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

Current through 2024-29, July 17, 2024
The following standards constitute all the requirements for
				  the operation of social clubs. By their very nature, social clubs demand
				  special consideration in terms of regulation. Due to this fact, social clubs
				  are the only service that need not comply with the generic standards section of
				  these regulations. Select standards from the core generic standards have been
				  modified and included in the standards below. In addition, a social club task
				  force has developed and included social club-specific requirements.
Access
SC.1 Each club shall have in effect a transportation plan
				  that assures accessibility to the club.
SC.1.A. The agency documents and takes steps to implement a
				  transportation plan that is directed toward assuring reasonable accessibility
				  to all services.
SC.2 The social club will have a process of determining
				  sufficient hours of operation which places a priority on the needs of the
				  members.
SC.2.A. Documentation of the process for determining the
				  hours is available for review.
SC.2.B. Documentation exists that the needs of the members
				  are reviewed annually.
SC.2.C. The club documents what alternative solutions are
				  explored if the need for extended hours requested by the members is limited in
				  any way.
SC.3 The club has documented evidence of membership criteria
				  that minimally includes people with mental illness.
Interpretive Guideline for SC.3
Self report of eligibility is sufficient for
				  membership.
SC.4 Membership will not be denied based on inability to pay
				  dues.
SC.4.A. No individuals will be refused membership due to
				  inability to pay dues. All substantiated complaints will be assessed for the
				  seriousness of the violation and actions taken to achieve compliance.
SC.5 The social club applies its eligibility criteria equally
				  and consistently to all members.
SC.5.A. Eligibility criteria will be consistently applied in
				  all instances. All substantiated complaints will be assessed for the
				  seriousness of the violation and actions taken to achieve compliance.
SC.6 There is no discrimination based upon race, color,
				  religion, age, national origin, gender, ancestry, physical or mental handicap,
				  sexual preference, or socioeconomic status.
SC.6.A. There are no substantiated complaints regarding
				  discrimination. All substantiated complaints will be assessed for the
				  seriousness of the violation and actions taken to achieve compliance.
SC.7 The club has a policy and procedure that explains what
				  resources will be used or what efforts will be made to assure that club
				  activities and information are available in the language chosen by the club
				  member or potential club member.
SC.7.A. There are no substantiated complaints by club members
				  or potential club members citing unavailability of activities or information in
				  their language of preference. All substantiated complaints will be assessed for
				  the seriousness of the violation and actions taken to achieve
				  compliance.
SC.8 The consumer board or governing body shall ensure that
				  each social club is in compliance with the Americans with Disabilities Act
				  (ADA), Section 504 of the Rehabilitation Act and the Maine Human Rights Act
				  (MRHA).
SC.8.A. There are no substantiated complaints regarding
				  violation of the ADA, MHRA, or Section 504, including lack of handicapped
				  accessibility. All substantiated complaints will be assessed for the
				  seriousness of the violation and actions taken to achieve compliance.
SC.8.A..1 Social clubs 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).
SC.8.B. The social club has policies and procedures regarding
				  compliance with the ADA, MHRA and Section 504 including how persons with
				  disabilities may access services.
SC.8.C. All plans for new buildings or renovation of existing
				  buildings receive approval from the State Fire Marshal's office or designees
				  for compliance with the ADA and Section 504.
SC.8.D. All existing buildings will receive approval from
				  DMHMR's Affirmative Action Officer for compliance with the ADA and Section 504.
Club Member Records
SC.9 The club shall maintain club member records in a manner
				  that provides security.
SC.9.A. Club records are stored in secure areas such as
				  locked file cabinets.
SC.9.B. Automated record keeping systems have restricted
				  access through access codes or other automated security measures.
SC.9.B.1. There is a back-up system for all automated club
				  member records.
SC.9.C. The club 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.
SC.9.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 club member, date and time taken and returned.
SC.9.E. There are no instances 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.
SC.10 Social clubs have a policy and procedure on what
				  documentation is to be maintained in club member records.
SC.11 Social clubs maintain club member records per club
				  policy and procedure.
Interpretive Guideline for SC.10
Documents that would be expected to be found in a club member
				  record include, but are not necessarily limited to, the following: application,
				  emergency contact, incident reports, verification that club member was notified
				  of club rules.
