STATE OF MICHIGAN

GRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES ELIZABETH HERTEL

GOVERNOR LANSING DIRECTOR

July 7, 2022

Hiawatha Behavioral Health

Dan McKinney, Chief Executive Officer
125 North Lake Street
Manistique, Michigan 49854

Dear Mr. McKinney,

Attached you will find the results of the assessment completed by MDHHS-ORR staff Cindy Shadeck and Janice
Terry from June 28-30, 2022. This assessment was conducted as a component of the MDHHS Community
Mental Health Services program certification process as required by §330.1232 (e) of the Michigan Mental
Health Code.

As a result of the assessment your rights system has achieved a score of 221 points out of a total of 426 and has
been found to be in LESS THAN SUBSTANTIAL COMPLIANCE with the standards established by the
Mental Health Code, Administrative Rules, and the Department in regard to the establishment and
implementation of a system which promotes and protects the rights of recipients.

Please carefully review the findings, comments and required actions contained in this report. Several standards
require a written corrective plan of action. This plan should be provided to Janice Terry no later than August 15,
2022. This plan must:
 Provide a clear and specific response to each standard for which “required action” is cited in the report.
 Assure implementation of corrective action across the entire service delivery system.
 Include documentation and/or other appropriate evidence of implementation of all corrective action
taken.
 Provide reasonable and specific dates certain for completion of any item that cannot be completed by
August 15, 2022.
Failure to provide the required plan of correction or evidence of action taken by the date due could result in
action by the Department up to and including contract sanctions or provisional certification.

Once again, I appreciate the assistance and cooperation offered to our staff during the assessment process.
MDHHS-ORR staff will be available to assist you with any concerns or questions you may have. Specific
questions relative to your assessment or the development of your plan of correction should be directed to Janice
Terry, Community Rights Specialist at 517-599-5953.

Sincerely,

320 SOUTH WALNUT STREET • PO BOX 30815 • LANSING, MICHIGAN 48909

www.michigan.gov/mdhhs • 517-241-3740
Raymie Postema, Director
MDHHS Office of Recipient Rights

cc:
Elizabeth Hertel, Director, MDHHS
MDHHS Leadership
Andrew Silver, Director of Education, Training & Compliance, MDHHS-ORR
Janice Terry, Community Rights Specialist, MDHHS-ORR
Elizabeth Eidenier, Recipient Rights Officer, Hiawatha Behavioral Health
 OFFICE OF RECIPIENT RIGHTS
2022 RIGHTS SYSTEM ASSESSMENT REPORT

AGENCY: HIAWATHA BEHAVIORAL HEALTH

ASSESSMENT DATES: June 28-30, 2022

REVIEWERS: Janice Terry (Lead) and Cynthia Shadeck

SECTION MAXIMUM WEIGHT MAXIMUM YOUR YOUR

POSSIBLE POSSIBLE INITIAL WEIGHTED
SCORE SCORE SCORE SCORE
(WEIGHTED)
1. CMHSP RESPONSIBILITIES 28 3 84 27 81
2. RIGHTS OFFICE OPERATIONS 16 3 48 14 42
3. EDUCATION AND TRAINING 12 3 36 10 30
4. POLICIES 6 1 6 6 6
5. RIGHTS ADVISORY COMMITTEE 16 1 16 16 16
6. COMPLAINT RESOLUTION - PROCESS 20 3 60 2 6
7. COMPLAINT RESOLUTION – CONTENT 34 3 102 4 12
8. COMPLAINT RESOLUTION - TIMEFRAMES 10 3 30 0 0
9. APPEALS (No Appeals) 2 2 4 2 4
10. SEMI-ANNUAL AND ANNUAL REPORTING 6 2 12 6 12
11. SITE VISITS 14 2 28 6 12
TOTAL SCORE 164 426 93 221

