Code of Maine Rules › 14 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 193 - OFFICE OF ADULT MENTAL HEALTH › Chapter 6 - MENTAL HEALTH LICENSING REGULATIONS › OUTPATIENT SERVICE STANDARDS

Current through 2024-29, July 17, 2024
These standards, in addition to the core standards, are
				  applied to agencies providing outpatient services.
Access
OP.1 The agency has policies and procedures governing the
				  establishment of a waiting list, that minimally includes the following:
				  prioritizing clients, selecting clients from the waiting list, and referring
				  clients to other providers.
Assessment
OP.2 A comprehensive assessment is conducted by an individual
				  chosen or agreed to by the client, with the client's participation, within 30
				  days of the client agreeing to initiate services.
OP. 2. A. The comprehensive assessment minimally addresses
				  the following:
OP. 2. A.1 the client's strengths and weaknesses;
OP. 2. A.2 the client's perception of his or her
				  needs;
OP. 2. A.3 the family/guardian's input and perception of the
				  client's needs when appropriate, and with the client's consent;
OP. 2. A.4 a personal, family, and social history;
OP. 2. A.5 the client's emotional, psychiatric, and
				  psychological strengths and needs;
OP. 2. A.6 a physical health status and history, including
				  current prescription and over-the-counter medication use;
OP. 2. A.7 past and current drug/alcohol use;
OP. 2. A.8 a developmental history;
OP. 2. A.9 possible sources of assistance and support in
				  meeting the needs expressed by the client or legally responsible party,
				  including state and federal entitlement programs;
OP. 2. A.10 physical and environmental barriers that may
				  impede the client and family's ability to obtain services;
OP. 2. A.11 history of physical and/or sexual abuse;
OP. 2. A.12 the vocational, educational, social, living,
				  leisure/recreation and medical domains;
OP. 2. A.13 potential need for crisis intervention
				  services
OP. 2. A.14 housing and financial needs,
OP. 2. A.15 status of the Individualized Support Plan;
				  and
OP. 2. A.16 the signature of the person who performed the
				  assessment,
Interpretive Guideline for OP.2.A.1 thru OP.2.A.13
The Division of Licensing recognizes that in some cases not
				  all of the information requested in these standards will be able to be
				  obtained. The Division also recognizes that the level of detail required will
				  vary given a variety of factors (the client's level of cooperation, the
				  integrity of the information sources, the length of services or treatment, the
				  condition being addressed, the practitioner's training, etc.). Although the
				  Division will attempt to be sensitive to these factors and flexible in
				  surveying this area, the agency should assure that assessments that do not
				  address all these standards have accompanying documentation that justifies
				  abbreviated or absent information.
OP. 2. B. The agency will establish policies and procedures
				  establishing criteria for the performance of the following assessments:
OP. 2. B.1 a nutritional assessment;
OP. 2. B.2 a cognitive functioning assessment;
Interpretive Guideline for OP.2.B.2
The client's cognitive functioning assessment should include
				  assessment of the following functions: problem solving, decision making,
				  organization, self-direction, system negotiation skills, concentration, and
				  abstract reasoning. For individuals over 60 years of age, this assessment
				  should also include memory, language, orientation, and visuo-spatial abilities.
OP. 2. B.3 an assessment of the client's capacity;
OP. 2. B.4 a neurological assessment.
Interpretive Guideline for OP.2.B thru OP.2.B.4
These assessments do not necessarily have to be performed in
				  the agency or by agency staff. The intent of these standards are to assure that
				  the agency has mechanisms by which to evaluate the need for these assessments
				  and to perform or refer for assessment those clients whose symptomatology
				  suggests the need for these assessment.
OP. 2. C The assessment(s) shall be obtained from the client,
				  legally responsible party, community service agencies, and to the extent
				  possible, from other individuals in the community as authorized by the client
				  or legally responsible party.
OP. 2. C.1. In instances in which the client receives
				  community support services and/or has an Individualized Support Plan, the
				  agency will, subject to the client's consent, attempt to coordinate the
				  assessment and subsequent service planning with the community support
				  provider.