SC.12 All documents or entries in the member's record shall
				  be legible, dated and signed (including full name) by the person making the
				  entry, written in ink or typed, and properly corrected as necessary.
Club Member Rights
SC.13 Social clubs comply with Section A of the Rights of
				  Recipients of Mental Health Services.
Social Club Management
SC. 14. Each social club will have a consumer board made up
				  of and elected by the social club membership.
SC.14.A. If the social club is a freestanding agency, the
				  governing body will be elected by the social club membership and will be
				  responsible for compliance with all of the standards in this section. For the
				  purposes of this section, "governing body" will be referred to as "consumer
				  board".
SC.14.B. If the social club is a part of a larger
				  organization, the club will have a consumer board elected by the social club
				  membership and will be responsible for compliance with all of the standards in
				  this section.
SC.15. If the social club is part of a larger organization,
				  the consumer board will be vested with authority for the operation and
				  day-to-day management of the social club.
SC.16. The social club consumer board develops bylaws that
				  address the needs and desires of the membership.
SC.17. The social club consumer board develops documented
				  rules, policies and procedures necessary for the ongoing daily operation of the
				  social club.
SC. 17. A.. The social club rules, policies and procedures
				  will minimally include the following:
SC. 17. A.1. a written mission statement, written by the
				  consumer board or governing body, describing its purpose, the activities it
				  provides and its accessibility and that is reviewed on at least an annual
				  basis;
SC. 17. A.2. a planning process that bases its short and long
				  term goals and objectives for activities on a periodic analysis of the wants
				  and needs of current or potential members;
SC. 17. A.3. a policy and procedure regarding conflict of
				  interest that minimally addresses the definition of conflict of interest and
				  the procedures for resolving these issues; and
SC. 17. A.4. documented criteria and process for suspension
				  of members which should be limited to threats, criminal activity and violent or
				  abusive behavior to self, others or property and which will adhere directly to
				  the "right to due process" with regard to grievances as stated in the Rights of
				  Recipients of Mental Health Services.
SC. 17. A.4.a. There is documented evidence that the rules
				  and suspension criteria are reviewed with each member.
SC. 17. A.4.b. The club will document that members who have
				  been suspended are given the opportunity to engage in the development of a
				  re-entry plan with an authorized representative of the club.
SC. 17. A.4.b.1. All reentry plans will clearly delineate the
				  responsibilities of the re-entering member and the club.
SC.18. The club rules are fairly applied and administered by
				  the consumer board or governing body.
SC. 18. A. There are no substantiated complaints regarding
				  unfair application or administration of rules by the consumer board or
				  governing body. All substantiated complaints will be assessed for the
				  seriousness of the violation and actions taken to achieve compliance.
SC.19. If the social club is part of a larger organization,
				  there will be documented evidence of governing body receipt and consideration
				  of the consumer board's input regarding issues and concerns raised by the
				  consumer board and club members.
SC.20. The social club has an organizational chart that
				  defines the lines of authority and responsibility for each position.
SC.21. The social club shall post the original, current
				  license issued by the Department.
SC.22. The social club shall report immediately to the
				  Division, any legal proceedings arising out of circumstances related to the
				  social club.
SC.23. The social club management will provide ongoing and
				  appropriate training to develop and support members as leaders and promote
				  member leadership.
Marketing
SC.24. The social club accurately portrays the scope of their
				  activities in audio, visual, or printed materials.
SC.25. The social club has evidence that its activities are
				  publicized.
SC.25.A. There is evidence that public information activities
				  have been implemented.
Financial Management
SC.26. 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.
SC.26.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.
SC.27. 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.
SC.27.A. 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.
Interpretive Guideline for SC.26 through SC.26.A
"Periodic is to be defined by the governing body. the club
				  will be evaluated on:
1. the existence
				of fiscal policies and procedures;
2. compliance with the governing body's
				requirements for policy development and periodic policy review; and
3. the minimum review and approval activities
				cited in SC.26.A.
SC.28. Social clubs will have documented annual audits from
				  an independent Certified Public Accountant verifying that generally accepted
				  accounting practices are being maintained.