SCORE: 221 points out of possible 426 points = LESS THAN SUBSTANTIAL COMPLIANCE

NO APPEALS WITH APPEALS

. MAXIMUM SCORE 426 474
FULL COMPLIANCE 405 450
SUBSTANTIAL COMPLIANCE 383 427
LESS THAN SUBSTANTIAL COMPLIANCE <383 <427
CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 1 - CMHSP RESPONSIBILITIES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755(1) 1.1.1 The Agency has established a recipient rights office 2 2
subordinate only to the executive director.
MHC 1.1.2 The Agency has appointed a designee to act in place of the 2 2
1100(a)(30) Executive Director in the absence of the Director.
MHC 1782
MHC 1755(2)(b) 1.2.1 The process for funding the rights office includes a review of 2 2
the funding by the recipient rights advisory committee.
MHC 1755(2)(c) 1.3.1 The recipient rights office is protected from pressures that 2 2
could interfere with the impartial, even-handed, and
thorough performance of its duties.
MHC 1755(2) (d) 1.3.2 The rights office has had unimpeded access to a) All 2 2
programs and services operated by, or under contract to, the
CMHSP; b) All staff employed by, or under contract to,
CMHSP; c) All evidence necessary to conduct a thorough
investigation or to fulfill its monitoring function.
MHC 1755(3) (a) 1.3.3 Complainants, rights office staff, and any staff acting on 2 2
No allegations of retaliation/
behalf of a recipient will be protected from harassment or
harassment since last assessment.
retaliation resulting from recipient rights activities.
MHC 1755(3) (a) 1.3.4 Appropriate disciplinary action was taken if there was 2 2
AR 7035(1) evidence of retaliation and harassment.
MHC 1755(4) 1.4.1 The executive director has selected a director of the rights 2 2
MHC 1757(2) (e) office who has the education, training, and experience to
fulfill the responsibilities of the office.
MHC 1755(4) 1.4.2 The Agency has established a process to assure ongoing 2 2
MHC 1778(1) rights protection in the absence of the rights director.
MHC 1757(2) [e] 1.4.3 The executive director has consulted with the Recipient 2 2 Since the last assessment there have
MHC 1755 (4) Rights Advisory Committee in the hiring of the Director of been two changes in the staffing of
the office. the Rights Director position. Both
times, the RRAC was consulted with
regarding the hiring of the new Rights
Director.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 1 - CMHSP RESPONSIBILITIES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755 (4) 1.4.4 The director of the rights office has no clinical service 2 1 The most recently hired Rights
responsibilities. Director was previously employed by
the CMH as a case manager. She REQUIRED ACTION: The
stated that, due to staffing problems newly hired Rights
at the agency, she has been required Director must not have
to continue to conduct case clinical service
management duties even after being responsibilities.
hired and starting in her role as Rights
Director.
CMHSP 6.3.2.3A 1.5.1 All contracts with licensed private hospitals/units included 2 2
language that required contractor's rights staff to comply
with Attachment 6.3.2.3A of the CMHSP contract.
MHC 1.5.2 Each contract between a CMHSP and a service provider 2 2
1755(2)(f)(ii) requires that all recipients be protected from rights
violations while receiving services.
MHC 1722 [2] 1.5.3 The CMHSP ensured that each service provider under 2 2
contract, including those allowed/required to have their own
rights protection system, took appropriate disciplinary action
against those who are engaged in abuse or neglect.
SECTION TOTAL 28 27

Citation Standard SECTION 2 – RIGHTS OFFICE OPERATIONS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1706 2.1.1 At the time services are initiated, ORR ensured that 2 2
recipients, parents of minor recipients, and guardians are
notified, in an understandable manner, of the rights
guaranteed by Chapter 7 and 7A of the Mental Health Code
and provided access to summaries of the rights guaranteed
by Chapter 7 and 7A both at the time services are initiated
and periodically during the time services are provided.
MHC 1776 (5) 2.2.1 ORR ensured there is a mechanism to advise recipients or 2 2
other individuals that there are advocacy organizations
available to assist in preparation of a written rights
complaint and offered to make the referral.
MHC 1776 (5) 2.3.1 As necessary, the office assists recipients or other individuals 2 2
with the complaint process.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 2 – RIGHTS OFFICE OPERATIONS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755[5][d][i] 2.4.1 ORR maintained a record system for all reports of apparent 2 0 The case numbers of all cases REQUIRED ACTION:
or suspected rights violations received including a reviewed were double-checked Ensure that the ORR
mechanism for logging all complaints. against the log data provided to complaint log is accurate.
assessors for assessment. For many Ensure that all complaints
cases reviewed, there were mistakes received are analyzed for
found related to case numbers and coding with attention
where case numbers were entered paid to whether they
into the logging system. For example, should be properly coded
for 8 cases reviewed, the case and resolved as OJ/NRI.
numbers were not found anywhere in
the ORR log. Some were incorrectly
logged as interventions or
investigations when they were not. In
some cases, the numbers logged were
incorrect, for instance, the numbers
were transposed. Also, there were no
OJ/NRI cases logged at all for the
entire assessment period. In the
experience of assessors, it is highly
unlikely that there were no complaints
received that should have been
categorized as OJ/NRI.
MHC 1755[5][d] 2.4.2 ORR has established a mechanism for secure storage of all 2 2
investigative documents and evidence.
MHC 1755[5][h] 2.5.1 ORR serves as a consultant to the director and to agency 2 2
staff in rights related matters.
MHC 1755[5][i] 2.6.1 Ensure that all reports of apparent or suspected violations of 2 2
rights within the community mental health services program
system are investigated in accordance with section 1778.
AR 7199 (g) 2.7.1 The Rights Office attended meetings of the Behavior 2 2
CMHSP 6.8.3.1 Treatment Review Committee as an ex-officio member.
SECTION TOTAL 16 14

