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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

 

2025 Rights System Assessment Results

Date CMHS Result
01/14 - 01/14 Pines Behavioral Health Services
02/04 - 02/06 Saginaw County CMH Services
03/11 - 03/13 Lapeer County CMH Services
04/01 - 04/03 Wellvance
04/22 - 04/24 Pivotal
05/13 - 05/15 CMHA of Clinton-Eaton-Ingham
06/03 - 06/05 Hiawatha Behavioral Health
06/24 - 06/26 HealthWest
07/08 - 07/10 Network180
07/29 - 07/31 North County CMH
08/26 - 08/28 Northern Lakes CMH Authority
09/09 - 09/11 Genesee Health System

 


 

2024 Rights System Assessment Results

Date CMHS Result
03/05 - 03/07 Monroe County CMH Full Compliance
03/19 - 03/21 Montcalm Care Network Full Compliance
04/02 - 04/04 Woodlands Behavioral Health Less than Substantial Compliance
04/23 - 04/25 OnPoint (Allegan) Less than Substantial Compliance
05/07 - 05/09 St. Clair County CMH Authority Full Compliance
06/11 - 06/13 Northpointe Behavioral Healthcare System Full Compliance
07/09 - 07/11 West Michigan CMH Less than Substantial Compliance
08/06 - 08/08 Northeast Michigan CMH Authority Full Compliance
08/20 - 08/22 Gogebic County CMH Authority Full Compliance
09/10 - 09/12 Newaygo County CMH Services Substantial Compliance
10/07 - 10/11 Oakland County Community Network Full Compliance
10/22 - 10/24 Huron Behavioral Health Services Substantial Compliance
11/05 - 11/07 Gratiot Integrated Health Network Full Compliance
11/19 - 11/21 Washtenaw CMH Full Compliance
12/03 - 12/05 Integrated Services of Kalamazoo Substantial Compliance

 


 

2023 Rights System Assessment Results

Date CMHS Result     
03/07 - 03/09 Central Michigan Full Compliance
04/18 - 04/20 Bay-Arenac Full Compliance
05/01 - 05/03 Lifeways Michigan Substantial Compliance
05/16 - 05/18 Livingston Less than Substantial Compliance
06/06 - 06/08 Berrien - Riverwood Full Compliance
06/27 - 06/29 Centra Wellness Substantial Compliance
07/18 - 07/20 CMH of Ottawa County Full Compliance
07/25 - 07/27 Pathways Full Compliance
08/15 - 08/17 Copper County Less than Substantial Compliance
09/12 - 09/14 Lenawee CMH Full Compliance
10/03 - 10/05 Tuscola Behavioral Health Systems Full Compliance
11/07 - 11/09 Right Door of Hope, Recovery & Wellness Full Compliance
11/14 - 11/16 Sanilac County CMH Services Full Compliance
12/12 - 12/14 Summit Pointe Behavioral Health Full Compliance
01/28 - 02/02 Detroit Wayne Integrated Health Network Substantial Compliance