STATE OF MICHIGAN

GRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES ELIZABETH HERTEL

GOVERNOR LANSING DIRECTOR

October 18, 2023

Mike Bach, Executive Director

Copper Country Mental Health Services
901 W. Memorial Dr.
Houghton, MI 49931

Dear Mr. Bach,

Attached you will find the results of the assessment completed by MDHHS-ORR staff Janice Terry August 15-
17, 2023. 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 401 points out of a total of 450 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 regarding the establishment and implementation
of a system that 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 November
29, 2023. 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
November 29, 2023.
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.

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

www.michigan.gov/mdhhs • 517-241-3740
Sincerely,

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
Sarah Rousseau, CCMHS Recipient Rights Officer
 OFFICE OF RECIPIENT RIGHTS
2023 RIGHTS SYSTEM ASSESSMENT REPORT

AGENCY: COPPER COUNTRY MENTAL HEALTH AUTHORITY

ASSESSMENT DATES: August 15-17, 2023

REVIEWER: Janice Terry (Lead)

SECTION MAXIMUM WEIGHT MAXIMUM YOUR YOUR

POSSIBLE POSSIBLE INITIAL WEIGHTED
SCORE SCORE SCORE SCORE
(WEIGHTED)
1. CMHSP RESPONSIBILITIES 26 3 78 24 72
2. RIGHTS OFFICE OPERATIONS 16 3 48 16 48
3. EDUCATION AND TRAINING 12 3 36 12 36
4. POLICIES 6 1 6 6 6
5. RIGHTS ADVISORY COMMITTEE 16 1 16 16 16
6. COMPLAINT RESOLUTION - PROCESS 18 3 54 11 33
7. COMPLAINT RESOLUTION – CONTENT 30 3 90 22 66
8. COMPLAINT RESOLUTION - TIMEFRAMES 10 3 30 10 30
9. APPEALS 26 2 52 24 48
10. SEMI-ANNUAL AND ANNUAL REPORTING 6 2 12 6 12
11. SITE VISITS 14 2 28 14 28
TOTAL SCORE 180 450 161 395

APPEALS
. MAXIMUM SCORE 450
FULL COMPLIANCE 428
SUBSTANTIAL COMPLIANCE 405
LESS THAN SUBSTANTIAL COMPLIANCE <405
CMHSP RIGHTS SYSTEM ASSESSMENT 2023 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 100(a)(30) 1.1.2 The Agency has appointed a designee to act in place of the 2 2
MHC 1782 Executive Director in the absence of the Director.
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 0 Evidence indicates that ORR staff were REQUIRED ACTION:
could interfere with the impartial, even-handed, and routinely impeded in their duty to Develop a new procedure
thorough performance of its duties. ensure that remedial and disciplinary for completing and
action was completed in a timely implementing remedial/
manner. This agency employs a disciplinary action for
procedure by which a team of substantiated rights
administrative staff consisting of the violations. Ensure that
Assistant Director and the Human when remedial and/or
Resources Director collaborate to disciplinary action is
decide what remedial and/or required to be taken
disciplinary action will be taken for resulting from a
every substantiated rights violation. substantiated rights
Documentary and testimonial violation, that such action
evidence supports that during the occurs preferably by the
most recent assessment period, the date of the sending of the
procedure became burdensome and Summary Report.
inefficient for the involved staff,
resulting in regular failures to enact
remedial/disciplinary action within a
reasonable time frame. Additionally, a
significant number of substantiated
investigations never had action
completed at all, even up to the time
of this assessment. The failure of the
administrative team to follow through
with completion of remedial/
disciplinary action resulted in a failure
to promptly notify potential appellants
of the results of their complaints, and
in many cases, a failure to notify
potential appellants that any action
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

