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

Current through 2024-29, July 17, 2024
Management in health service organizations can be broken into
				  five general functions: planning, organizing, staffing, directing, and
				  controlling. This section presents the core facility management standards
				  arranged according to these general management functions.
Planning
Planning is an orderly process for giving organizational
				  direction, coping with change, and coping with uncertainty by formulating
				  future courses of action. The following standards are designed to assist in
				  developing an organization's planning capability. This section addresses
				  planning in relation to governance, marketing, and health and safety.
Governance:
GOV.1 The agency has governing body bylaws or policies and
				  procedures that reflect how governing body members are recruited and
				  oriented.
GOV.2 The agency has a written mission statement that
				  describes the purpose of the organization and the shared values of the
				  organization's members.
GOV.3 The governing body acts to assure that the agency's
				  operation and management practices are consistent with the purpose and shared
				  values in the mission statement.
GOV.4 The governing body and its committees should meet with
				  a frequency sufficient to carry out their responsibilities effectively.
GOV. 4. A All governing body responsibilities set forth in
				  these standards are met, or the failure to meet governing body standards is not
				  due to an insufficient number of meetings.
GOV. 4. B. The governing body meetings and actions are
				  documented in written minutes.
Interpretive Guideline for GOV.3
Compliance is evaluated using a variety of methods. These
				  methods include, but are not necessarily limited to the following : staff and
				  client interviews, policy, procedure, and meeting minutes review, and
				  compliance with these standards or those established by the agency. Compliance
				  with this standard, to some degree, must be based on surveyor judgment. Since
				  the quality of services is ultimately the responsibility of the governing body,
				  a preponderance of evidence suggesting inadequate attention or support by the
				  governing body may result in citation of non-compliance.
GOV.5 The governing body documents its role, responsibilities
				  and duties in the governance of the agency and its relationship to the
				  management of the agency.
GOV.6 The governing body or a designee shall provide
				  notification in writing to the Division of any major program changes.
Interpretive Guideline for GOV.6
Major program changes include, but are not necessarily
				  limited to the following:
1. The
				addition of new services or deletion of existing services;
2. Serving a population not served by the
				agency previously
3. Significant
				increases or decreases in service capacity as defined by the governing
				body
4. Significant changes in the
				organizational structure as defined by the governing body;
5. Changes in the executive director, name or
				ownership of the agency; or
6.
				Relocation of services.
GOV. 6. A Except under extraordinary circumstances, the
				  governing body will notify the Division at least 30 days before the
				  implementation of any major program change to determine whether any change in
				  licensing status is necessary.
GOV.7 The governing body shall appoint an executive director
				  responsible for the overall operation of the agency.
GOV.7A. The agency has an executive director whose job
				  description reflects responsibility for overall operation of the agency.
GOV. 7. B. The organizational chart indicates a sole
				  directorship.
GOV.8 The Executive Director meets minimum qualifications for
				  his/her position.
GOV. 8. A. The agency has a job description for the executive
				  director position that includes minimum qualifications.
GOV. 8. B. The executive director's personnel file has
				  documented evidence that he/she meets the minimum professional criteria.
GOV.9 The governing body has a mechanism for obtaining
				  clients' input regarding the agency's services.
GOV. 9. A. The agency's governing body has client membership
				  or complies with GOV.9.B.
GOV. 9. B. The agency has a mechanism for obtaining feedback
				  from clients, family members, and guardians that includes a procedure for
				  direct input to the governing body.
GOV. 9. B.1 The governing body minutes reflect consideration
				  of the recommendations' from the agency's client feedback process.
GOV.10 The agency has a policy and procedure regarding
				  conflict of interest that minimally addresses the definition of conflict of
				  interest and the procedures for resolving these issues.
GOV.11 The governing body shall insure that each agency and
				  program is in compliance with the Americans with Disabilities Act (ADA),
				  Section 504 of the Rehabilitation Act and the Maine Human Rights Act (MHRA).
