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

Current through 2024-29, July 17, 2024
This section of the core standards addresses the clinical
				  management processes deemed to be critical in providing care or services to the
				  client.
Access
AC.1 Each agency facility shall have in effect a
				  transportation plan that assures accessibility to services.
AC. 1. A The agency documents and takes steps to implement a
				  transportation plan that is directed toward assuring reasonable accessibility
				  to all services,
AC.2 Service hours of the agency and the means for accessing
				  services outside of normal business hours are clearly defined at each service
				  site and in literature distributed to the public.
Interpretive Guideline for AC.2
"Normal business hours" are interpreted to mean Monday
				  through Friday for an 8 hour period some time between the hours of 8:00am and
				  5:00 pm. Agencies that do not provide access to services outside of normal
				  business hours must be able to produce compelling evidence as to why these
				  service hours are not necessary or possible. Agencies that do not provide
				  access to services outside of normal business hours must be able to produce
				  compelling evidence as to shy these service hours are not necessary possible.
AC. 2. A. All substantiated complaints regarding
				  accessibility to services will be assessed for the seriousness of the violation
				  and actions taken to achieve compliance.
AC.3 The agency has a mechanism for providing services in the
				  language chosen by the applicant or client.
AC. 3. A Services will be made available to all potential
				  clients in their language of preference. All substantiated complaints will be
				  assessed for the seriousness of the violation and actions taken to achieve
				  compliance.
AC.4 No individual may be denied access to services solely on
				  the basis of having a known substance use/abuse disorder in addition to his/her
				  mental illness.
AC. 4. A. The agency shall develop and maintain a written
				  protocol or policy that describes its service approach to individuals with
				  co-occurring mental illness and substance abuse disorders.
AC.5 Agencies shall insure that clients are not denied access
				  to services based solely upon the clients' refusal of any other service.
Client Rights
CR.1 At the request of the client,, or the legally
				  responsible party, the agency will arrange for a second opinion to be offered
				  by another practitioner from within the agency, who is mutually agreed upon by
				  the client or legally responsible party and the agency.
CR. 1. A. The agency has a documented policy and procedure
				  describing the process for seeking second opinions that minimally addresses who
				  notifies the client of this right and who documents the request and actions
				  taken in the client record.
CR. 1. B Second opinion requests and actions the agency takes
				  as a result are documented in the client's record. Second opinion record
				  entries minimally include:
CR. 1. B.1 the date of the request;
CR. 1. B.2 the reason for the request;
CR. 1. B.3 the actions taken by the agency as a result of the
				  request
CR. 1. C. The practitioner(s) offering the second opinion
				  document in the client record the date they conducted their assessment, their
				  findings, conclusions, and recommendations.
Interpretive Guideline for CR.1.C
It is expected that the practitioner(s) offering the second
				  opinion will minimally see the client in person and review their record.
CR.2 When a client or legally responsible party requests and
				  agrees to pay the cost of a second opinion, the agency does not impede the
				  right to seek a second opinion from a practitioner of his/her choice and does
				  not terminate the client solely because of seeking this second opinion.
CR. 2. A. An agency will not impede the right of, or
				  terminate services to clients seeking a second opinion. All substantiated
				  complaints will be assessed for the seriousness of the violation and actions
				  taken to achieve compliance.
CR.4 Only staff who have completed training in physical
				  intervention shall implement physical intervention techniques.
Treatment and Care Processes
Preliminary Screening:
SCR.1 The agency determines an applicant's eligibility for
				  services through a timely preliminary screening process that assesses the
				  applicant's appropriateness for services based on the service's admission or
				  intake criteria.
SCR. 1. A. An eligibility screening is conducted and
				  documented for each applicant.
SCR. 1. B. The documented screening contains a determination
				  of the applicant's appropriateness for services.
SCR. 1. C. Eligibility criteria and screening processes for
				  all programs and services will be in compliance with the requirements of
				  GOV.11.
Interpretive Guideline for SCR.1
Preliminary screening will not trigger the time-limited
				  documentation requirements, e.g., assessment, service plan, that begin with
				  initiation of service, unless otherwise required by agency policy.
SCR.2 The agency has documented admission or intake policies
				  and procedures that assure thorough evaluation of each applicant's eligibility.
SCR. 2. A. There are documented policies and procedures for
				  routine or non-emergency admissions or intakes that minimally include:
SCR. 2. A.1 the procedures for accepting referrals from
				  outside agencies;
SCR. 2. A.2 the information to be obtained on all applicants
				  or referrals for admission or receipt of service;
SCR. 2. A.3 the records to be kept on all applicants and for
				  what length of time the records are kept;
SCR. 2. A.4 the statistical data to be kept on the intake
				  process;
SCR. 2. A.5 the procedures to be Mowed, including alternative
				  referrals, when an applicant is found ineligible or inappropriate for admission
				  or services; and
SCR. 2. A.6 the procedure for aggregating and analyzing
				  collected dam for use in the agency planning process.