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 3 – EDUCATION AND TRAINING MAX SCORE FINDINGS REQUIRED ACTION
SCORE
CMHSP 6.3.2 3.1.1 The staff of the rights office attended and successfully 2 2 The newly hired Rights Director,
completed the Basic Skills Training programs within 90 days of Elizabeth Eidenier, is scheduled to
hire. attend the next MDHHS-ORR Basic
Skills trainings.
CMHSP 6.3.2 3.1.2 The Executive Director has completed the MDHHS CEO Rights 2 2
training program within 180 days of hire.
MHC 1755[2][e] 3.2.1 The staff of the rights office have complied with the 2 2
CMHSP 6.3.2.3 (A) continuing education requirements identified in the contract
attachment, including that a minimum of 12 of the required
36 hours were approved as either Category I or II.
MHC 1755[5][f] 3.3.1 All individuals employed by the CMHSP, or its contract 2 0 82.2% compliance REQUIRED ACTION:
agencies received training related to recipient rights Ensure that all newly
protection before or within 30 days after being employed. hired CMH and
contracted provider staff
receive recipient rights
training within 30 days
after being hired.
CMHSP 6.3.2.3B 3.3.2 Training related to recipient rights protection addressed all 2 2
training standards identified in the contract attachment.
MHC 1755[2][a] 3.4.1 Education and training in recipient rights policies and 2 2
procedures are provided to the recipient rights advisory
committee and appeals committee.
SECTION TOTAL 12 10

Citation Standard SECTION 4 – POLICIES MAX SCORE FINDINGS REQUIRED ACTION

SCORE
MHC 1752[1] 4.1.1 The policies and procedures provided a mechanism for prompt 2 2
reporting, review, investigation, and resolution of apparent or
suspected rights violations, and are designed to protect
recipients from, and prevent repetition of, violations of rights
guaranteed by Chapters 7 and 7A.
MHC 1752[1] 4.1.2 Policies and procedures included, at a minimum, all those 2 2
specifically delineated in MHC 330.1752 (1).
MHC 1752 (1) 4.1.3 Policies and procedures meet the criteria established in the 2 2
MHC 1704 (1) Mental Health Code, Administrative Rules, and contractual
requirements and those reflected in the MDHHS-ORR Policy
Review Standards.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 4 – POLICIES MAX SCORE FINDINGS REQUIRED ACTION

SCORE
SECTION TOTAL 6 6

Citation Standard SECTION 5 – RECIPIENT RIGHTS ADVISORY COMMITTEE MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1757[1] 5.1.1 The board of each community mental health services program 2 2
shall appoint a recipient rights advisory committee consisting
of at least 6 members who represent the varied perspectives
of the CMHSP’s geographic area and meet the statutory
requirements of the Mental Health Code.
MHC 1757[2](a) 5.1.2 The RRAC met at least semiannually or as necessary to carry 2 2 Meets quarterly.
out its responsibilities.
MHC 1757[2](b) 5.1.3 The CMHSP maintains a current list of members’ names. This 2 2
list is available to individuals upon request.
MHC 1757[2](c) 5.1.4 The CMHSP maintains a current list of categories represented 2 2
by members. This list is available to individuals upon request.
MHC 1757[2](d) 5.1.5 The RRAC acts to protect the recipient rights office from 2 2
pressures which could interfere with the impartial, even-
handed, and thorough performance of its duties and serves in
an advisory capacity to the CMHSP director and the director of
the rights office.
MHC 1757[2][g] 5.1.6 The RRAC reviewed and provided comments on the annual 2 2
rights report submitted by the executive director to the Board
of the CMHSP.
MHC 1757[2][i] 5.1.7 Meetings of the RRAC complied with the Open Meetings Act 2 2
(Act 257 of 1976).
MHC 1757[2][i] 5.1.8 Minutes of the RRAC meetings were maintained and made 2 2
available to individuals upon request.
SECTION TOTAL 16 16

Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1776[3] 6.1.1 Each rights complaint was recorded upon receipt by the rights 2 0 At least 8 complaints were found to REQUIRED ACTION:
office. have not been recorded in the ORR Ensure that every
complaint log. complaint is recorded
accurately on the
complaint log.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 4 – POLICIES MAX SCORE FINDINGS REQUIRED ACTION