GOV. 11. A. There are no substantiated complaints of
				  violations of the ADA, MHRA or Section 504, including instances of lack of
				  handicapped accessibility. All substantiated complaints will be assessed for
				  the seriousness of the violation and actions taken to achieve
				  compliance.
GOV. 11. A.1. All agencies must notify the Division of
				  complaints pursuant to the above cited laws resulting in a reasonable grounds
				  finding by an external regulatory body (MHRC/EEOC).
GOV. 11. B. The agency has a policy and procedure regarding
				  compliance with the ADA, MHRA and Section 504, including how persons with
				  disabilities may access services.
GOV. 11. C. All existing buildings will receive approval from
				  DMHMR's Affirmative Action Officer for compliance with the ADA and Section 504.
GOV. 11. D. All plans for new buildings or renovation of
				  existing buildings receive. approval from the State Fire Marshal's office or
				  designee for compliance with the ADA and Section 504.
Strategic Planning:
SP.1 The agency has a documented planning process for mental
				  health services based on a periodic analysis of the needs of current and
				  potential clients.
Marketing:
MRK.1 The agency accurately portrays the scope of their
				  licensed mental health services in audio, visual, or printed material by
				  including only those services provided by the agency.
MRK.2 The agency has evidence that its services are
				  publicized.
MRK. 2. A. There is evidence that public information
				  activities have been implemented.
Health and Safety:
HS.1 The agency complies with all applicable health codes.
HS. 1. A. There are no substantiated health code violations.
HS.2 Any agency not using a public water and/or sewer system
				  shall be inspected and approved by the process outlined by the Department of
				  Human Services.
HS. 2. A Any agency without a public water and/or sewer
				  system shall be able to produce a Sanitary Survey report from the approved
				  process of the Health Engineering Division of the Department of Human
				  Services.
HS. 2. B. Any agency without public water and/or sewer system
				  will have Sanitary Surveys conducted as often as required by the Department of
				  Human Services Health Engineering Division regulation.
HS.3 The agency has policies and procedures for managing and
				  controlling infections.
HS. 3. A. The agency has documented evidence that they have
				  implemented policies and procedures regarding the management and control of
				  infections.
Interpretive Guideline for HS.3 and HS.3.A
The management and control of infection has become on of the
				  most serious issues for society, in general, to address. The management staff
				  should determine the extent to which their agency, clients, employees, and
				  others are at risk for acquiring and transmitting infections. Based on this
				  determination, the agency should develop and implement reasonable policies and
				  procedures to manage and control the potential for acquiring or transmitting
				  infections. For example, an inpatient service that commonly treats IV drug
				  users would be expected to have more extensive mechanisms in place for
				  preventing and controlling infections than an outpatient clinic.
HS.4 Agencies shall be inspected by the State Mire Marshal or
				  the Fire Marshal's designee to assure compliance with the NFPA 101 Life Safety
				  Code (current edition).
HS. 4. A Residential facilities have verification of annual
				  fire inspections from the State Fire Marshal or Fire Marshal's designee
				  assuring compliance with NFPA 101 Life Safety Code and safe occupancy.
HS. 4. B. Non-residential programs have biennial letters from
				  the State Fire Marshal or the Fire Marshal's designee assuring compliance with
				  NFPA 101 Life Safety Code and safe occupancy.
HS.5 Quarterly fire drills are conducted and documented for
				  non-residential services and monthly for residential services per NFPA 101 Life
				  Safety Code (current edition).
HS. 5. A. There is documented evidence that the agency is in
				  compliance with fire drill requirements.
Interpretive Guideline for HS.4 through HS.5
Consult the current edition of the NFPA 101 Life Safety Code
				  for requirements in each type of occupancy.
HS.6 The agency has a written disaster and evacuation plan
				  specifying procedures for personnel and designating specific tasks and
				  responsibilities.
HS. 6. A. The agency disaster plan addresses a variety of
				  pertinent disasters, e.g., fires, power outages, storms.