OP. 2. C.1.a. Services provided to these clients will be
				  consistent with the targets and objectives of the Individualized Support
				  Plan.
OP. 2. C.1.b. Services provided to these clients will be
				  delivered pursuant to a service agreement negotiated with the community support
				  worker.
OP. 2. D The client record contains a summary evaluation of
				  the data collected in the comprehensive assessment.
OP.3 The agency has a documented policy and procedure on
				  updating assessments that assures that assessments are current and in no case
				  exceed annual updates.
Service Planning
OP.4 There is documented evidence that the service planning
				  and revision process involves the client, legally responsible party, and other
				  representatives and professionals whom the client identifies.
OP.5 A comprehensive service plan is developed for each
				  client, with the client's consent, and within 30 days of initiation of
				  service.
Interpretive Guideline for OP.4
The client and legally designated guardian shall be fully and
				  actively involved in the development or revision of the service plan, if
				  possible. It the client consents, the client's designated representative e,
				  family members or significant others shall be included in the development and
				  revision of the service plan, unless contraindicated. When these individuals do
				  not attend, their absence is noted. Each agency shall document good faith
				  efforts, including at least 3 days notice of any service planning meeting, to
				  involve guardians, representatives or legally responsible parents.
OP. 5. A.. The comprehensive service plan minimally contains
				  the following:
OP. 5. A.1 problem statements;
OP. 5. A.2 short- and long-range goals based upon client
				  needs with a projection of when such goals will be attained;
OP. 5. A.3 objectives stated in terms which allow objective
				  measurement of progress;
OP. 5. A.4 multidisciplinary input and specification of
				  treatment responsibilities;
OP. 5. A..5 client input and signature;
OP. 5.A. 6 signatures of all people participating in the
				  development of the plan;
OP. 5. A.7 the methods and frequency of treatment,
				  rehabilitation, support;
OP5.A.8 a description of any physical handicap and any
				  accommodations necessary to provide the same or equal services and benefits as
				  those afforded non-disabled individuals; and
OP. 5. A..9 criteria for discharge.
OP. 5. B Justification for not addressing problems identified
				  in the assessments is documented in the client record.
Interpretive Guideline for OP.5.B
The intent of this standard is to assure that the clinical
				  staff considers all of the client's identified problems in formulating the
				  service plan. problems that are not reflected on the service plan should have
				  accompanying documentation identifying the rationale for not addressing the
				  problems at this time. This documentation can take many forms including
				  progress notes service plan narratives, etc.
OP. 5. C For those clients with ISP's and service agreements
				  to the extent that the ISP and service agreement meet all requirements of a
				  service plan, and are completed by a person qualified to provide outpatient
				  services, EL service plan will not be required.
0P.6 The service plan is designed so that the client's
				  progress towards service plan goals can be monitored and evaluated.
Interpretive Guideline for OP.6
Service plans should have measurable goals and some means for
				  reflecting when, or to what degree, a goal has been attained. The organization
				  should also have mechanisms that document monitoring and evaluation of client
				  goals, e.g., quality assessment, treatment plan review documents.
OP.7 The service plan is reviewed at major decision points in
				  each client's treatment course, upon client request, and no less frequently
				  than every 90 days.
Interpretive Guideline for OP.7
Major decision points may include, but are not necessarily
				  limited to the following: when there is a change in the client's condition,
				  when a service appears not to benefit the client, when the client is under- or
				  over- utilizing services.
OP.8 Unmet service needs are documented in the service
				  plan.
OP.9 The agency has a policy and procedure for providing
				  clients with a copy of their service plan within one week following its
				  formulation, review or revision and notification of client recourse should they
				  disagree with any aspect of the plan.
Interpretive Guideline for OP.8
If at the time of the service planning meeting, team members
				  know on the basis of reliable information that the needed services are
				  unavailable, they shall note them as "unmet service needs" on the service plan
				  and develop an interim plan based upon available services that meet, as nearly
				  as possible, the actual needs of the client. The organization should also
				  document notification of the organization's leadership and the Commissioner
				  regarding the unavailability of service that is causing the unmet service
				  need.