SCR.3 The agency has documented policies and procedures for
				  handling emergency intakes or admissions.
Interpretive Guideline for SCR.3
Agencies or serves that do not accept emergency intakes will
				  have a policy stating the justification for refusal or emergency intakes or
				  admissions.
Assessments:
AS.1 Assessments are conducted by qualified staff.
Interpretive Guideline for AS.1
This standard is surveyed following review of the service
				  specific assessment standards. That is, "qualified" is determined by the degree
				  of compliance with assessment standards rather than on other qualifications,
				  e.g., degrees or certifications.
Progress Notes:
PN.1 Progress notes are current and address progress towards
				  service plan goals as well as other interactions that may be pertinent to the
				  service needs of the client.
PN. 1. A. Progress notes are written at least weekly unless
				  services are designed to be offered less frequently.
PN. 1. A.1 For services that are provided on such an
				  intermittent or infrequent basis to make weekly notes inappropriate, the agency
				  shall develop a policy and procedure concerning the frequency with which notes
				  should be written.
PN. 1. B. For services provided on an intensive basis the
				  agency shall develop policies and procedures establishing a frequency of
				  documentation sufficient to reflect the intensity of service delivery.
Discharge Planning and Transfers:
DPT.1 The agency shall develop and implement a discharge plan
				  consistent with the needs and goals of the client.
DPT. 1. A. Upon review, the discharge plan is consistent with
				  the needs and goals identified in the service plan.
DPT. 1. B. Clients are discharged in a manner and to a
				  setting consistent with their discharge plan.
DPT. 1. C. Clinical justification is documented when
				  referring a client to an alternative setting.
DPT. 1. D. Discharge planning in residential settings will be
				  conducted in compliance with the requirements of standards RS.11 through RS.16.
DPT.2 When discharge planning indicates the need for
				  residential services, the agency shall provide clients with information about
				  residential options sufficient for clients to, make informed choices.
DPT.3 Upon the client's or legally responsible party's
				  documented informed consent, the agency transferring or discharging the client
				  will provide a written transfer or discharge summary to the receiving
				  agency.
DPT.4 The agency transferring a client to another service
				  within the organization or to an outside service provider assures that the
				  transfer is completed in a manner that protects the client's safety, comfort,
				  and dignity.
DPT. 4. A. All transfers of clients will be accomplished in a
				  manner that assures the client's safety, comfort, or dignity. All substantiated
				  complaints will be assessed for the seriousness of the violation and actions
				  taken to achieve compliance.
Continuity of Care:
CC.1 When an Agency offers services through another provider,
				  a documented affiliated service agreement exists.
CC.2 The agency has a policy and procedure that identifies
				  how service components of their agency and other providers work collaboratively
				  in planning and providing services that are sensitive to client's transition
				  needs.
CC. 2. A. All substantiated complaints regarding transition
				  from one service to another will be assessed for the seriousness of the
				  violation and actions taken to achieve compliance.
CC.3 Clients are referred to contracted service providers
				  only after a determination of need has been documented in the client's service
				  plan.
CC.4 The agency has a policy and procedure concerning the
				  delivery or referral to family support groups, which minimally contains how the
				  determination for family support is made and how delivery or referral is
				  accomplished.
Medications:
MED.1 Where medications are available, administered, or
				  supervised by staff in the agency, the agency shall retain and securely store
				  medications.
MED. 1. A. Medications are kept in original containers in a
				  locked storage cabinet.
MED. 1. B. The storage cabinet shall be equipped with
				  separate cubicles, plainly labeled, and locked when not in use.
MED. 1. C. Medications marked "for external use only" shall
				  be stored separate from other medications.
MED. 1. D. Refrigerated medications shall be kept separate
				  from food by placing them in special trays or containers.
MED.2 Where clients self-administer medications, the agency
				  shall provide to clients the capacity for secure storage.
MED. 2. A. Clients that self-administer medications shall be
				  allowed to keep such medications in a locked storage container in their private
				  living areas.
MED. 2. B. No client shall maintain a private drug supply for
				  which there are no physician's orders or prescription label with the client's
				  name.
MED.3 Agencies retain a professionally qualified individual
				  to provide education and supervision when agency clients self-administer
				  medications and agency staff monitor compliance and observe for side effects.