SCORE
MHC 1776[3] 6.1.2 For each rights complaint recorded, an acknowledgement 2 0 11 investigation files and 9 intervention REQUIRED ACTION:
letter and copy of the complaint was sent to the complainant. files were reviewed (the log indicated Ensure that for every
there were no OJ/NRI complaints complaint received, an
received). In 3 of the cases reviewed, Acknowledgement Letter
there was no Acknowledgement Letter is sent to the required
found, and in 2 cases reviewed, there persons, and ensure that
was no complaint attached to the a copy of the written
Acknowledgement Letter. complaint is attached to
the Acknowledgement
Letter.
MHC 1776[6] 6.2.1 If a rights complaint had been filed regarding the conduct of 2 2 No complaints were made against the
the agency director, the rights investigation was conducted by Executive Director since last assessment.
the office of another CMHSP or, if requested by the CMHSP
Board of Directors, by the MDHHS Office of Recipient Rights.
MHC 1778[1] 6.3.1 The rights office immediately initiated investigation of 2 0 In 5 of the 11 investigation files REQUIRED ACTION:
apparent or suspected rights violations involving the death of reviewed, there was no RIF or Ensure that all required
a recipient, alleged abuse or neglect of a recipient, or the Summary Report. Therefore, it was investigation
alleged retaliation or harassment of an individual using the impossible to determine if the documentation is
rights system. investigation was initiated completed and
immediately or in a timely and distributed in accordance
efficient manner. with applicable
standards.
MHC 1778[1] 6.3.2 The rights office initiated investigation of apparent or 2 0 See above comments for standard See above REQUIRED
suspected rights violations in a timely and efficient manner. 6.3.1 above. ACTION for standard
6.3.1. above.
MHC 1778{2] 6.4.1 Investigation activities for each rights complaint were 2 0 In 5 of the 11 investigation files See above REQUIRED
accurately recorded by the office. This includes interview reviewed, there was no RIF or ACTION for standard
notes, documents reviewed, policies, and other sources of Summary Report. Therefore, it was 6.3.1.
evidence pertaining to the investigation being contained in impossible to determine if
the complaint case file. investigation activities were
accurately recorded.
MHC 1778[5] 6.5.1 Upon completion of the investigation, the office completed a 2 0 In 5 of the 11 investigation files See above REQUIRED
written investigative report (RIF) and submitted it to the reviewed, there was no RIF or ACTION for standard
respondent and to the RMHA. Summary Report. 6.3.1.

MHC 1782[1] 6.6.1 The executive director submitted a written summary report to 2 0 In 5 of the 11 investigation files See above REQUIRED
the complainant, recipient if different, guardian/parent of a reviewed, there was no Summary ACTION for standard
minor recipient. Report. 6.3.1.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1782[2] 6.7.1 Information in the summary report did not violate the rights 2 0 In 5 of the 11 investigation files See above REQUIRED
of any employee (ex. Bullard-Plawecki Employee Right to reviewed, there was no Summary ACTION for standard
Know Act). Report. Therefore, it was impossible 6.3.1.
to determine if information in the
Summary Report violated the rights
of any employee.
MHC 1784[3] 6.8.1 The rights office advised the appellant that there are advocacy 2 0 In 5 of the 11 investigation files See above REQUIRED
organizations available to assist in preparing the written reviewed, there was no Summary ACTION for standard
appeal and offered to make the referral. In the absence of Report. Therefore, appellants were 6.3.1.
assistance from an advocacy organization, the rights office not advised of the availability of
assisted the appellant in meeting the procedural requirements advocacy organizations. Nor were
of a written appeal. they advised of their appeal rights.
SECTION TOTAL 20 2

Citation Standard SECTION 7 – COMPLAINT RESOLUTION - CONTENT MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1776 (4) 7.1.1 Complaints identified as out-of-jurisdiction or no right 2 2 Although assessors find it REQUIRED ACTION:
involved were correctly categorized and responded to. implausible that no complaints Ensure that all complaints
Sufficient rationale was provided to the complainant. were received that should have received by ORR,
been categorized as OJ/NRI, including complaints
there is no affirmative evidence to deemed to be outside
prove that there were such jurisdiction and not
complaints received. Therefore, involving a code
no points were deducted.
protected right, are
However, as indicated above, in
correctly categorized and
assessors’ experience, it’s
unlikely that no such complaints responded to. Rights
were expressed to the ORR since staff must recognize
the last assessment. when complaints are not
within the jurisdiction of
the rights office and
when complaints do not
express an apparent or
suspected rights
violation. Then, rights
staff must correctly log
and generate
documentation correctly
responding to such
complaints.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