I
Interpretive Guideline for SC.28
The club must contact the Division for written approval of
				  alternative auditing mechanisms.
SC.29. The social club complies with all applicable health
				  codes.
SC.29.A. There are no substantiated health code
				  violations.
SC.29.B. The social club complies with all health standards
				  in this section.
SC.30. Any social club not using a public water and/or sewer
				  system shall be inspected and approved by the Department of Human
				  Services.
SC.30.A. Any social club without a public water and/or sewer
				  system shall be able to produce a Sanitary Survey report from the Health
				  Engineering Division of the Department of Human Services.
SC.30.B. Any social club without public water and/or sewer
				  system will have Sanitary Surveys conducted at least every 3 years per
				  Department of Human Services Engineering Division regulation.
SC.31. The social club has policies and procedures for
				  managing and controlling infections.
SC.31.A. The social club has documented evidence that they
				  have implemented policies and procedures regarding the management and control
				  of infections.
Interpretive Guideline for SC.31 and SC.31.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.
SC.32. Social clubs shall be inspected by the State Fire
				  Marshal or the Fire Marshal's designee to assure compliance with the NFPA 101
				  Life Safety Code (current edition).
SC.32.A. Social clubs 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.
SC.33. Quarterly fire drills are conducted and documented for
				  non-residential services and monthly for residential services per NFPA 101 Life
				  Safety Code (current edition).
SC.33.A. There is documented evidence that the agency is in
				  compliance with fire drill requirements.
Interpretive Guideline for SC.32 through SC.33
Consult current edition of NFPA 101 Life Safety Code for
				  requirements in each type of occupancy.
SC.34. The agency has a written disaster and evacuation plan
				  specifying procedures for personnel and designating specific tasks and
				  responsibilities.
SC.34.A. The agency disaster plan addresses a variety of
				  pertinent disasters (e.g., fires, power outages, storms).
SC.34.B. The disaster plan addresses staff preparedness,
				  including staff requirements and the designation of roles and functions,
				  particularly in terms of capabilities and limitations.
SC.35. There is documented evidence that staff members
				  receive initial and continuing education concerning disaster and evacuation
				  procedures.
Human Resource Management
SC.36. The social club has written documentation that each
				  person's duties, responsibilities and performance expectations are clearly
				  communicated upon hire.
SC.37. Staff members meet minimum qualifications for their
				  job as determined by the requirements of the Division of Public
				  Education.
SC.38. Each position in the organization has a job
				  description.
SC.38.A. Job descriptions minimally include the
				  following:
SC.38. A.1 title;
SC.38.A.2 supervisor;
SC.38.A.3 supervisees;
SC.38.A.4 duties and responsibilities; and
SC.38.A.5 minimum education, training and experience
				  qualifications
SC.39. The social club 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 procedures.
SC.39.A. The social club 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 SC.39.A
Documentation may include a form indicating the employee has
				  reviewed policies/procedures or the distribution of personnel policy,
				  handbooks, etc.
SC.40. The social club has policies and procedures for the
				  recruitment, selection, and retention and promotion of employees, volunteers,
				  and students.
SC.41. The social club has a policy and procedure
				  establishing practices for the termination or temporary layoff of employees,
				  including provision for notification or the employee and mechanisms for
				  appeal.
SC.42. The social club has a policy and procedure concerning
				  employee grievances that includes notifying employees of the procedure and
				  maintaining confidential communications and records.
SC.43. Each employee, student and volunteer has a personnel
				  record.
SC.43.A. The social club has a policy and procedure
				  concerning maintaining personnel records for each employee, student or
				  volunteer.
SC.43.B. Personnel records should be maintained similarly and
				  contain documentation pertinent to the employee's, student's or volunteer's
				  work, supervision and training.
SC.44. Each personnel rile contains information documenting
				  and verifying the positions held by the employee, volunteer or student and
				  their qualifications and experience.
SC.44.A. The personnel record minimally contains the
				  individual's:
SC.44.A.1 job description;
SC.44.A.2 copies of appropriate licenses and
				  certifications;
SC.44.A.3 copies of the employee's diplomas, transcripts or
				  documentation of verbal verification from the school officials citing date and
				  school official contacted;
SC.44.A.4 records of employee continuing education and
				  training
Interpretive Guidelines for SC.44.A.4
These record of training may be the form of certificates
				  noting date, title of training, number of hours of CEU's or other listing of
				  training received with content, date, presenter and length of training
				  documented.