HS. 6. B. The disaster plan addresses staff preparedness,
				  including staff requirements and the designation of roles and functions,
				  particularly in terms of capabilities and limitations.
HS.7 There is documented evidence that staff members receive
				  initial and continuing education concerning disaster and evacuation
				  procedures.
Organizing
Organizing is the manner in which an agency structures itself
				  to accomplish work. It includes establishing lines of authority; specifying
				  work and reporting responsibilities; job design and methods; and coordination,
				  information and feedback systems. This section includes standards on
				  organizational structure, client records, management information systems, and
				  physical plant management.
Organizational Structure:
OS.1 There is a written table of organization that accurately
				  depicts the organization and lines of responsibility for each budgeted position
				  by program category or service type.
Client Records:
REC.1 The agency shall maintain client records in a manner
				  that provides security.
REC. 1. A. Client records are stored in secure areas such as
				  locked file cabinets.
REC. 1. B. Automated record keeping systems have restricted
				  access through access codes or other automated security measures.
REC. 1. B.1 There is a back-up system for all automated
				  client records.
REC. 1. C. The agency has a policy and procedure regarding
				  personnel who are authorized to have access to records that is in compliance
				  with federal, state and local laws.
REC. 1. D. There is a method for documenting when records are
				  accessed and taken from the area where they are stored (i.e., outguides, logs).
				  This method should minimally document the person's name, title or relation to
				  the client, date and time taken and returned.
REC. 1. E. That are no substantiated complaints of breaches
				  of confidentiality that result from improper records management. All
				  substantiated complaints will be assessed for the seriousness of the violation
				  and actions taken to achieve compliance.
REC.2 Client records shall contain identifying information
				  sufficient to describe the client's background, resources, and need for
				  treatment.
REC. 2. A. Records should minimally contain the following
				  information about the client:
REC. 2. A.1 full name;
REC. 2. A.2 address;
REC. 2. A.3 phone number(s);
REC. 2. A.4 date of birth;
REC. 2. 5 gender;
REC. 2. A.6 unique client identifier;
REC. 2. A.7 income and financial resources;
REC. 2. A.8 next of kin or other contact person;
REC. 2. A.9 occupation;
REC. 2. A.10 current school and grade level or highest level
				  achieved;
REC. 2. A.11 family composition;
REC. 2. A.12 marital status
REC. 2. A.13 living arrangement outside the agency, if
				  applicable;
REC. 2. A.14 prescription and over-the-counter medications
				  used previously and currently;
REC. 2A. 15 allergies and drug reactions.
Interpretive Guideline for REC.2.A. through REC.2.A.15
Emergency services shall provide documentation of as many of
				  the above elements as possible.
REC. 2. B When the client is a minor or ward, the record
				  should also include: the name, address and phone number of the legally
				  responsible parent, guardian or custodian.
REC.3 ALL documents or entries in the client record shall be
				  legible, dated and signed by the person making the entry, written in ink or
				  typed, and properly corrected as necessary.
Interpretive Guideline for REC.3
"Properly corrected" is interpreted to mean that errors have
				  voided by crossing out the incorrect entry with one line, writing "void" next
				  to the crossed entry, and initialing and dating the correction. Although
				  writing "error" is acceptable, most attorneys/risk managers suggest that
				  agencies avoid writing "error" in client records. White shall not be used to
				  correct errors in client records.
Signature stamps are only allowed for individuals with
				  handicapping conditions and when a written agency policy and procedure on he
				  use of signature stamps is present.
REC.4 The agency has a documented internal record review
				  process that at periodically determines and improves compliance with these
				  standards and other policies and procedures the agency may develop.
Management Information Systems:
MIS.1 Agencies providing services to AMHI class members will
				  supply data to the Department necessary to meet the Department's obligations
				  under the AMHI Consent Decree.
MIS. 1. A. The agency cooperates in the State's licensing,
				  contract review and quality assurance activities.