Citation Standard SECTION 7 – COMPLAINT RESOLUTION - CONTENT MAX SCORE FINDINGS REQUIRED ACTION
SCORE
CMHSP 6.4.3.2 7.1.2 For complaints where the intervention process was utilized, 2 0 9 intervention files were reviewed. REQUIRED ACTION:
the rights office conducted the intervention in compliance All of them were deficient in some Ensure that if complaints
with the standards established by MDHHS and utilizing the way. For instance, in 6 of these, the are handled as
preponderance of evidence standard. facts were not clear, therefore they interventions, they are
should have been handled as correctly processed and
resolved. Ensure that
investigations.
complaints are correctly
categorized as
interventions and that
they are not handled as
interventions when they
should have been
investigated.
CMHSP 6.4.3.2 7.1.3 The results of the intervention indicated whether a rights 2 1 In 2 of 9 interventions reviewed, REQUIRED ACTION:
violation was substantiated. the intervention responses did not Ensure that the
indicate whether or not an procedural and
allegation was substantiated. composition standards
for interventions are
completed correctly.
CMHSP 6.4.3.2 7.1.4 The correspondence clearly indicated that process for 2 1 In 2 of 9 interventions reviewed, REQUIRED ACTION:
requesting an investigation if the complainant was not the response documents did not Ensure that the
satisfied with the result of the intervention. indicate the process for procedural and
requesting an investigation if composition standards
complainant was not satisfied with for interventions are
the results of the intervention. completed correctly.
MHC 1778[4] 7.2.1 Issued status reports contained all required elements and 2 0 In 8 of the 11 investigation files REQUIRED ACTION:
were sent to all required persons. reviewed, required Status Reports Ensure that Status
were missing, or it was impossible to Reports are issued when
determine if Status Reports were required to be, and that
required because there were no RIFs Status Reports contain all
and/or Summary Reports in the files. the required elements.
MHC 1778[5][a] 7.3.1 The written investigative report included a statement of 2 0 In 5 of the investigation files REQUIRED ACTION:
allegations as required by MDHHS standards. reviewed, there were no RIFs or Ensure that Allegations
Summary Reports, therefore it was sections include all the
impossible to review their Allegation elements required by
sections. In the files that did have applicable legal and
Allegation sections, 4 displayed training standards.
SUBMIT THE NEXT 5 RIFs
various deficiencies.
WRITTEN BY THIS ORR

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

TO LEAD ASSESSOR FOR

REVIEW.
MHC 1778[5][c] 7.3.2 The written investigative report included citations to relevant 2 0 In 5 of the investigation files REQUIRED ACTION:
provisions of the Mental Health Code, other applicable laws, reviewed, there were no RIFs or Ensure that Citations
rules, policies, and guidelines. Summary Reports, therefore it was sections include all
impossible to review their Citations relevant correct citations.
sections. In 2 RIFs reviewed, there SUBMIT THE NEXT 5 RIFs
WRITTEN BY THIS ORR
were various deficiencies, such as
TO LEAD ASSESSOR FOR
incorrect and missing citations.
REVIEW.
MHC 1778[5][b] 7.3.3 The written investigative report included a statement of the 2 0 In 5 of the investigation files REQUIRED ACTION:
issues involved as required by MDHHS standards. reviewed, there were no RIFs or Ensure that Issues
Summary Reports, therefore it was sections are correctly
impossible to review their Issues written to address the
sections. In 3 RIFs reviewed, there relevant facts and
citations. SUBMIT THE
were various deficiencies. For
NEXT 5 RIFs WRITTEN BY
instance, no Issue question
THIS ORR TO LEAD
regarding risk of harm in a neglect
ASSESSOR FOR REVIEW.
case and including issues that were
not relevant to the alleged violation.

MHC 1778[5][d] 7.3.4 The written investigative report included findings of the 2 0 In 5 of the investigation files REQUIRED ACTION:
investigation that were sufficient to provide a detailed inquiry reviewed, there were no RIFs or Ensure that Findings
and systematic examination of the allegation. Summary Reports, therefore it was sections are correctly
impossible to review their Findings written to describe that
sections. In 3 RIFs reviewed, all necessary and relevant
Findings were deficient in various investigative activities
ways. For instance, not all witnesses were conducted. SUBMIT
were interviewed in all 3 cases. THE NEXT 5 RIFs
WRITTEN BY THIS ORR
TO LEAD ASSESSOR FOR
REVIEW.

MHC 1778[5][e] 7.3.5 The written investigative report included a conclusion section 2 0 In 5 of the investigation files REQUIRED ACTION:
which provided an analysis of the findings and a decision as to reviewed, there were no RIFs or Ensure that Conclusion
whether a violation occurred using a preponderance of Summary Reports, therefore it was sections are correctly
evidence standard. impossible to review their written to thoroughly
Conclusion sections. In 2 RIFs describe why the
reviewed, the Conclusions could Conclusions were
have been better written to more reached. SUBMIT THE
NEXT 5 RIFs WRITTEN BY
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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

clearly describe why the Conclusions THIS ORR TO LEAD

were reached. ASSESSOR FOR REVIEW.

