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 2024-13, March 27, 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:

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:

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 :

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.