MIS.2 There is documented evidence of the client or legal
				  representative's informed consent of releasing data outside the agency except
				  when such release is allowed by law.
MIS. 2. A. The agency will not breach client and family
				  confidentiality through data distribution or deny services due to the refusal
				  of the client to release data. All substantiated complaints will be assessed
				  for the seriousness of the violation and actions taken to achieve
				  compliance.
MIS.3 The agency has a policy and procedure establishing
				  practices that protect the confidentiality of clients when using cellular
				  phones, facsimile machines, automated information systems and/or other
				  technologies that can be used to store, analyze or transmit Information.
MIS.4 The agency has a policy and procedure for granting
				  client, and/or legally responsible party, access to information and/or data
				  maintained internally or transmitted externally that is specific to that
				  particular client.
Physical Plant Management
PHY.1 Agencies assure the personal health, safety, dignity
				  and privacy of clients and strive for provision of services in surroundings in
				  keeping with the needs of the client population.
PHY. 1. A. The agency complies with all Rights of Recipients
				  regulations concerning health, safety, dignity and privacy.
PHY. 1. B. The agency will not violate health, safety,
				  physical plant or client rights regulations.
PHY.2 All grounds, space, equipment, and physical plant shall
				  be in good repair and provisions shall be made, either through staff or
				  contracts, to maintain the facilities.
PHY. 2. A. The grounds, space, equipment, and physical plant
				  are in good repair upon inspection.
PHY. 2. B. There is documented evidence, through staff job
				  descriptions, policies and procedures, or contracts, that both routine and
				  emergency physical plant needs are maintained.
PHY. 2. C. Maintenance and repairs me done according to
				  federal, state, and local safety codes.
PHY.3 The agency assures that all client areas within their
				  organization are provided with appropriate furnishings.
PHY. 3. A. Furnishings are appropriate to the ages and
				  physical condition of the clients.
PHY. 3. B. Furnishings are structurally designed and
				  maintained to promote a comfortable and safe environment.
PHY. 3. C. Furnishings are available and conducive to their
				  purpose and function.
PHY. 3. D. Furnishings are clean and in good repair.
PHY.4 The agency assures that staff-client, staff-family, and
				  client case communications are conducted in a confidential manner and
				  environment.
Interpretive Guideline for PHY.4
Staff-client communications and/or client case discussions
				  are conducted in an area that assures confidentiality (a separated space or a
				  sound-masked area).
PHY. 4. A. There are no substantiated cases of breaching
				  client confidentiality.
Staffing
Staffing as used in this context is another word for human
				  resource management. It describes a wide range of activities, programs and
				  policies related to acquisition and retention of human resources. This section
				  includes standards on human resource management and volunteers and
				  students.
Human Resource Management:
HRM.1 The agency has written documentation that each person's
				  duties, responsibilities and performance expectations are clearly communicated
				  upon hire.
HRM.2 Staff members meet minimum qualifications for their job
				  as cited in their job description.
HRM. 2. A. Each position in the organization has a job
				  description that minimally contains the:
HRM. 2. A.1 title;
HRM. 2. A.2 supervisor;
HRM. 2. A.3 supervisees;
HRM. 2. A.4 duties and responsibilities; and
HRM. 2. A.5 minimum education, training and experience
				  qualifications
HRM.3 The agency has a policy and procedure that addresses
				  the mechanism by which all employees have access to, or receive a copy of, the
				  personnel policies and procedure,
HRM. 3. A. The agency documents that each employee has
				  reviewed or received a copy of the personnel policies and procedures by way of
				  signature in the employee's personnel file.
Interpretive Guideline for HRM.3.A
Documentation may include a form indicating the employee has
				  reviewed policies/procedures, the distribution of personnel policy handbooks,
				  etc.
HRM.4 The agency has policies and procedures for the
				  recruitment, selection, and retention and promotion of employees, volunteers,
				  and students.
HRM.5 The agency has a policy and procedure establishing
				  practices for the termination or temporary layoff of employees, including
				  provision for notification of the employee and mechanisms for appeal.
