Community Services Programs

Mental Health Agency Licensing Standards; Agency Management - Health and Safety

HS.1
The agency complies with all applicable health codes.

  • HS.1.A.
    There are no substantiated health code violations.

HS.2
Any agency not using a public water and/or sewer system shall be inspected and approved by the process outlined by the Department of Human Services.

  • HS.2.A.
    Any agency without a public water and/or sewer system shall be able to produce a Sanitary Survey report from the approved process of the Health Engineering Division of the Department of Human Services.
  • HS.2.B.
    Any agency without public water and/or sewer system will have Sanitary Surveys conducted as often as required by the Department of Human Services Health Engineering Division regulation.

HS.3
The agency has policies and procedures for managing and controlling infections.

  • HS.3.A. The agency has documented evidence that they have implemented policies and procedures regarding the management and control of infections.
  • Interpretive Guideline for HS.3 and HS.3.A
    The management and control of infections has become one of the most serious issues for society, in general, to address. The management staff should determine the extent to which their agency, clients, employees, and others are at risk for acquiring and transmitting infections. Based on this determination, the agency should develop and implement reasonable policies and procedures to manage and control the potential for acquiring or transmitting infections. For example, an inpatient service that commonly treats IV drug users would be expected to have more extensive mechanisms in place for preventing and controlling infections than an outpatient clinic.

HS.4
Agencies shall be inspected by the State Fire Marshal or the Fire Marshal's designee to assure compliance with the NFPA 101 Life Safety Code (current edition).

  • HS.4.A.
    Residential facilities have verification of annual fire inspections from the State Fire Marshal or Fire Marshal's designee assuring compliance with NFPA 101 Life Safety Code and safe occupancy.
  • HS.4.B.
    Non-residential programs have biennial letters from the State Fire Marshal or the Fire Marshal's designee assuring compliance with NFPA 101 Life Safety Code and safe occupancy.
  • Interpretive Guideline for HS.4 through HS.5
    Consult the current edition of the NFPA 101 Life Safety Code for requirements in each type of occupancy.

HS.5
Quarterly fire drills are conducted and documented for non-residential services and monthly for residential services per NFPA 101 Life Safety Code (current edition).

  • HS.5.A.
    There is documented evidence that the agency is in compliance with fire drill requirements. 
  • Interpretive Guideline for HS.4 through HS.5
    Consult the current edition of the NFPA 101 Life Safety Code for requirements in each type of occupancy.

HS.6
The agency has a written disaster and evacuation plan specifying procedures for personnel and designating specific tasks and responsibilities.

  • HS.6.A.
    The agency disaster plan addresses a variety of pertinent disasters, e.g., fires, power outages, storms.
  • HS.6.B.
    The disaster plan addresses staff preparedness, including staff requirements and the designation of roles and functions, particularly in terms of capabilities and limitations.
  • HS.7
    There is documented evidence that staff members receive initial and continuing education concerning disaster and evacuation procedures.