MHC 1778[5][f] 7.3.6 When appropriate, the written investigative report included 2 0 In 5 of the investigation files REQUIRED ACTION:
recommendations which provided for appropriate remedial reviewed, there were no RIFs or Ensure that
action and attempted to prevent a recurrence of the violation. Summary Reports, therefore it was Recommendations
impossible to review their sections include all the
Recommendations sections. In 3 necessary disciplinary
RIFs reviewed, the and/or remedial action
Recommendations sections were language. SUBMIT THE
missing required language regarding NEXT 5 RIFs WRITTEN BY
disciplinary and/or remedial action, THIS ORR TO LEAD
and/or included language that was ASSESSOR FOR REVIEW.
not relevant.
MHC 1722[2] 7.4.1 On substantiated rights violations involving abuse or neglect, 2 0 In 5 of the investigation files REQUIRED ACTION:
the RMHA/ respondent took disciplinary action which reviewed, there were no RIFs or Ensure that Summary
remediated the violation and action to prevent recurrence. Summary Reports, therefore it was Reports are submitted as
impossible to review the Action required. Ensure that for
Taken sections of Summary Reports. substantiated rights
violations involving abuse
or neglect, the RMHA/
respondent took
disciplinary action which
remediated the violation
and action to prevent
recurrence. SUBMIT THE
NEXT 5 SUMMARY
REPORTS WRITTEN BY
THIS ORR TO LEAD
ASSESSOR FOR REVIEW.
MHC 1755[3][b] 7.4.2 On substantiated rights violations not requiring disciplinary 2 0 In 5 of the investigation files REQUIRED ACTION:
MHC 1780[1] action, the RMHA/respondent took remedial action to remedy reviewed, there were no RIFs or Ensure that Summary
the violation and prevent recurrence. Summary Reports, therefore it was Reports are submitted as
impossible to review the Action required. Ensure that for
Taken sections of Summary Reports. substantiated rights
violations, the RMHA/
respondent took remedial
action to remedy the
violation and prevent
recurrence. SUBMIT THE
NEXT 5 SUMMARY
REPORTS WRITTEN BY
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THIS ORR TO LEAD

ASSESSOR FOR REVIEW.

Citation Standard SECTION 7 – COMPLAINT RESOLUTION - CONTENT MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1782 [1] 7.5.1 Summary reports reflected the information from the 2 0 In 5 of the investigation files REQUIRED ACTION:
(a)(b)(c)(d)(e)(f)(g) allegation, citation, and issues, and recommendation sections reviewed, there were no RIFs or Ensure that Summary
of the RIF and provided a summary of the investigative Summary Reports, therefore it was Reports are submitted as
findings of the rights office. impossible to review the content of required. Ensure that
Summary Reports. Summary Reports reflect
the information from the
allegation, citation, and
issues, and
recommendation sections
of the RIF and provide a
summary of the
investigative findings of
the rights office. SUBMIT
THE NEXT 5 SUMMARY
REPORTS WRITTEN BY
THIS ORR TO LEAD
ASSESSOR FOR REVIEW.

MHC 1780 7.5.2 The Summary Report provided detailed information as to the 2 0 In 5 of the investigation files REQUIRED ACTION:
action taken (or action planned to be taken) in order to meet reviewed, there were no Summary Ensure that Summary
the requirements stated in MHC 1780. Reports, therefore it was impossible Reports are submitted as
to review the Action Taken sections required. Ensure that for
of Summary Reports. substantiated rights
violations, the RMHA/
respondent took remedial
action to remedy the
violation and prevent
recurrence. SUBMIT THE
NEXT 5 SUMMARY
REPORTS WRITTEN BY
THIS ORR TO LEAD
ASSESSOR FOR REVIEW.

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Citation Standard SECTION 7 – COMPLAINT RESOLUTION - CONTENT MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1782[1][h] 7.5.3 As part of the Summary Report the complainant, recipient, if 2 0 In 5 of the investigation files REQUIRED ACTION:
different, guardian or parent of a minor were informed of reviewed, there were no Summary Ensure that Summary
their right to appeal, the grounds for filing the appeal, and Reports, therefore it was impossible Reports are submitted as
information about where to send the appeal. to know if appeal notices were required. Ensure that all
provided to the potential appellants Summary Reports include
in those cases. a notice of appeal rights.
SUBMIT THE NEXT 5
SUMMARY REPORTS
WRITTEN BY THIS ORR
TO LEAD ASSESSOR FOR
REVIEW.