had been taken at all. These delays

continued to occur despite repeated
efforts by the Rights Officer to request
administrative staff to promptly
complete remedial/disciplinary action.
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 complaints of retaliation/
behalf of a recipient will be protected from harassment or harassment received since last
retaliation resulting from recipient rights activities. assessment.
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
No change in position of Recipient
MHC 1757(2) (e) office who has the education, training, and experience to
Rights Director since last assessment.
fulfill the responsibilities of the office.
MHC 1755(4) 1.4.2 The CMH has established a process to assure ongoing rights 2 2
MHC 1778(1) 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
MHC 1755 (4) Rights Advisory Committee in the hiring of the Director of
the office.
MHC 1755 (4) 1.4.4 The director of the rights office has no clinical service 2 2
responsibilities.
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.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

Citation Standard SECTION 1 - CMHSP RESPONSIBILITIES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
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.
SECTION TOTAL 26 24

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.
MHC 1755[5][d][i] 2.4.1 ORR maintained a record system for all reports of apparent 2 2
or suspected rights violations received including a
mechanism for logging all complaints.
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 16

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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 Two new ORR staff were hired since
completed the Basic Skills Training programs within 90 days of last assessment. Both successfully
hire. completed received Basic Skills
Training.
CMHSP 6.3.2 3.1.2 The Executive Director has completed the MDHHS CEO Rights 2 2 Two persons have been hired as
training program within 180 days of hire. Executive Director since last
assessment. Both correctly received
Executive Director Training.
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 2 91% compliance.
agencies received training related to recipient rights
protection before or within 30 days after being employed.
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 12

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 CMH recipient rights policies were REQUIRED ACTION:
reporting, review, investigation, and resolution of apparent or reviewed by assessor for this Ensure that all recipient
suspected rights violations, and are designed to protect assessment. Please see attached rights related policies
recipients from, and prevent repetition of, violations of rights document describing results of policy contain language that
guaranteed by Chapters 7 and 7A. review. Changes to policies are matches the language
required to occur in multiple places. and requirements of all
applicable laws, including
the Mental Health Code,
Administrative Rules,
MDHHS-CMH Contract,
etc. Make required
changes to policies and
resubmit for re-review.

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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.
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
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

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Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1776[3] 6.1.1 For each rights complaint recorded, an acknowledgement 2 2
letter and copy of the complaint was sent to the complainant.
MHC 1776[6] 6.2.1 If a rights complaint had been filed regarding the conduct of 2 2 No complaints were submitted
the agency director, the rights investigation was conducted by against the Executive Director since
the office of another CMHSP or, if requested by the CMHSP the last assessment.
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 The majority of investigations REQUIRED ACTION:
apparent or suspected rights violations involving the death of reviewed that required immediate Ensure that all
a recipient, alleged abuse or neglect of a recipient, or the initiation of investigation did not investigations regarding
alleged retaliation or harassment of an individual using the include evidence proving this allegations of abuse and
rights system. occurred. This lack of evidence neglect are immediately
occurred because reports of initiated. Ensure that
investigative findings routinely did dates of interviews and
not include dates of interviews and document review are
document review. ORR staff stated included in reports of
that they did not know they were investigative findings.
required to include these dates is
their RIFs.
MHC 1778[1] 6.3.2 The rights office initiated investigation of apparent or 2 1 1 of 2 files that required timely and REQUIRED ACTION:
suspected rights violations in a timely and efficient manner. efficient initiation of investigation Ensure that for all
were not initiated in a timely and investigations that are
efficient manner. required to be initiated in
a timely and efficient
manner, this occurs.
MHC 1778{2] 6.4.1 Investigation activities for each rights complaint were 2 2
accurately recorded by the office. This includes interview
notes, documents reviewed, policies, and other sources of
evidence pertaining to the investigation being contained in
the complaint case file.
MHC 1778[5] 6.5.1 Upon completion of the investigation, the office completed a 2 2
written investigative report (RIF) and submitted it to the
respondent and to the RMHA.

