Community Mental Health Program Assessments

The Mental Health Code requires that the Michigan Department of Health & Human Services to establish standards for certification and the certification review process for CMHSPs.  Administrative Rule 330.2801 requires the Department to assess the CMHSPs compliance with these certification standards by determining the degree to which all of the following provisions apply:

a)  The CMHSP has established processes, policies and procedures necessary to achieve the required result.

b)  The established processes, policies and procedures are properly implemented.

c)  The expected result of the processes, policies and procedures is being achieved.

The Code also requires that MDHHS, through the Office of Recipient Rights, review the CMHSP rights systems to "ensure a uniformly high standard of recipient rights protection throughout the state."

The certification standards must include those for the protection and promotion of recipient rights (MCL 330.232a[1][b]).  Standards regarding of CMHSP governance, resource management, quality improvement, service delivery and safety management may be waived by the Department in whole or in part as the result of the CMHSP's accreditation by a nationally recognized accrediting body. However, standards established by the Department which address the protection and promotion of recipient rights cannot be waived.

Assessment Process  

Each CMHSP recipient rights system is assessed annually by the ORR Education, Training and Compliance Unit. The annual assessment is a paper review of the semi-annual and annual reports required by the Mental Health Code and a review of the annual monitoring reports submitted by CMHSPs.

In addition, ORR conducts an on-site review of the rights protection system of each CMH triennially.  This assessment evaluates compliance with standards established by Federal and State laws, rules, guidelines, and contractual requirements. 

The onsite reviews consists of:

• An entrance and exit conference;
• Interviews with the CEO, rights office staff, Recipient Rights Advisory and Appeals Committee members. Interviews may be conducted with other staff of the agency and/or provider agencies as the situation warrants;
• Compliance review of complaint case files, logs, Code-mandated reports and notices, appeals cases;
• A review of the rights-related language in contracts executed by the agency to determine how rights will be protected;
• An evaluation of the recipient rights training provided by the agency to assure it is adherent to the contractual standards established by the Department;
• A compliance review of all twenty-two rights-related policies required by the Code;
• A detailed review of the process of compliant resolution to assure that timeframes established in the Mental Health Code are adhered to.

Related Documents

To access assessment forms select:

/mdhhs/keep-mi-healthy/mentalhealth/mentalhealth/recipientrights/staff/forms-templates

2025 Rights System Assessment Results

2024 Rights System Assessment Results

2023 Rights System Assessment Results