HRM.6 The agency has a policy and procedure concerning
				  employee grievances that includes notifying employees of the procedure and
				  maintaining confidential communications and records.
HRM.7 Each employee, student and volunteer has a personnel
				  record.
HRM. 7. A. The agency has a policy and procedure concerning
				  maintaining personnel records for each employee, student or volunteer.
HRM. 7. B. Personnel records should be maintained similarly
				  and contain documentation pertinent to the employee's, student's or volunteer's
				  work, supervision and training.
HRM.8 Each personnel file contains information documenting
				  and verifying the positions held by the employee, volunteer or student and
				  their qualifications and experience.
HRM. 8. A. Each employee,, volunteer or student's personnel
				  record minimally contains the following:
HRM. 8. A.1 job description;
HRM. 8. A.2 copies of appropriate licenses and
				  certifications
HRM. 8. A.2.a this will include either licensure as a mental
				  health professional in the state of Maine, certification by the Bureau of
				  Mental Health or Bureau of Children with Special Needs as an Other Quality
				  Mental Health Professional, or certification by the HRD program as an MHRT;
HRM. 8. A.3 copies of diplomas, transcripts or documentation
				  of verbal verification from the school officials citing date and school
				  official contacted;
HRM. 8. A.4 records of continuing education and training
Interpretive Guideline for HRM.8.A.4
Continuing education or training records may be in the form
				  of certificates noting date, title of training, number of hours or CEU's or
				  other listings of training received with content, date, presenter and length of
				  training documented. Although documenting all training in the personnel record
				  is preferred, documentation of training received within the organization may be
				  kept in alternative records, e.g., training log.
HRM. 8. A.5 documentation regarding the individual's criminal
				  abuse history (e.g., checking with SBI, DHS).
HRM. 8. A.5.a If checks with SBI or DHS produce information
				  regarding an employee, the agency will document in the personnel file its
				  assessment of the seriousness of the information provided and take appropriate
				  actions if indicated.
HRM.9 An individual's need for training and continuing
				  education is assessed with the individual's participation and documented within
				  6 months of hire or job change and at least annually thereafter.
HRMA.10 All employees, students and volunteers are given a
				  copy of the Rights of Recipients (Adult and/or Children as appropriate).
HRM. 10. A There is documented evidence that all employees,
				  students and volunteers review the Rights of Recipients (Adult and/or
				  Children's editions) before commencing the duties of their job and when there
				  is a change in the Rights regulations.
Interpretive Guideline for HRM.10.A.
Documented evidence may be statement or other documentation,
				  signed and dated by the employee, student or volunteer that confirms that they
				  have reviewed the Rights of Recipients (Adult and/or Children's
				  editions).
HRM.11 The agency has policies mad procedures on access to
				  personnel files that minimally include: the employee's right to access,
				  protection of confidential information, secure storage, making record entries,
				  and distribution of information upon staff request.
HRM. 11. A. The agency has policies and procedures that
				  minimally address the following personnel records issues:
HRM. 11. A.1 who in addition to the employee, has access to
				  personnel records;
HRM. 11. A.2 how confidential personnel information is
				  protected;
HRM. 11. A.3 how personnel records are securely
				  stored;
HRM. 11. A.4 who in addition to the employee may enter
				  information into the personnel records; and
HRM. 11. A.5 how and to whom information from personnel
				  records may be disseminated.
HRM.12 The agency has a policy and procedure that addresses
				  when a personnel record is considered inactive and what practices are followed
				  in its disposal to assure the employee's confidentiality.
HRM.13 The agency has documented processes for addressing
				  employee issues, including policies and procedures on employee recognition,
				  supervision and discipline.
HRM.14 The agency is an Equal Opportunity Employer.
HRM. 14. A. The governing body establishes and adheres to
				  policies and procedures that provide for periodic review and approval of the
				  personnel policies for compliance with federal, state and local laws.