CMHSP 6.3.2.4 II.D 7.5.4 If the Summary Report included a “Plan of Action”, written 2 0 In 5 of the investigation files REQUIRED ACTION:
notice was issued to the potential appellants upon completion reviewed, there were no Summary Ensure that Summary
of the plan. If the action taken was different than the plan, the Reports, therefore it was impossible Reports are submitted as
notice detailed the action that was taken and the date it to know if a case required that a required. Ensure that for
occurred as well as informed potential appellants of the right Notice of Completion of Plan of all Summary Reports that
to appeal on action only. Action be sent. In one file, it was require a Notice of
apparent that a Notice of Completion of Plan of
Completion of Plan of Action was Action, the Notice is sent.
required to be sent, but it was not SUBMIT THE NEXT 5
sent. SUMMARY REPORTS
WRITTEN BY THIS ORR
TO LEAD ASSESSOR FOR
REVIEW.

SECTION TOTAL 34 4

Citation Standard SECTION 8 – COMPLAINT RESOLUTION - TIMEFRAMES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1776 (3) 8.1.1 For each complaint received, the Rights Office provided, to the 2 0 Prior to assessment, the CMH was REQUIRED ACTION:
complainant within 5 business days, an acknowledgement of required to submit data regarding Ensure that the data
receipt and a copy of the complaint. the dates of completion for all collected and logged
required ORR complaint resolution regarding dates of
documentation. This data was required ORR
submitted. However, during the on- documentation is
site assessment, assessors observed accurate and reliable.
that there were multiple mistakes Ensure that timelines
and inaccuracies found when established by law and
comparing the contents of the standards are met.
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complaint resolution files to the

dates that were provided on the
data report. Therefore, it was
impossible to accurately and reliably
establish compliance related to
timeliness.
CMHSP 6.4.3.2 8.1.2 For each complaint utilizing the intervention process, 2 0 See comments for standard 8.1.1 See REQUIRED ACTION
responses were provided to the complaint within 30 calendar above. for standard 8.1.1 above.
days.
MHC 1778 (4) 8.1.3 For each investigation, status reports were issued every 30 2 0 See comments for standard 8.1.1 See REQUIRED ACTION
days, as required. above. Additionally, according to for standard 8.1.1 above.
the data that was provided by the
CMH, there was only 83.3%
compliance with this requirement.
MHC 1778 (1) 8.1.4 Subject to delays involving pending action by external 2 0 See comments for standard 8.1.1 See REQUIRED ACTION
agencies, the office completed investigations no later than 90 above. Additionally, according to for standard 8.1.1 above.
calendar days following receipt. the data that was provided by the
CMH, there was only 88.2%
compliance with this requirement.
MHC 1782 (1) 8.1.5 A written Summary Report was issued for each Report of 2 0 See comments for standard 8.1.1 See REQUIRED ACTION
Investigative Findings (RIF) within 10 business days after above. Additionally, according to the for standard 8.1.1 above.
receipt of the RIF. data that was provided by the CMH,
there was only 58.8% compliance
with this requirement.
SECTION TOTAL 10 0

Citation Standard SECTION 9 – APPEALS MAX SCORE FINDINGS REQUIRED ACTIONS

SCORE
MHC 1774[2][a,b] 9.1.1 The Board of the CMHSP appointed an appeals committee to 2 2
hear appeals of recipient rights matters OR designated the
RRAC as the appeals committee.
MHC 1784[4] 9.2.1 Within 5 business days after receipt of a written appeal, at 0
C6.3.2.4.III.F. least 2 committee members reviewed the appeal to
determine whether it met criteria.
MHC 1784(2) 9.2.2 Requests for appeal were correctly accepted or rejected in 0
C6.3.2.4 accordance with the standards established in the Code and
Contract language.

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Citation Standard SECTION 9 – APPEALS MAX SCORE FINDINGS REQUIRED ACTIONS

SCORE
C 6.3.2.4.III.G. 9.2.3 Within 7 business days of the receipt of the appeal, written 0
MHC 1784(4) notification was provided to the appellant as to the
acceptance or denial of the appeal. A notice of rejection shall
describe the reason for not accepting the appeal.
MHC 1784(4) 9.2.4 A copy of the appeal was provided to the Rights Office, the 0
respondent, and the RMHA.
MHC 1774[6] 9.3.1 A member of the Appeals Committee who has a personal or 0
professional relationship with an individual involved in the
appeal abstained from participating in the appeal.
MHC 1784[5][a-d] 9.4.1 Within 30 days after the written appeal was received, the 0
C 6.3.2.4.III.H. Appeals Committee met in a closed session and reviewed the
facts as stated in all complaint investigation documents.
MHC 1784[5] 9.4.2 The Appeals Committee took an action that was in compliance 0
C 6.3.2.4.III.H. with the Code, Rules, and contract requirements.
MHC 1784[5] 9.4.3 The decision of the appeals committee was based upon a 0
C 6.3.2.4.III. H review of the facts and an analysis of the investigative reports.
MHC 1784[6] 9.5.1 The Appeals Committee documented its decision in writing 0
C 6.3.2.4.III.J. and provided written justification for that decision.
MHC 1784[6] 9.5.2 Within 10 days after reaching its decision, the Appeals 0
Committee provided copies of the decision to the respondent,
appellant, recipient, if different than appellant, recipient’s
guardian, the RMHA and the rights office.
MHC 1786 9.5.3 Were all other actions taken in response to the appeals 0
C 6.3.2.4.V.C-D. committee decision completed in compliance with the
requirements of applicable contract standards?”
C 6.3.2.4 9.6.1 Processing of appeals to Step 2 is handled in accordance with 0
the MHC and CMHSP Contract attachment 6.3.2.4.
SECTION TOTAL 2 2