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Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1782[1] 6.6.1 The executive director submitted a written summary report to 2 0 10 investigation files were reviewed REQUIRED ACTION:
the complainant, recipient if different, guardian/parent of a at assessment. Of these, 9 included Provide an accounting of
minor recipient. substantiated rights violations and the status of all
all 9 did not have remedial/ substantiated rights
disciplinary action completed when violations completed
the Summary Report was issued. since the previous
There were no Notices of assessment. Specifically,
Completion of Action subsequently address the matters
sent out for any of the 9 nine cases. described in the email
Therefore, for those 9 cases the from assessor Janice
potential appellants were never Terry to Executive
notified of the action taken in Director Mike Bach of
response to the substantiated August 31, 2023.
violations, and none were notified of Additionally, develop a
their right to appeal on action taken. new procedure for
Evidence provided at assessment promptly determining
supports that this occurred with appropriate remedial/
many other cases that were not fully disciplinary action for
reviewed at assessment. substantiated rights
violations, for promptly
delivering the
remedial/disciplinary
action notification to the
accused staff person,
ORR, and CCMHS human
resources file, and
promptly notifying
potential appellants of
the action taken and their
right to appeal.
MHC 1782[2] 6.7.1 Information in the summary report did not violate the rights 2 2
of any employee (ex. Bullard-Plawecki Employee Right to
Know Act).

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Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1784[3] 6.8.1 The rights office advised the appellant that there are advocacy 2 0 Based on the findings in 6.6.1. it is REQUIRED ACTION:
organizations available to assist in preparing the written evident that potential appellants Provide potential
appeal and offered to make the referral. In the absence of were not provided this notification. appellants with
assistance from an advocacy organization, the rights office information regarding
assisted the appellant in meeting the procedural requirements advocacy organizations
of a written appeal. available to assist with
the appeal process, or
indicate that the rights
office is available to
provide this assistance.
SECTION TOTAL 18 11

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
involved were correctly categorized and responded to.
Sufficient rationale was provided to the complainant.
CMHSP 6.4.3.2 7.1.2 For complaints where the intervention process was utilized, 2 2
the rights office conducted the intervention in compliance
with the standards established by MDHHS and utilizing the
preponderance of evidence standard.
CMHSP 6.4.3.2 7.1.3 The results of the intervention indicated whether a rights 2 2
violation was substantiated.
CMHSP 6.4.3.2 7.1.4 The correspondence clearly indicated that process for 2 2
requesting an investigation if the complainant was not
satisfied with the result of the intervention.
MHC 1778[4] 7.2.1 Issued status reports contained all required elements and 2 2
were sent to all required persons.
MHC 1778[5] [a-c] 7.3.1 The written investigative report included a statement of the 2 2
alleged rights violation, all relevant citations, and a statement
of the issues involved.
MHC 1778[5][d] 7.3.2 The written investigative report included findings of the 2 1 9 of 10 Reports of Investigative REQUIRED ACTION:
investigation that were sufficient to provide a detailed inquiry Findings (and their related Summary Ensure that all RIFs and
and systematic examination of the allegation. Reports) reviewed did not include Summary Reports include
the dates of interviews or the dates dates of interviews and
documents were reviewed. ORR document review.
staff expressed that they did not
know they were required to include
these dates in the reports.
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Citation Standard SECTION 7 – COMPLAINT RESOLUTION - CONTENT MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1778[5][e] 7.3.3 The written investigative report included a conclusion section 2 2
which provided an analysis of the findings and a decision as to
whether a violation occurred using a preponderance of
evidence standard.
MHC 1778[5][f] 7.3.4 When appropriate, the written investigative report included 2 2
recommendations which provided for appropriate remedial
action and attempted to prevent a recurrence of the violation.
MHC 1722[2] 7.4.1 On substantiated rights violations involving abuse or neglect, 2 0 In response to inquiry by assessor, REQUIRED ACTION: See
the RMHA/ respondent took disciplinary action which ORR staff conducted a preliminary REQUIRED ACTION for
remediated the violation and took action to prevent review of completed investigations standard 6.6.1 above.
recurrence. back to June 2021, to determine if The required audit of
disciplinary action had been substantiated
“delivered” to accused staff and investigations shall
therefore completed. They encompass all
determined on initial examination investigations from the
that since June of 2021 there were 5 date of the last
substantiated abuse and neglect assessment through the
cases for which discipline was present. Additionally, for
completed very late (from 2 to 12 all investigations
months after Summary Report discovered to NOT have
issued), and 11 abuse and neglect yet had appropriate
cases for which disciplinary actions remedial/disciplinary
were not completed at all, going action completed, the
back to February 2023. Executive Director shall
ensure that such action is
completed as soon as
possible, and that notices
of completion of action
are sent to all involved
potential appellants.
MHC 1755[3][b] 7.4.2 On substantiated rights violations not requiring disciplinary 2 2
MHC 1780[1] action, the RMHA/respondent took remedial action to remedy
the violation and took action to prevent recurrence.
MHC 1782 [1] 7.5.1 Summary reports reflected the information from the 2 0 For 9 of 10 Summary Reports REQUIRED ACTION:
(a)(b)(c)(d)(e)(f)(g) allegation, citation, and issues, and recommendation sections reviewed, the summary of Ensure that the Summary
of the RIF and provided a summary of the investigative investigative findings was not of Investigative Findings
findings of the rights office. The summary of investigative sufficient for potential appellants to sections of Summary
findings was sufficient for the potential appellant to determine if they wanted to appeal. Reports contain all the
determine if they want to appeal. This is because in these reports, information necessary to
there were no dates of interviews or enable potential
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

