Community Services Programs

Mental Health Agency Licensing Standards; Agency Management - 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 o rganization'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.

  • 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 a citation of non-compliance.

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.

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.

  • 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.
  • Interpretive Guideline for GOV.6
    Major program changes include, but are not necessarily limited to the following:
    1. the addition of new services or deletion of existing services;
    2. serving a population not served by the agency previously;
    3. significant increases or decreases in service capacity as defined by the governing body;
    4. significant changes in the organizational structure as defined by the governing body;
    5. changes in the executive director, name or ownership of the agency; or
    6. relocation of services.
GOV.7
The governing body shall appoint an executive director responsible for the overall operation of the agency.
  • GOV.7.A.
    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 DHHS'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.