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.


Domestic Violence Intervention Services, Inc.

Donna Mathews, Associate Director

Becoming accredited and maintaining our accreditation through COA has helped us increase our professionalism and thereby provide better services to domestic violence, sexual assault, stalking, and dating violence survivors.
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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.

RTX 9: Healthcare Services

Residents receive comprehensive healthcare services to promote optimal physical, emotional, and developmental health.

Rating Indicators
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.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • For the most part, established timeframes are met; or
  • Proper documentation is the norm and any issues with individual staff members are being addressed through performance evaluations (HR 6.02) and training (TS 2.03); or
  • Active client participation occurs to a considerable extent.
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Timeframes are often missed; or
  • A number of client records are missing important information  or
  • Client participation is inconsistent; or
  • One of the Fundamental Practice Standards received a rating of 3 or 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.,
  • No written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • 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
    • Healthcare services procedures, including the initial medical screening, comprehensive medical examination, and dental care
    • Informational health and wellness materials 
    • Interview:
      1. Program director
      2. Relevant personnel
      3. Residents
    • Review case records
    • Verify employment of physician either directly or via contract

  • FP
    RTX 9.01

    An initial health screening is conducted by a qualified medical practitioner for all residents within 24 hours of admission to identify the need for immediate medical care and assess for communicable disease.

    Interpretation: Qualified medical practitioner refers to a licensed physician, registered nurse, nurse practitioner, physician’s assistant, or other healthcare professional that is permitted by law and the organization to provide medical care and services without direction or supervision. When possible, the screening should be performed by the resident’s primary care physician who has knowledge of the resident’s medical history or a physician that can serve as the resident’s medical home while in care.  

    For the purposes of this standard, qualified medical practitioners are distinct from other clinicians who are not permitted by law to provide medical care and services without direction or supervision (e.g., clinical social workers, licensed vocational/practical nurses, and medical assistants). To meet the standard, the initial medical screening must be administered by a qualified medical practitioner.

    Interpretation: In situations where the resident is unable to receive an initial health screening by a qualified medical practitioner within 24 hours, the organization can receive a rating of 2 if it has procedures in place for accommodating exceptional circumstances and is able to provide evidence that the screening occurred within 72 hours of admission. Examples of exceptional circumstances include, but are not limited to: 
    • weekend placements; and 
    • when a client is transferring from the care of a public agency that has arranged for an initial health screening to be conducted within 72 hours of admission to the program.
    Interpretation: If the organization does not have a qualified medical practitioner on staff, it should research community resources and consider creating a formal arrangement or a memorandum of understanding (MOU) with a local physicians group, their local health department, federally-qualified health center, urgent care clinic, community-based health clinic, or telehealth providers.

    For children in care, the local child welfare agency may be responsible for ensuring the initial health screening is completed or may assist the organization to identify possible medical resources.

    Interpretation: Conditions that require immediate or prompt medical attention include, but are not limited to: signs of abuse or neglect, serious or accidental injury, signs of infection or communicable diseases, hygiene or nutritional problems, pregnancy, and significant developmental or mental health disturbances.

    Interpretation: When a resident returns following a runaway episode, a health screen should be conducted within 24 of entry back into care to identify whether he or she was victimized or otherwise hurt or injured while on the run. For further guidance on protocols for preventing and responding to missing and runaway children and youth, please refer to ASE 6.06.

  • FP
    RTX 9.02

    Every resident receives:
    1. a comprehensive medical examination five days after admission, unless the resident has received a medical exam within the last year, and annually thereafter; and 
    2. a dental examination six months prior to or one month after admission, with appropriate follow-up thereafter.

    Interpretation: When records from the most recent medical and dental examinations are unavailable, or examinations are incomplete, the organization must ensure that examinations are completed within the required timeframe.