MED. 3. A Unlicensed personnel shall be trained to observe
				  for side effects and drug reactions to psychotropics; and frequently used
				  medications (such as antibiotics) by a registered nurse consultant, and/or
				  physician, and/or pharmacist.
MED. 3. B. There shall be documentation of the activities of
				  the professionally qualified individual including staff training and review of
				  client records/logs.
MED.4 Where medications are available, administered or
				  supervised by staff in the agency, the agency shall have a procedure for
				  prescribing.
MED. 4. A. Written orders to administer/discontinue
				  medications are generated by a physician, dentist, or physician
				  extender.
MED. 4. B Physicians review medications at least every 30
				  days in inpatient settings, every 90 days in outpatient settings and, in
				  residential settings, psychotropic medications will be renewed every 90 days
				  and all other medications no less frequently than one year.
MED. 4. C. Telephone orders are accepted by a registered
				  nurse or pharmacist, and only when necessary because of emergency
				  circumstances.
MED. 4. D. Written dated orders taken by agency staff must be
				  signed by the physician within 24 hours.
MED.5 Where medications are available, administered, or
				  supervised by staff in the agency, there is a policy regarding their
				  administration.
MED. 5. A. The agency has policies regarding medication
				  administration that take into account the client's right, to privacy and
				  dignity.
MED.6 No medication is prescribed and administered without
				  the written informed consent of the client or legally responsible party.
MED. 6. A. There is a process by which the prescribing
				  physician informs the client and/or legally responsible party, and when
				  appropriate, the community support worker, of the potential effects and side
				  effects of medications they prescribe, e.g., information sheets.
MED.7 Where medications are available, administered, or
				  supervised by staff in the agency, there is a policy regarding -inventory of
				  medications and paraphernalia.
MED. 7. A. There is documentation that controlled drugs are
				  counted by the incoming and outgoing medication personnel at the change of each
				  shift.
MED.8 Where medications are available, administered, or
				  supervised by staff in the agency, there is it policy regarding reporting and
				  disposing of outdated medications.
MED. 8. A. There is documented monitoring for outdated
				  medications at least quarterly.
MED. 8. A.1 This monitoring shall include documentation of
				  where the outdated drugs are sent and whether they were disposed of according
				  to applicable federal, state and local laws.
MED.9 Where medication is prescribed, administered, or
				  supervised by staff in the agency, a medication record and a record of each
				  occasion of medication administration shall be maintained.
MED. 9. A. A medication record shall be maintained which
				  minimally includes:
MED. 9. A.1 the prescribing physician;
MED. 9. A.2 personnel administering the medication;
MED. 9. A.3 type and frequency of monitoring for effects of
				  the medication.
MED. 9. B. A medication administration record shall be
				  maintained which minimally includes:
MED. 9. B. 1 the type of medication;
MED. 9. B.2 the dosage; and
MED. 9. B.3 the frequency of use.
MED.10 In instances of medication errors, side effects,
				  adverse reactions, client or staff concerns regarding medication, staff inform
				  the prescribing physician and document the problem in an occurrence
				  report.
MED.11 When the agency prescribes, administers, or supervises
				  medications, there is a process for monitoring the effectiveness of
				  medications.
MED. 11. A. Staff members with a minimum of a medication
				  technician certification approved by Maine's Department of Human Services,
				  regularly review and document client response to medication.
MED. 11. B. Side effects, adverse reactions and client
				  concerns are documented, treated in a timely fashion, and corrected.
MED.12 When medications are prescribed by agency staff or
				  consultants prescribing as part of the agency program, the prescribing
				  professional is available to discuss medication issues and concerns between
				  appointments. MED. 12. A. Documented concerns regarding medications are quickly
				  followed by documented consultation with the prescribing physician.
MED. 12. . B. All substantiated complaints regarding the
				  availability or accessibility of the prescribing physician will be assessed for
				  the seriousness of the violation and actions taken to achieve compliance.
MED.13 The agency complies with all federal, state and local
				  laws concerning medication administration.
.
MED. 13. A. All substantiated violations of any federal,
				  state or local laws concerning medication administration will be assessed for
				  the seriousness of the violation and actions taken to achieve compliance
SERVICE-SPECIFIC STANDARDS
In addition to the core standards, which all mental health
				  agencies need to comply with, an agency will also be surveyed according to the
				  services they provide. In this way, an agency is given a tailored survey that
				  reviews the full scope of their services. This manual currently addresses the
				  following services:
Community Support
Crisis Residential
Emergency
Inpatient
Outpatient
Residential
Social Clubs'
2Social clubs are the only type of
				  service that are not required to comply with the core standards contained in
				  this manual. Social clubs, due to their unique nature and services, have it
				  separate set of standards used during the licensing process.