Community Services Programs

Mental Health Agency Licensing Standards; Staffing - Human Resource Management

The agency has written documentation that each person's duties, responsibilities and performance expectations are clearly communicated upon hire.

Staff members meet minimum qualifications for their job as cited in their job description.

Each position in the organization has a job description that minimally contains the:




duties and responsibilities; and

minimum education, training and experience qualifications

The agency has a policy and procedure that addresses the mechanism by which all employees have access to, or receive a copy of, the personnel policies and procedures.

The agency documents that each employee has reviewed or received a copy of the personnel policies and procedures by way of signature in the employee's personnel file.

Interpretive Guideline for HRM.3.A
Documentation may include a form indicating the employee has reviewed policies/procedures, the distribution of personnel policy handbooks, etc.

The agency has policies and procedures for the recruitment, selection, and retention and promotion of employees, volunteers, and students.

The agency has a policy and procedure establishing practices for the termination or temporary layoff of employees, including provision for notification of the employee and mechanisms for appeal.

The agency has a policy and procedure concerning employee grievances that includes notifying employees of the procedure and maintaining confidential communications and records.

Each employee, student and volunteer has a personnel record.

The agency has a policy and procedure concerning maintaining personnel records for
each employee, student or volunteer.

Personnel records should be maintained similarly and contain documentation pertinent
to the employee's, student's or volunteer's work, supervision and training.

Each personnel file contains information documenting and verifying the positions held by the employee, volunteer or student and their qualifications and experience.

Each employee, volunteer, or student's personnel record minimally contains the following:

job description;

copies of appropriate licenses and certifications;

a this will include either licensure as a mental health professional in the state of Maine, certification by the Bureau of Mental Health or Bureau of Children with Special Needs as an Other Quality Mental Health Professional, or certification by the HRD program as an MHRT;

copies of diplomas, transcripts or documentation of verbal verification from the school officials citing date and school official contacted;

records of continuing education and training

Interpretive Guideline for HRM.8.A.4
Continuing education or training records may be in the form of certificates noting date, title of training, number of hours or CEU's or other listings of training received with content, date, presenter and length of training documented. Although documenting all training in the personnel record is preferred, documentation of training received within the organization may be kept in alternative records, e.g., training log.

documentation, before start date, regarding the individual's criminal/abuse history (e.g., checking with SBI, DHS).

a If checks with SBI or DHS produce information regarding an employee, the agency will document in the personnel file its assessment of the seriousness of the information provided and take appropriate actions if indicated.

An individual's need for training and continuing education is assessed with the individual's participation and documented within 6 months of hire or job change and at least annually thereafter.

All employees, students and volunteers are given a copy of the Rights of Recipients (Adult and/or Children as appropriate).

There is documented evidence that all employees, students and volunteers review the
Rights of Recipients (Adult and/or Children's editions) before commencing the duties of their job
and when there is a change in the Rights regulations.

Interpretive Guideline for HRM.10.A
Documented evidence may be a statement or other documentation, signed and dated by the employee, student or volunteer that confirms that they have reviewed the Rights of Recipients (Adult and/or Children's editions).

The agency has policies and procedures on access to personnel files that minimally include: the employee's right to access, protection of confidential information, secure storage, making record entries, and distribution of information upon staff request.

The agency has policies and procedures that minimally address the following
personnel records issues:

who in addition to the employee, has access to personnel records;

how confidential personnel information is protected;

how personnel records are securely stored;

who in addition to the employee may enter information into the personnel records;

how and to whom information from personnel records may be disseminated.

The agency has a policy and procedure that addresses when a personnel record is considered inactive and what practices are followed in its disposal to assure the employee's confidentiality.

The agency has documented processes for addressing employee issues, including policies and procedures on employee recognition, supervision and discipline.

The agency is an Equal Opportunity Employer.

The governing body establishes and adheres to policies and procedures that provide for periodic review and approval of the personnel policies for compliance with federal, state and local laws.

Interpretive Guideline for HRM.14.A
The definition of "periodic review" is determined by the governing body and is the basis upon which compliance will be determined by licensing staff. Failure to define periodic review will result in a citation for this standard.

There are no substantiated cases where an agency fails to follow personnel policies and procedures as required by federal, state or local laws.

All agencies must notify the Division of discrimination complaints resulting in a reasonable grounds finding by an external regulatory body (MHRC/EEOC).

The agency has received approval from the Department's Affirmative Action Officer as an Equal Opportunity Employer.

Each employee's job performance shall be evaluated on at least an annual basis based upon performance criteria established for the position.

Each employee's personnel files shall contain a copy of that employee's performance evaluation.