WHO IS ACCREDITED?

Private Organization Accreditation

Northside Psychological Services is a combination of both private practice and community mental health provider. We provide services to children and adults (EAP, private insurance, private pay, etc.) in our private practice setting. In our Community Care Program, we provide services to children and adolescents in their homes.
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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.

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
1
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,  
  • With some exceptions, staff (direct service providers, supervisors, and program managers) possess the required qualifications, including: education, experience, training, skills, temperament, etc., but the integrity of the service is not compromised.
    • Supervisors provide additional support and oversight, as needed, to staff without the listed qualifications.
    • Most staff who do not meet educational requirements are seeking to obtain them.
  • With some exceptions staff have received required training, including applicable specialized training.
    • Training curricula are not fully developed or lack depth.
    • A few personnel have not yet received required training.
    • Training documentation is consistently maintained and kept up-to-date with some exceptions.
  • A substantial number of supervisors meet the requirements of the standard, and the organization provides training and/or consultation to improve competencies.
    • Supervisors provide structure and support in relation to service outcomes, organizational culture and staff retention.
  • With a few exceptions caseload sizes are consistently maintained as required by the standards.
  • Workloads are such that staff can effectively accomplish their assigned tasks and provide quality services, and are adjusted as necessary in accord with established workload procedures.
    • Procedures need strengthening.
    • With few exceptions procedures are understood by staff and are being used.
  • With a few exceptions specialized staff are retained as required and possess the required qualifications.
  • Specialized services are obtained as required by the standards.
3
Practice requires significant improvement, as noted in the ratings for the Practice standards.  Service quality or program functioning may be compromised; e.g.,
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
  • A significant number of staff, e.g., direct service providers, supervisors, and program managers, do not possess the required qualifications, including: education, experience, training, skills, temperament, etc.; and as a result the integrity of the service may be compromised.
    • Job descriptions typically do not reflect the requirements of the standards, and/or hiring practices do not document efforts to hire staff with required qualifications when vacancies occur.
    • Supervisors do not typically provide additional support and oversight to staff without the listed qualifications.
  • A significant number of staff have not received required training, including applicable specialized training.
    • Training documentation is poorly maintained.
  • A significant number of supervisors do not meet the requirements of the standard, and the organization makes little effort to provide training and/or consultation to improve competencies.
  • There are numerous instances where caseload sizes exceed the standards' requirements.
  • Workloads are are excessive and the integrity of the service may be compromised. 
    • Procedures need significant strengthening; or
    • Procedures are not well-understood or used appropriately; or
  • Specialized staff are typically not retained as required and/or many do not possess the required qualifications; or
  • Specialized services are infrequently obtained as required by the standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,

For example:
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

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 organization;
      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

  • 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
    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.


  • 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.


  • 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
    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 organization can receive a rating of 2 if they have an advanced practice registered nurse (APRN) supervised by a physician.


  • RTX 22.06

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


  • 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.  


  • 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, organizations 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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