Interpretive Guideline for HRM.14.A
The definition of "periodic review" is determined by the
				  governing body and is the basis upon which compliance will be determined by
				  licensing staff. Failure to define periodic review will result in a citation
				  for this standard.
HRM. 14. B. The agency shall follow personnel policies and
				  procedures as required by federal, state or local laws. All substantiated
				  complaints will be assessed for the seriousness of the violation and actions
				  taken to achieve compliance.
HRM. 14. C All agencies must notify the Division of
				  discrimination complaints resulting in a reasonable grounds finding by an
				  external regulatory body (MHRC/EEOC).
HRM. 14. D. The agency has received approval from the
				  Department's Affirmative Action Officer as an Equal Opportunity Employer.
HRM.15 Each employee's job performance shall be evaluated on
				  at least an annual basis based upon performance criteria established for the
				  position.
HRM. 15. A. Each employee's personnel files shall contain a
				  copy of that employee's performance evaluation.
Volunteers and Students:
VS.1 Individuals who work as volunteers for the agency or who
				  are students shall be clearly identified by title as volunteers or
				  students.
VS.2 Student supervision shall include documenting in their
				  personnel record contact with the person at the school who is supervising the
				  student's educational progress.
Interpretive Guideline for VS.2
If the school does not designate a liaison, documentation of
				  this should be placed in the student's personnel record.
VS.3 Students or volunteers are supervised by individuals
				  with licensure, certification, or experience in an area germane to the work
				  assigned.
Directing
Directing is a management function that attempts to
				  facilitate or initiate action within an agency. Activities of directing
				  generally involve interpersonal aspects of management such as motivation,
				  leading, communicating, conflict resolution, and change management. This
				  section includes standards on staff development and supervision.
Staff Development:
SD.1 The agency has an orientation program that is in place
				  for all new employees that assures that each new employee receives specific
				  information relevant to their duties and the organization.
SD. 1. A. The agency has an orientation program for new
				  employees that minimally provides training in the following areas:
SD. 1. A..1 The Rights of Recipients (Adult and/or Children's
				  current editions);
SD. 1. A..2 the identification, response and reporting of
				  abuse, neglect, and exploitation;
SD. 1. A..3 the employee's specific job responsibilities;
SD. 1. A..4 the agency's mission, philosophy, clinical and
				  other mental health services;
SD. 1. A..5 the agency's service and therapeutic modalities
				  designed to facilitate health, growth, and recovery;
SD. 1. A.6 the client and family's right to privacy and
				  confidentiality;
SD. 1. A..7 the physical intervention techniques used, if
				  applicable;
Interpretive Guideline for SD.1.A.7
The determination of the need for training in physical
				  intervention techniques shall be based upon a documented assessment of the
				  client's potential for and history of assaultivness. Agencies that do not
				  provide training in physical intervention techniques must be able to document
				  compelling evidence that physical intervention training is unnecessary.
SD. 1. A.8 safety/emergency procedures;
SD. 1. A.9 infection control and prevention;
SD. 1. A.10 the terms of the AMHI Consent Decree, as
				  applicable;
SD. 1. A.11 the perspectives and values of clients of mental
				  health services conducted by a consumer of mental health services.
Interpretive Guideline for SD.1.A.11
For children service agencies, the perspectives and values of
				  families are addressed. Children service agencies may also have a family member
				  provide this orientation.
SD. 1. A. 12 the individual community support planning
				  process, if applicable;
SD. 1. A.13 the mental health service system;
SD. 1. A.14 the family support services;
SD. 1. A.15 the role state and private psychiatric hospitals
				  play in relation to the agency;
SD. 1. A.16 adverse reactions to psychoactive medications, if
applicable;
SD. 1. A.17 child development and children's educational
				  needs for staff
who work with children and/or adolescents;
SD. 1. A.18 for staff working with individuals over the age
				  of 60, psychogeriatrics and communication techniques with elderly persons; and
SD. 1. A.19 training in the inter-relationship of
				  co-occurring conditions and referral and treatment processes for staff members
				  who work with individuals with co-occurring conditions.