    Interpretation: The purpose of the medical examination is to identify and assess medical, developmental, and mental health conditions that require treatment, additional evaluation, and/or referrals to other healthcare professionals or specialists. The examination must be comprehensive, build on history gathered during the initial medical screening, and focus on specific assessments that are appropriate to the individual’s age and developmental level. Findings from the exam are used to develop individualized treatment plans, as well as inform follow-up assessments and services.
    Interpretation: In situations where resources are not available for preventive dental care to occur every six months, the organization can receive a rating of 2 if there is an annual preventive exam and evidence that recommendations from the dental practitioner indicate the child is not in need of more frequent care. Children with dental issues or at high risk of dental problems must be receiving the care they need. Families should be engaged in the process and solution for getting their child the needed dental care.

    Research Note: Best practice indicates that the most common interval for dental exams is every six months though some individuals may require more frequent exams based on clinical, historical or radiographic findings. Individuals with dental issues or at high risk of dental problems benefit from exams at frequencies greater than every six months. 
    Research Note: Traumatic stress can have a profound impact on an individual’s physical wellbeing and health. Trauma can manifest itself in the body in the form of physical tension and/or health complaints. Traumatized individuals may experience problems with movement and sensation, including hypersensitivity to physical contact and insensitivity to pain, exhibit unexplained physical symptoms (e.g., aches, pains, and headaches), or increased medical problems. 
    Research Note: Trafficking victims commonly suffer from multiple physical and psychological health issues as a result of inhumane living conditions, isolation, poor sanitation and hygiene, malnutrition, physical and emotional abuse from their traffickers, dangerous working situations, alcohol and other drug use, and overall lack of health care.

    NA The organization only operates a crisis stabilization unit or a short-term diagnostic center. 

  • RTX 9.03

    Health services include direct provision or referral for needed services, and health records include a written summary of the resident’s and his or her family’s known medical history, including immunizations, operations, medications, and medical conditions and illnesses.

    Interpretation: Copies of the medical history are provided to the resident and/or his or her legal guardian when requested and retained in the case record.

  • RTX 9.04

    Direct service workers promote good health habits and healthy living.

    Interpretation: Examples of how personnel can promote good health habits and healthy living include:
    1. offering a variety of physical and recreational activities;
    2. implementing a youth education curriculum on healthy living;
    3. facilitating support and education groups on proper nutrition and exercise, personal hygiene, and good health habits;
    4. helping residents and their families make healthy choices by including them in nutrition planning; and/or
    5. promoting good health habits and healthy living in day-to-day interactions with residents. 

    Recognizing that there are communities where access to affordable, quality food is limited, it is important for personnel to take into consideration where residents will reside after they are discharged so healthy eating habits can continue long after they leave care. 

  • FP
    RTX 9.05

    A physician or other qualified medical practitioner assumes 24-hour on-call medical responsibility.

    Interpretation: The standard requires professional medical oversight to ensure that residents’ health needs are identified and promptly addressed. Physicians or other qualified medical practitioners must be familiar with the needs of the resident population.

    Interpretation: COA recognizes that geographic placement and resources can pose barriers. The use of an emergency room or urgent care facility is acceptable for overnight hours when protocols are established. Organizations can also leverage alternative service delivery methods such as telehealth when regional shortages of certain professional groups make in-person consultation impractical.

    NA All residents have private physicians.

  • FP
    RTX 9.06

    Residents receive age and developmentally appropriate support and education regarding:
    1. sexual development;
    2. safe and healthy relationships;
    3. pregnancy prevention and effective parenting;
    4. HIV/AIDS prevention; and
    5. prevention and treatment of sexually transmitted diseases.

    NA The organization only operates a crisis stabilization unite or short-term diagnostic center. 

  • RTX 9.07

    The organization provides or arranges specialized health services to meet the needs of the service population, as appropriate.

    Interpretation: Specialized health services should be provided or arranged as necessary. Services may be needed by older adults, pregnant and parenting individuals, individuals with eating disorders, individuals with substance-use related conditions, or children with autism and pervasive developmental disorders. Health services may include but are not limited to:

    1. tobacco cessation programs;
    2. speech, language, and occupational therapy;
    3. gender identity counseling; and
    4. screening for the onset of or existence of common cancers.

    Note: Services for pregnant and parenting individuals are addressed in RTX 13, services for substance use conditions are addressed in RTX 14, and populations with specialized care needs are addressed in RTX 15. 

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