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/0,5885,7-339-71550_2941_4868_4901_57938_82825---,00.html

 

2019 Rights System Assessment Results

Date CMHS Score Result
03/05 - 03/07 Macomb County CMH Services* 180/180 FC
03/19 - 03/21 Saginaw County CMH Authority 176/180 SC
04/29 - 05/01 Lapeer County CMH Services 172/180 SC
04/16 - 04/18 Pines Behavioral Health 134/180 LSC
05/07 - 05/09 AuSable Valley CMHA 155/180 LSC
05/21 - 05/23 HealthWest 162/180 LSC
06/11 - 06/13 CMHA of Clinton Eaton Ingham Counties 170/180 SC
07/09 - 07/11 Northern Lakes CMH 172/180 SC
07/23 - 07/25 Hiawatha Behavioral Health 152/161 LSC
08/06 - 08/08 North Country CMH 178/180 SC
08/20 - 08/22 CMH and SA Services of St. Joseph County 151/161 LSC
09/17 - 09/19 network180 174/180 SC
10/08 - 10/10 Genesee Health System 180/180 FC
10/22 - 10/24 Van Buren CMH 146/161 LSC
11/19 - 11/21 Shiawassee Health and Wellness 173/180 SC
12/03 - 12/05 Barry County CMHA    
  *Return visit due to scheduling adjustment    

 

2018 Rights System Assessment Results

Date CMHS Score Result
03/13 - 03/15 Monroe CMH Authority 194 FC
03/27 - 03/29 Montcalm Care Network 194 FC
04/17 - 04/19 Woodlands Behavioral Healthcare Network 150 LSC
05/08 - 05/10 Allegan County CMH Services 135 LSC
05/22 - 05/24 Newaygo County Mental Health Center 194 FC
06/12 - 06/14 St. Clair County Mental Health Authority 192 SC
07/10 - 07/12 Northpointe Behavioral Healthcare Systems 168 SC
07/24 - 07/26 West Michigan CMH System 171 SC
08/14 - 08/16 Gogebic CMH Authority 171 SC
08/28 - 08/30 Northeast Michigan CMH Authority 186 SC
09/24 - 09/28 Oakland Community Health Network 184 SC
10/09 - 10/11 Huron Behavioral Health 167 SC
10/22 - 10/25 Macomb County CMH Services 194 FC
11/13 - 11/15 Washtenaw County Community Mental Health 193 SC
12/04 - 12/06 Kalamazoo CMH & Substance Abuse Services 193 SC
12/10 - 12/14 Gratiot Integrated Health Network 173 SC

 

2017 Rights System Assessment Results

Date CMHS Score Result
03/14 - 03/16 Livingston County CMH 169 SC
03/28 - 03/30 The Right Door … (Ionia)  160 LSC
04/11 - 04/13 CMH for Central Michigan  167 SC
04/25 - 04/27 Bay-Arenac Behavioral Health  167  SC
05/16 - 05/18 LifeWays  160 LSC
06/06 - 06/08 Berrien-Riverwood Center 165 SC
07/11 - 07/13 Centra Wellness Network 164  SC
07/25 - 07/27 Copper Country CMH Services  164  SC
08/08 - 08/10 Ottawa County CMH  170  FC
08/22 - 08/24 Pathways 170  FC
10/02 - 10/06 Detroit Wayne MH Authority  162* LSC
10/17 - 10/19 Lenawee County CMH Authority  169  SC
10/31 - 11/02 Tuscola Behavioral Health Systems  167  SC
11/14 - 11/16 Sanilac County CMH Services 142 LSC
12/05 - 12/07 Summit Pointe Behavioral Health  167 SC

2016 Rights System Assessment Results

Full Compliance (FC) = 170 Points
Substantial Compliance (SC) = 162 Points
* Represents Repeat Citations

CMHS Score Result
Saginaw County CMH Authority  166  SC
CMH Authority of CEI Counties  143  *LSC
Lapeer County CMH Services  170  FC
Pines Behavioral Health Services  161  *LSC
AuSable Valley CMHA  167  SC
HealthWest  163  *SC
Northern Lakes CMH  168  *SC
Hiawatha Behavioral Health  169  SC
North Country CMH  164  SC
CMH and SAS of St. Joseph County  156  *LSC
network180  169  SC
Genesee Health System  170  FC
Van Buren CMH Authority  167  SC
Shiawassee County CMH Authority  166  SC
Barry County CMHA  168  SC