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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

 

2022 Rights System Assessment Results

    NO APPEALS  WITH  APPEALS
MAXIMUM SCORE 426 474
FULL COMPLIANCE (95%) 405 450
SUBSTANTIAL COMPLIANCE (90%) 383 427
LESS THAN SUBSTANTIAL COMPLIANCE (<90%) <383 <427
Date CMHS Score Result
03/08 - 03/10 Saginaw County CMH Services 468/474 FC
04/05 - 04/07 Pines Behavioral Health Services 386/426 SC
04/19 - 04/21 Lapeer County CMH Services 456/474 FC
05/03 – 05/05 AuSable Valley  
05/24 - 05/26 Health West  
06/14 - 06/16 CMHA of Clinton-Eaton-Ingham  
06/28 - 06/30 Hiawatha Behavioral Health  
07/19 - 07/21 network180  
08/02 - 08/04 Northern Lakes CMH Authority  
08/16 - 08/18 North Country CMH  
09/07 - 09/09 CMH and SA Services of St. Joseph County    
09/20 - 09/22 Genesee Health System    
10/04 - 10/06 Van Buren CMH Authority    
10/18 - 10/20 Shiawassee Health and Wellness    
11/16 - 11/18 Barry County CMH Authority  
12/05 - 12/09 Macomb County CMH Services    

 


 

2021 Rights System Assessment Results

    NO APPEALS  WITH  APPEALS
 MAXIMUM SCORE  406  452
 FULL COMPLIANCE (95%)  386  430
 SUBSTANTIAL COMPLIANCE (90%)  365  407
 LESS THAN SUBSTANTIAL COMPLIANCE (<90%)  <365  <407
Date CMHS Score Result
03/09 - 03/11* Monroe CMH Authority 406/406 FC
03/23 - 03/25* Montcalm Care Network 400/406 FC
04/06 - 04/08* Woodlands Behavioral Healthcare Network 324/406 LSC
04/20 - 04/22* Allegan County CMH Services 411/452 SC
05/04 - 05/06* St. Clair County CMH Services 466/452 FC
05/18 - 05/20* Newaygo County CMH Services 404/430 LSC
06/08 - 06/10* Gratiot Integrated Health Services 392/406 FC
06/22 - 06/24* Northpointe Behavioral Healthcare System 440/452 FC
07/13 - 07/15* West Michigan Community Mental Health 443/452 FC
07/27 - 07/29* Gogebic CMH Authority 385/406 SC
08/17 - 08/19* Northeast Michigan CMH Authority 416/452 SC
09/13 - 09/17* Huron Behavioral Health Services 381/406 SC
10/04 - 10/08* Oakland Community Health Network 422/452 SC
11/02 - 11/04* Washtenaw County Community Mental Health 434/452 SC
12/06 - 12/08* Integrated Services of Kalamazoo 452/452 FC

 


 

NO APPEALS/APPEALS
FULL COMPLIANCE = 424/462
SUBSTANTIAL COMPLIANCE = 403/439
LESS THAN SUBSTANTIAL COMPLIANCE = <403/<439

2020 Rights System Assessment Results

Date CMHS Score Result
03/24 - 03/26 CMH for Central Michigan 450/462 FC
04/21 - 04/23 Bay-Arenac Behavioral Health 450/462 FC
05/12 - 05/14 Lifeways Community Mental Health 392/462 LSC
05/18 - 05/21 Livingston County CMH Services 424/424 FC
06/02 - 06/04 Berrien - Riverwood Center 292/424 LSC
06/16 - 06/18 Centra Wellness Network 424/424 FC
07/14 - 07/16 Copper Country CMH Services 352/462 LSC
07/28 - 07/30 CMH of Ottawa County 461/462 FC
08/11 - 08/13 Pathways 424/424 FC
08/25 - 08/27 Right Door - Ionia 444/462 FC
10/05 - 10/09 Detroit-Wayne Integrated Health Network 423/492 SC
10/20 - 10/22 Lenawee County CMH Authority 453/462 FC
11/04 - 11/06 Tuscola Behavioral Health Systems 444/462 FC
11/17 - 11/19 Sanilac County CMH Services 378/424 LSC
12/08 - 12/10 Summit Pointe Behavioral Health 444/462 FC