The Mental Health Code requires that the Department of Community Health promulgate rules to establish standards for certification and the certification review process for CMHSPs.  Administrative Rule 330.2801 requires the department to assess the CMHSPs compliance with certification standards by determining the degree to which all of the following provisions apply:

a)  The CMHSP has established processes, policies and procedures necessary to achieve the required result.

b)  The established processes, policies and procedures are properly implemented.

c)  The expected result of the processes, policies and procedures is being achieved.

The Mental Health Code also requires that DCH, through this Office, review the CMHSP rights systems in order to "ensure a uniformly high standard of recipient rights protection throughout the state."

The certification standards must include those for the protection and promotion of recipient rights (MCL 330.232a[1][b]).  Although standards as to matters of CMHSP governance, resource management, quality improvement, service delivery and safety management may be waived by the department in whole or in part as the result of the CMHSP's accreditation by a nationally recognized accrediting body, this is not the case relative to standards established by the department in regard to the protection and promotion of recipient rights.

Assessment Process

Each CMHSP recipient rights system is assessed annually by two ORR Community Rights Specialists through careful review of and follow-up on semi-annual and annual reports prepared by each CMHSP rights office and submitted by their executive director.  Annually, the Rights Specialists also conduct an onsite assessment of approximately one-third of the CMHSPs.  This three day, onsite review includes an entrance conference; interviews with the executive director, rights office staff, consumers, CMHSP staff and staff of contract providers, Recipient Rights Advisory and Appeals Committee members; compliance review of complaint case files, logs, Code-mandated reports and notices, appeals cases; review of contract language to ascertain clarity as to how rights will be protected during the contract period and training requirements; compliance review of all twenty-two rights-related policies required by the Code; site visits to a representational sample of CMHSP directly operated and contracted service; and an exit conference.  Site visits are also made to the LPH/U under contract with the CMHSP.  Areas of non-compliance with Code and Rules evidenced by the rights system at the LPH/U are cited in the CMHSP assessment report.  Additionally, if a serious deficiency were found, this would also be reported to the Psychiatric Licensing Consultant with the Department of Community Health.

2008 Rights System Assessment Results

Assessments Results 2006

Fifteen (15) CMHSP rights protection systems were evaluated through onsite assessments conducted by the Office of Recipient Rights Community Rights Unit Specialists from March 2006 through December 2006.  Beginning in March of 2001, a rights system was scored as being in less than substantial compliance, even if the overall score was in the range of substantial compliance, if the Specialists determined that a deficiency which was previously cited in the last assessment had not been corrected at the time of the current assessment.   CMHSPs that were scored in this manner have an * in the table which follows.  Evidence that the repeat citation has been corrected must be provided to DCH-ORR within 30 days of receipt by the CMHSP of the assessment report.

2006 Rights System Assessment Results

¹As the rights system for Detroit-Wayne County CMH Agency was found to be in less than substantial compliance in 2005, a focus visit was conducted in 2006 to determine if the plan of correction submitted by the Agency had brought the Agency into, and maintained the system in, substantial compliance with the standards.