Community Services Programs

Mental Health Agency Licensing Standards; Controlling - Quality Management

Quality management is broadly defined as management philosophies and behavioral and statistical tools aimed at improving quality, customer satisfaction, and profitability. Although all effective quality management processes have distinct similarities, each agency must adopt quality management principles and practices that are sensitive to their organizational culture and effective in their particular setting. For this reason, the Department and the Division of Licensing does not espouse one particular model of quality management. Therefore, the first four standards in this section relate to an agency's ability to demonstrate that they have an ongoing and effective quality management process that is customer-focused and strives for customer satisfaction.

The agency has a written plan that addresses how the organization currently monitors, evaluates and improves quality.

The agency can demonstrate that it identifies, monitors, and attempts to improve areas deemed to be critical to quality client care.

There is documented evidence that quality management activities are conducted on an ongoing and regular basis.

The effectiveness of quality management is assessed and documented at least annually and involves input from clients, family members, guardians, client representatives, staff, and referral sources.

The agency shall have, available for review, insurance policies citing professional and commercial liability coverage for the organization, staff, volunteers, and students.

The agency has a policy and procedure regarding the reporting and recording of adverse and potentially adverse occurrences, including the recording of complaints.

  • QM.6.A.
    Reports of adverse and potentially adverse occurrences will be evaluated for the need for follow-up actions and opportunities for improvements in agency management and/or service delivery.
  • QM.6.A.1
    In such instances, follow-up actions will be documented.
  • QM.6.A.2
    The agency shall have a policy and procedure for reporting allegations of abuse, neglect and exploitation of clients in accordance with the requirements of the Adult and Child Protection laws.
  • Interpretive Guideline for QM.6
    Some examples of adverse or potentially adverse occurrences include, but are not necessarily limited to:
    1. deaths;
    2. injuries;
    3. violations of agency policies; and
    4. violations of client rights.

Each agency has a process for monitoring and evaluating the appropriateness of admission to or initiation of service and the provision of continued service to the client, based on admission and continued service criteria.

The agency has admission or service initiation criteria and continued service criteria that are used in reviewing each case upon admission or initiation of service and regularly thereafter to assure the delivery of services/care in a least restrictive environment.

Individuals are not inappropriately admitted or served in an agency, service or setting.

The agency has a process for documenting clients' needs and determining how well the organization's services meet those needs.

The agency shall report immediately to the Division any legal proceedings arising out of circumstances related to providing mental health services.

  • Interpretive Guideline for QM.9
    Agencies must immediately provide a verbal report to the Division once the agency is legally served notice of legal proceedings. Written notice must be received within 3 working days following receipt of verbal reports. Some examples of legal proceedings that should be reported include, but are not necessarily limited to the following:
    1. bankruptcy;
    2. professional licensing body sanctions;
    3. discrimination;
    4. lawsuits; and
    5. criminal activity by a staff member(s) that has implications for the programmatic and/or fiscal integrity of the agency and the safety of its clients.

The agency shall post the original current license issued by the Department in a clearly visible place within the central facility and copies in all branch locations.

  • Interpretive Guideline for QM.10
    Residential facilities may post the license in an office area of the residence or similar inconspicuous location.

The agency can demonstrate compliance with all client rights regulations as stated in the current edition of the Rights of Recipients (Adult and/or Children's Services editions).

  • QM.11.A.
    The agency will have a policy and procedure establishing the means by which compliance with the Rights of Recipients will be achieved.
  • QM.11.B. All substantiated complaints of violations of the Rights of Recipients will be assessed for the seriousness of the violation and actions taken to achieve compliance.