SD. 1. B. Each staff member completes orientation within 60
				  days of hire
Interpretive Guideline for SD.1.B *
Allowances will be made for individuals receiving Mental
				  Health Rehabilitation Technician training I through IV.
SD. 1. C. New employees shall not be assigned to duties
				  requiring direct involvement with clients until the italicized topics above
				  have been completed.
SD.2 The agency plans for and provides ongoing training and
				  technical assistance to improve staff performance.
SD. 2. A. There is an agency staff development plan
				  formulated annually which highlights areas for training on issues pertinent to
				  the service(s) offered by the agency.
SD. 2. B There is documented evidence that ongoing training
				  and continuing education is conducted and is based on areas assessed in HRM.9.
SD.3 There is documented evidence that mental health staff
				  employed 20 or more hours a week participate in at least 20 hours of training
				  annually and/or maintain the number of training hours required by their
				  licensure, whichever is greater.
SD.4 There is documented evidence that mental health staff
				  employed fewer than 20 hours per week minimally receive annual training in the
				  following areas:
SD. 4. A. the results of the assessment required in HRM.9;
				  and
SD. 4. B. the new agency policies and practices pertinent to
				  the individual's role.
Supervision
SUP.1 The agency has evidence that it provides administrative
				  supervision to each employee, student and volunteer.
SUP.2 The agency has written policies and procedures on the
				  provision of clinical supervision or consultation to each individual with
				  clinical responsibilities.
Interpretive Guideline for SUP.2
Minimum supervision/consultation requirements are one hour
				  consultation per month for those licensed to practice independently and 4 hours
				  per month for practitioners not licensed to practice independently or the
				  amount of supervision required by their professional licensing authority
				  (whichever is greater). For independent practitioners consultation can include
				  case reviews and team meeting in which the individual is not acting in a
				  supervisory capacity.
SUP.3 Clinical supervisors are trained to provide supervision
				  as evidenced by documentation of supervision training and licensure or
				  certification germane to the supervision of the service provided.
Controlling
Controlling is the management function that measures,
				  monitors, and regulates the agency's activities and resources. These activities
				  are usually based on established standards for measuring results as well as
				  methods for taking corrective action or instituting improvements. This section
				  includes standards on quality, risk, utilization, financial, and contract
				  management.
Quality Management
Quality management is broadly defined as management
				  philosophies and behavioral and statistical tools aimed at improving quality,
				  customer satisfaction, and profitability. Although all effective quality
				  management processes have distinct similarities, each agency must adopt quality
				  management principles and practices that are sensitive to their organizational
				  culture and effective in their particular setting. For this reason, the
				  Department and the Division of licensing does not espouse one particular model
				  of quality management. Therefore, the first four standards in this section
				  relate to an agency's ability to demonstrate that they have an ongoing and
				  effective quality management process that is customer-focused and strives for
				  customer satisfaction.
QM.1 The agency has a written plan that addresses how the
				  organization currently monitors, evaluates and improves quality.
QM.2 The agency can demonstrate that it identifies, monitors,
				  and attempts to Improve areas deemed to be critical to quality client
				  care.
QM.3 There is documented evidence that quality management
				  activities are conducted on an ongoing and regular basis.
QM.4 The effectiveness of quality management is assessed and
				  documented at least annually and involves Input from clients, family members,
				  guardians, client representatives, staff, and referral sources.
QM.5 The agency shall have, available for review, insurance
				  policies citing professional and commercial liability coverage for the
				  organization, staff, volunteers, and students.
QM.6 The agency has a policy and procedure regarding the
				  reporting and recording of adverse and potentially adverse occurrences,
				  including the recording of complaints.
QM. 6. A. Reports of adverse and potentially adverse
				  occurrences will be evaluated for the need for follow-up actions and
				  opportunities for improvements in agency management and/or service delivery.
