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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Shelter Services meet the basic needs of individuals and families who are homeless or in transition, support family stabilization or independent living, and facilitate access to services and permanent housing. 

SH 1: Service Philosophy

The program is guided by a service philosophy that:

  1. sets forth a logical approach for how services, supports, activities, and interventions will empower and meet the needs of service recipients;
  2. ensures that services are strengths-based, person- or family-centered, culturally and linguistically competent, and trauma-informed; and
  3. guides the development and implementation of program activities and individualized services based on the best available evidence of service effectiveness.

Interpretation: A functional service philosophy, logic model, or similar framework guides program development and implementation by linking the organization’s mission or purpose with strategies, practices, or tools needed to integrate these into daily work. A well-defined and visible practice framework will help staff and stakeholders think systematically about how the program can make a measureable difference by drawing clear connections between program values, service population needs, available resources, program activities and interventions, program outputs, and desired outcomes.

Interpretation: Organizational self-assessments can evaluate the extent to which organizations’ policies and practices are trauma-informed, as well as identify strengths and barriers in regards to trauma-informed service delivery and provision. For example, organizations can evaluate staff training and professional development opportunities and review supervision ratios to assess whether personnel are trained and supported on trauma-informed care practices. Organizations can also conduct an internal review of their assessment and service planning processes to ensure that services are being delivered in a trauma-informed manner.

    Research Note: A trauma-informed approach is one that involves recognizing the signs and symptoms of trauma, and responding by emphasizing/considering the following during service delivery:

    • safety; 
    • trustworthiness and transparency;
    • peer support; 
    • collaboration and mutuality; 
    • empowerment, voice, and choice; and 
    • cultural, historical, and gender issues. 
    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
    • Written service philosophy needs improvement or clarification; or
    • Procedures need strengthening; or
    • With few exceptions procedures are understood by staff and are being used; 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
    • In a few rare instances required consent was not obtained; or
    • Monitoring procedures need minor clarification; or
    • With few exceptions the policy on prohibited interventions is understood by staff, or the written policy needs minor clarification.
    Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
    • The written service philosophy needs significant improvement; or
    • Procedures and/or case record documentation need significant strengthening; or
    • Procedures are not well-understood or used appropriately; or
    • Documentation is inconsistent or in in some instances is missing and no corrective action has not been initiated; or
    • Required consent is often not obtained; or
    • A few personnel who are employing non-traditional or unconventional interventions have not completed training, as required; or
    • There are gaps in monitoring of interventions, as required; or
    • Policy on prohibited interventions does not include at least one of the required elements; or
    • Service philosophy is not clearly related to expressed mission or programs of the organization; 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.,
    • There is no written service philosophy; or
    • There are no written policy or 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
      • Service philosophy
      • Policies for prohibited interventions
    No On-Site Evidence
      • Interview:
        1. Program director
        2. Relevant personnel

    • SH 1.01

      The program is guided by a philosophy that provides a logical basis for services and supports to be delivered in a trauma-informed and culturally and linguistically competent manner, based on program goals and the best available evidence of service effectiveness.

    • FP
      SH 1.02

      Organization policy prohibits:

      1. corporal punishment;
      2. the use of aversive stimuli;
      3. interventions that involve withholding nutrition or hydration, or that inflict physical or psychological pain;
      4. the use of demeaning, shaming or degrading language or activities;
      5. unnecessarily punitive restrictions including cancellation of visits as a disciplinary action;
      6. forced physical exercise to eliminate behaviors;
      7. punitive work assignments;
      8. punishment by peers;
      9. group punishment or discipline for individual behavior; and
      10. unwarranted use of invasive procedures and activities as a disciplinary action.

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