SC.45. 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 last annually thereafter.
SC.46. All employees, students and volunteers are given a
				  copy of the Rights of Recipients (Adult and/or Children as appropriate).
SC.46.A There is documented evidence that all employees,
				  students and volunteers review the applicable sections of 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 SC.46.A
Documented evidence may be a statement of other
				  documentation, signed and dated by the employee, student or volunteer that
				  confirms that they have reviewed the Rights of Recipients (Adult and/or Child
				  edition's).
SC.47. The social club has policies and procedures on access
				  to personnel riles that minimally include the following: the employee's right
				  to access, protection of confidential information, secure storage, making
				  record entries, and distribution of information upon staff request.
SC.47.A. The social club has policies and procedures that
				  minimally address the following personnel records issues:
SC.47.A.1 who in addition to the employee, has access to
				  personnel records;
SC.47.A.2 how confidential personnel information is
				  protected;
SC.47.A.3 how personnel records are securely stored;
SC.47.A.4 who in addition to the employee may enter
				  information into the personnel records; and
SC.47.A.5 how and to whom information from personnel records
				  may be disseminated.
SC.48. The social club 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.
SC.49. The social club has documented processes for
				  addressing employee issues, including policies and procedures on employee
				  recognition, supervision, and discipline.
SC.50. The social club is an Equal Opportunity
				  Employer.
SC.50.A. The governing body or consumer board 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 SC.50.A
The definition of "periodic review" is determined by the
				  governing body. compliance with this standard and the subsequent standard
				  (SC.53.A.1) depend on the definition.
SC.50.B. The social club will follow personnel policies and
				  procedures as required by federal, state or local laws in all instances.
SC.50.C All social clubs must notify DMHMR of discrimination
				  complaints resulting in a reasonable grounds finding by an external regulatory
				  body (MHRC/EEOC.
SC.50.D. The social club has received approval from DMHMR
				  Affirmative Action Officer as an Equal Opportunity Employer.
Volunteers and Students
SC.51. Individuals who work as volunteers for the agency or
				  who are students shall be clearly identified by title as students or
				  volunteers.
SC.52. Student supervision shall include documenting in their
				  personnel record, contact with the person supervising the student's educational
				  progress.
Interpretive Guideline for SC.52
If the school does not designate a liaison, documentation of
				  this should be placed in the student's personnel record.
SC.53. Students or volunteers are supervised by' individuals
				  with licensure, certification, or experience in an area germane to the work
				  assigned.
Supervision
SC.54. The social club shall develop and maintain clear lines
				  of supervision by assuring that each employee, student and volunteer has a
				  supervisor.
SC.54.A. The social club has a table of organization that
				  clearly indicates lines of supervision within the club and if applicable, how
				  the club staff relate to a larger agency.
SC.55. The social club has a policy and procedure and
				  documented evidence that ongoing supervision is provided for employees,
				  students, and volunteers.
SC.56. All supervisory personnel will have documented
				  evidence in their personnel records of training in supervision.
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 no espouse one particular model
				  of quality management. Therefore, the 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.
SC.57. The agency has a written plan that addresses how the
				  organization currently monitors, evaluates and improves quality.
SC.58. The agency can demonstrate that it identifies,
				  monitors, and attempts to improve areas deemed to be critical to quality client
				  care.
SC.59. There is documented evidence that quality management
				  activities are conducted on an ongoing and regular basis.
SC.60. 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.
SC.61. The agency shall have, available for review, insurance
				  policies citing professional and commercial liability coverage for the
				  organization, staff, volunteers, and students.
SC.62. The agency has a policy and procedure regarding the
				  reporting and recording of adverse and potentially adverse occurrences,
				  including the recording of complaints.
Interpretive Guideline for SC.62
Some examples of adverse or potentially adverse occurrences
				  include, but are not limited to the following:
1. deaths;
2. injuries;
3. violations of agency policies;
				and
4. violations of clients
				rights.