Community Mental Health Program Assessment Results

The 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 these 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 Code also requires that DCH, through the Office of Recipient Rights, 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 the ORR Community Rights Specialists. This is accomplished through careful review of and follow-up on semi-annual and annual reports.  Annually, the Rights Specialists also conduct an onsite assessment of approximately one-third of the CMHSPs.  These three day, onsite reviews include:

• An entrance and exit 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;
  
  
• A 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.

Related Documents

Click this link to view a copy of Attachment A

Click this link to view a copy of Attachment B

2011 Rights System Assessment Results  

2010 Rights System Assessment Results  

2009 Rights System Assessment Results  

2008 Rights System Assessment Results  

2006 Rights System Assessment Results