relationships.

PA-WT 1: Screening and Intake

The agency’s screening and intake practices ensure that individuals receive prompt and responsive access to appropriate services.

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
    • Screening and intake procedures
    • Procedures for expedited admissions
    • Procedures for placement
    • Blank consent form
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Youth or families served
    • Review case records

  • PA-WT 1.01

    Youth and families are screened and informed about:

    1. how well the individuals request matches the agency’s services; and
    2. what services will be available, and when.

    NA Another agency is responsible for screening, as defined in a contract.

  • PA-WT 1.02

    Criteria used to determine if the service and specific activities are appropriate for the individual include:

    1. physical, social, developmental, and mental health status;
    2. interpersonal relationships and social skills;
    3. prior treatment history and experience with outdoor programming;
    4. the appropriateness of adventure-based therapeutic outdoor services to address the individual’s needs; and
    5. other significant factors.

  • FP
    PA-WT 1.03

    Prompt, responsive intake practices:

    1. ensure equitable treatment;
    2. give priority to urgent needs and emergency situations;
    3. support timely initiation of services; and
    4. provide for placement on a waiting list, if applicable.

  • PA-WT 1.04

    During intake, the agency gathers information to identify critical service needs and/or determine when a more intensive service is necessary, including:

    1. personal and identifying information;
    2. emergency health needs; and
    3. safety concerns, including imminent danger or risk of future harm.

  • PA-WT 1.05

    Each applicant is engaged in the admission process and:

    1. is helped to understand the reasons for admission;
    2. receives a pre-admission visit to the program, when feasible; and
    3. is adequately prepared to begin the program.

  • PA-WT 1.06

    The agency adheres to intake criteria and assessment requirements for expedited admissions and follows established procedures for integrating participants into existing groups.

  • PA-WT 1.07

    Applicants who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources.

    NA The agency accepts all clients.

  • FP
    PA-WT 1.08

    Critical care decision making is carried out by, or under the direct supervision of, experienced or licensed personnel.

  • FP
    PA-WT 1.09

    Prior to providing consent, parents or legal guardians, referral or placing representatives, and youth, whenever possible, receive information about:

    1. the type of adventure activities the participant will undertake;
    2. educational options; and
    3. any actual or perceived risks.

  • PA-WT 1.10

    Informed, written consent is obtained from the parent or legal guardian and, whenever possible, the youth before admission to the program.

    Interpretation: The legal guardian can include the court.

  • FP
    PA-WT 1.11

    The agency describes:

    1. personal items a participant may bring with them, consistent with a safe, therapeutic setting;
    2. items that are discouraged or prohibited; and
    3. any safety procedures the program follows, or consequences that can result, when prohibited items are brought to the program site.

    Interpretation: Permitted personal items will vary as appropriate to the program’s design but can include photos, books, or clothing.

    Wilderness and Adventure-Based Therapeutic Outdoor Services

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