document reviews, so it was nearly appellants to determine

impossible for readers to know if the whether or not they have
investigations were initiated grounds for appeal.
immediately or in a timely and
efficient manner. Because one of
the grounds for appeal is that the
investigation “was not initiated or
completed on a timely basis,”
potential appellants were not
provided the information they
needed to determine the timeliness
of the initiation or completion of
those investigations. Also, the
timeframe within which witnesses
are interviewed is important to
know, since logically, the longer the
time that elapses between an
incident and when the witness
describes it, the more unreliable the
witness’s testimony becomes, which
can potentially affect the reliability
of evidence obtained in an
investigation, resulting in dispute
over “facts,” which is a grounds for
appeal.
MHC 1780 7.5.2 The Summary Report provided detailed information as to the 2 2 A significant number of Summary REQUIRED ACTION:
action taken (or action planned to be taken) in order to meet Reports reviewed indicated in the Ensure that the ACTION
the requirements stated in MHC 1780. ACTION TAKEN section that action TAKEN/ PLAN OF ACTION
had not yet been taken but would be sections of Summary
taken, without specifying what that Reports contain detailed
action would be. It is sometimes information describing to
unavoidable that a planned action potential appellants what
cannot be “delivered” to the accused the CMH plans to do to
staff by the time the Summary correct, remediate, and
Report must be sent. Also, there is prevent recurrence of
no requirement that the ACTION substantiated rights
TAKEN section MUST describe violations. This
SPECIFICS of the planned action. requirement necessarily
However, there is typically no reason includes the requirement
why the ACTION TAKEN section of that the Executive
the Summary Report can’t include Director decide on the
the planned action, and “best action to be taken by the
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