tation Standard SECTION 10 – SEMI-ANNUAL AND ANNUAL REPORTING MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755[5][j] 10.1.1 By June 30 of each year, the Rights Office provided to MDHHS 2 2
CMHSP 6.5.1.1 and to the agency RRAC, a summary of complaint data
together with a remedial action taken on substantiated
complaints.
MHC 1755[6] 10.2.1 By December 30 of each year, the CMHSP submitted to 2 2
CMHSP 6.5.1.1 MDHHS, an annual report prepared by the recipient rights
office on the current status of recipient rights in the agency

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CMHSP RIGHTS SYSTEM ASSESSMENT 2022 ASSESSMENT REPORT

and a review of the operations of the rights office for the

preceding fiscal year.

MHC 1755[6] 10.3.1 By January 30 of each year, the Rights Office submitted the 2 2
CMHSP 6.5.1.1 ORR Annual Report Monitoring form for the preceding
calendar year to MDHHS-ORR.
SECTION TOTAL 6 6

Citation Standard SECTION 11 – SITE VISITS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755 (5)(e) 11.1.1 The agency ensured that for all service providers - other than 2 2 95.8% compliance
ORR Guidance LPHs and other providers that have their own rights system –
17-01 the service site is visited with the frequency necessary for
protection of rights but in no case less than annually.
MHC 1755 (b)(c) 11.1.2 The agency ensured that for each site review of service 2 2
(i) MHC 1776 (1) providers - other than LPHs and other providers that have their
(5) MHC 1723 own rights system – the review contained all elements
required by Code, Rules, Contract and MDHHS-ORR standards.
MHC 1755 (5)(g) 11.2.1 The agency ensured that for each site review of service 2 2
providers - other than LPHs and other providers that have their
own rights system – any necessary follow up or remedial
action required to bring providers into compliance with ORR
standards is addressed and completed.
MHC 1755 (5)(e) 11.2.2 The Agency ensured that the service sites of all LPHs and other 2 0 33.3% compliance according to the REQUIRED ACTION:
providers that have their own rights system are visited with data provided by CMH. Additionally, Ensure that ALL LPHs
the frequency necessary for protection of rights but in no case assessor observed that data was only for whom NorthCare
less than annually. provided for one LPH (War Memorial holds a contract on
Hospital). It was confirmed that behalf of HBH are
contracts are held with at least 7 visited at least
LPHs, but no evidence was provided annually.
regarding the timeliness of the visits
for those other hospitals.

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Citation Standard SECTION 11 – SITE VISITS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755 (5)(e) 11.2.3 The Agency ensured that for site reviews of LPHs and other 2 0 Because data was only provided for REQUIRED ACTION:
providers that have their own rights system, the review one LPH, assessors were unable to Ensure that all LPHs for
contained all elements required by Code, Rules, Contract and determine if other hospital visits whom NorthCare holds
MDHHS-ORR standards. occurred, or if the quality of the visits a contract on behalf of
met applicable standards. HBH are visited at least
annually, and that the
quality of the visits and
the visit documentation
meets MDHHS-ORR
standards.
MHC 1755 (5)(e) 11.2.4 The Agency ensured that, for each site review of LPHs and 2 0 See comments for standard 11.2.3 See REQUIRED ACTION
other providers that have their own rights system, any above. for standard 11.2.3
necessary follow up or remedial action required to bring above.
providers into compliance with ORR standards is addressed
and completed.
MHC 1755 (5)(e) 11.2.5 The Agency ensured that the recipient rights policies of LPHs 2 0 See comments for standard 11.2.3 See REQUIRED ACTION
and other providers that have their own rights system are above. for standard 11.2.3
reviewed, and that the reviews are done in compliance with above. Additionally,
applicable standards for rights policy reviews. ensure that the
recipient rights policies
of all contracted LPHs
are reviewed at least
once every 3 years (at
least once during each
assessment period).
SECTION TOTAL 14 6

Report Prepared by: Date: 7/5/2022

Janice W. Terry, Community Rights Specialist, MDHHS-ORR

Report Reviewed by: Date: 7/5/2022

Raymie Postema, Director, MDHHS-ORR
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