QM. 6. A.1 In such instances, follow-up actions will be
				  documented.
QM. 6. A.2 The agency shall have a policy and procedure for
				  reporting allegations of abuse, neglect and exploitation of clients in
				  accordance with the requirements of the Adult and Child Protection laws.
Interpretive Guideline for QM.6
Some examples of adverse or potentially adverse occurrences
				  include, but are not necessarily limited to:
1. deaths;
2. injuries;
3. violations of agency policies; and
4. violations of clients rights
QM.7 Each agency has a process for monitoring and evaluating
				  the appropriateness of admission to or initiation of service and the provision
				  of continued service to the client, based on admission and continued service
				  criteria.
QM. 7. A. The agency has admission or service initiation
				  criteria and continued service criteria that are used in reviewing each case
				  upon admission or initiation of service and regularly thereafter to assure the
				  delivery of services/care in a least restrictive environment.
QM. 7. B. Individuals are not inappropriately admitted or
				  served in an agency, service or soling.
QM.8 The agency has a process for documenting clients' needs
				  and determining how well the organization's services meet those needs.
QM.9 The agency shall report immediately to the Division any
				  legal proceedings arising out of circumstances related to providing mental
				  health services.
Interpretive Guideline for QM.9
Agencies must immediately provide a verbal report to the
				  Division once the agency is legally served notice of legal proceeding. Written
				  notice must be received within 3 working days following receipt of verbal
				  reports. Some examples of legal proceeding that should be reported include, but
				  are not necessarily limited to the following:
1. bankruptcy;
2. professional licensing body
				sanctions;
3.
				discriminations;
4. lawsuits;
				and
5. criminal activity by a staff
				member(s) that has implications for the programmatic and/or fiscal integrity of
				the agency and the safety of its clients.
QM.10 The agency shall post the original current license
				  issued by the Department in a clearly visible place within the central facility
				  and copies in all branch locations.
Interpretive Guideline for QM.10
Residential facilities may post the license in an office area
				  of the residence or similar inconspicuous location.
QM.11 The agency can demonstrate compliance with all client
				  rights regulations as stated in the current edition of the Rights of Recipients
				  (Adult and/or Children's Services editions).
QM. 11. A. The agency will have a policy and procedure
				  establishing the means by which compliance with the Rights of Recipients will
				  be achieved.
QM. 11. B. All substantiated complaints of violations of the
				  Rights of Recipients will be assessed for the seriousness of the violation and
				  actions taken to achieve compliance.
Financial Management:
FM.1 The governing body is responsible for insuring the
				  establishment and maintenance of sound fiscal practices as evidenced by the
				  development and periodic review of policies regarding the fiscal practices of
				  the agency.
FM. 1. A. The governing body reviews the financial status of
				  the agency on a periodic basis, and minimally reviews the agency's annual audit
				  and approves the annual budget.
Interpretive Guideline for FM.1 and FM.1.A
"Periodic is to be defined by the governing body. The
				  organization will be evaluated on :
1.
				the existence of fiscal policies and procedures;
2. compliance with the governing body's
				requirement for policy development and periodic policy review; and
3. the minimum review and approval activities
				cited in FM.1.A
FM.2 Where fees are charged, a schedule of fees for services
				  and policies concerning collection of fees shall be made available to each
				  client or their legally responsible party or posted in the facility for public
				  view.
FM. 2. A. There is a documented fee schedule.
FM. 2. B. When the fee schedule is not posted for public
				  view, there is documented evidence that clients and/or the legally responsible
				  party have received notification of the fee schedule.
FM.3 Agencies will have documented annual audits from an
				  independent certified public accountant verifying that generally accepted
				  accounting practices are being maintained.
Interpretive Guideline for FM.3
The agency must contact the Division for written approval of
				  alternative auditing mechanisms.
Contract Management:
CM.1 Agencies that have a contract with a bureau of the
				  Department of Mental Health and Mental Retardation must be in compliance with
				  this contract as measured by the contracting
				  bureau.