OP. 9. A. The agency will not fail to provide a copy of the
				  client's service plan and/or notify them of recourse should they
				  disagree.
Discharge Planning
OP.10. Each client record contains documentation of current
				  discharge or termination planning.
OP.11. The agency has discharge planning policies and
				  procedures.
OP. 11. A The agency has a policy and procedure for
				  determining when a client is considered "inactive".
OP. 11. A.1 The inactive status policy and procedure notes
				  what documentation is kept on the client during inactive status.
OP. 11. A.2 The inactive status policy and procedure notes
				  the duration of inactive status before the case is considered closed.
OP.12 A discharge summary is entered in the client record
				  within 15 days of discharge or on the 90th day of inactive status and includes
				  the client's course of treatment and ongoing needs at discharge.
OP. 12. A Each discharge summary minimally addresses, but
				  need not be limited to the following:
OP.12. A..1 the reasons for termination of service;
OP. 12. A. 2 the final assessment, including general
				  observations and significant findings of the client's condition initially,
				  while services were being provided and at discharge;
OP. 12. A.3 the course and progress of the client with regard
				  to each identified problem; and
OP. 12. A.4 the recommendations and arrangements for further
				  continued service needs.
Interpretive Guideline for OP.12
For clients on inactive status, a discharge summary should be
				  completed no later that 90 days following placement on inactive status or
				  earlier given the following conditions:
1. another agency submits a request for the client's
				  discharge summary prior to the 90th day of inactive status;
2. agency policy requires that discharge summary be completed
				  earlier than the 90th day of inactive status; and
3. practitioners who are leaving agency employment must
				  complete discharge summaries on all of their inactive status clients regardless
				  of time frame.
OP.13 The agency has policies and procedures that specify
				  under what conditions services may be discontinued or interrupted which
				  minimally include how and when the client is notified.
OP. 13. A. For agencies serving DMHMR class members, the
				  agency shall first obtain prior written approval for discontinuing or
				  interrupting services from the Department.
OP. 13. B For agencies serving DMHMR class members, the
				  agency shall give thirty days advance written notice to the client and the
				  client's guardian. If the client poses a threat of imminent harm to persons
				  employed or served by the agency, the agency shall give notice that is
				  reasonable under the Circumstances.
OP. 13. C For agencies serving DMHMR class members, the
				  agency shall give such notice as may be required by law or regulation.
OP. 13. D For agencies serving DMHMR class members, the
				  agency shall assist the client in obtaining the services from another
				  agency.
OP. 13. E For agencies serving DMHMR class members, the
				  agency shall provide documented evidence in the client record of compliance
				  with these standards, through letters, progress notes, phone logs, and/or
				  facsimile.
OP.14 Applicants, who are not eligible for services, will be
				  referred to appropriate services, if required, available and desired.
OP. 14. A. The agency has a policy and procedure on referral
				  and/or transfers of individuals deemed inappropriate for services offered by
				  the agency that minimally includes communicating the rationale for the
				  referral/transfer to the applicant and providing them with a list of
				  alternative service providers and advocacy services.
OP. 14. B. The agency provides and documents other assistance
				  as required to assist the individual to obtain/access the services to which
				  they are referring him/her.
Health
OP.15 If food services are provided, the facilities for the
				  preparation and serving of food shall be inspected and approved by the
				  Department of Human Services.
OP. 15. A.. If food is either prepared or served at the
				  facility, then the agency shall either a DHS Eating Establishment license or
				  show written evidence from DHS indicating that they need no such
				  license.
OP. 15. B. When the agency requires a DHS license, the
				  agency's Eating Establishment license is current.
OP.16 The agency shall have methods for obtaining on- or
				  off-site medical services for all clients.
OP. 16. A. The agency defines in policy and procedure those
				  medical services delivered on-site. For those medical services not provided
				  on-site, letters of agreement and/or procedures for accessing medical service
				  provider(s) are in effect.