practice,” good “customer service” time the Summary

standards, and the obvious intent of Reports are sent.
the MHC require this be done.
Further, MHC 780 (1)(b) requires
action “to be implemented in a
timely manner.” Evidence supports
that at this CMH, their procedure for
determining action and
administering the delivery of that
action to accused staff is
burdensome, inefficient, and
ineffective, particularly due to
regularly being “untimely.” The final
result is that often potential
appellants are not informed of the
action taken. Because that
deficiency is addressed in 2 other
standards, and because ACTION
TAKEN sections of Summary Reports
were not left completely blank,
points will not be deducted in this
standard.
MHC 1782[1][h] 7.5.3 As part of the Summary Report the complainant, recipient, if 2 1 All Summary Reports reviewed had REQUIRED ACTION: Fix
different, guardian or parent of a minor were informed of appeal instructions attached. appeal notice to add an
their right to appeal, the grounds for filing the appeal, and However, the appeal instructions instruction that appeal
information about where to send the appeal. template does not include the requests can be sent
address to send an appeal to. It directly to the Recipient
informs potential appellants to Rights Appeals
“request an appeal from the Committee at a specified
Recipient Rights Appeals Committee address.
or the Director’s Office. The
Recipient Rights Office will assist you
in submitting an appeal upon
request.” Because this standard has
multiple parts, and appeal notices
describing grounds for appeal are
sent as required, only 1 point will be
deducted for this standard.
CMHSP 6.3.2.4 II.D 7.5.4 If the Summary Report included a “Plan of Action”, written 2 0 See comments for related standard See REQUIRED ACTION
notice was issued to the potential appellants upon completion 6.8.1 above, which apply to this for standard 6.6.1 above,
of the plan. If the action taken was different than the plan, the standard as well. which also applies to this
notice detailed the action that was taken and the date it standard.
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

occurred as well as informed potential appellants of the right

to appeal on action only.
SECTION TOTAL 30 22

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 2 93% compliance.
complainant within 5 business days, an acknowledgement of
receipt and a copy of the complaint.
CMHSP 6.4.3.2 8.1.2 For each complaint utilizing the intervention process, 2 2 100% compliance.
responses were provided to the complaint within 30 calendar
days.
MHC 1778 (4) 8.1.3 For each investigation, status reports were issued every 30 2 2 96% compliance.
days, as required.
MHC 1778 (1) 8.1.4 Subject to delays involving pending action by external 2 2 100% compliance.
agencies, the office completed investigations no later than 90
calendar days following receipt.
MHC 1782 (1) 8.1.5 A written Summary Report was issued for each Report of 2 2 90% compliance.
Investigative Findings (RIF) within 10 business days after
receipt of the RIF.
SECTION TOTAL 10 10

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 2 2 One appeal received since last
C6.3.2.4.III.F. least 2 committee members reviewed the appeal to assessment.
determine whether it met criteria.
MHC 1784(2) 9.2.2 Requests for appeal were correctly accepted or rejected in 2 2
C6.3.2.4 accordance with the standards established in the Code and
Contract language.
C 6.3.2.4.III.G. 9.2.3 Within 7 business days of the receipt of the appeal, written 2 2
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.

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Citation Standard SECTION 9 – APPEALS MAX SCORE FINDINGS REQUIRED ACTIONS

SCORE
MHC 1784(4) 9.2.4 A copy of the appeal was provided to the Rights Office, the 2 1 A copy of the appeal request was REQUIRED ACTION:
respondent, and the RMHA. provided to the rights office, but not Modify appeal
to the respondent, who was the acceptance letter
CMH. template to include
language indicating that a
copy of the appeal
request was provided to
the respondent and
RMHA, as well as ORR.
MHC 1774[6] 9.3.1 A member of the Appeals Committee who has a personal or 2 2
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 2 2
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 2 2
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 2 2
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 2 1 The decision was documented in REQUIRED ACTION:
C 6.3.2.4.III.J. and provided written justification for that decision. writing, but it did not include written Modify appeal decision
justification for the decision. letter template to include
language describing the
justification for the
committee’s decision.
MHC 1784[6] 9.5.2 Within 10 days after reaching its decision, the Appeals 2 2
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 2 2
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 2 2
the MHC and CMHSP Contract attachment 6.3.2.4.
SECTION TOTAL 26 24

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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

Citation 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
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
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 2
providers that have their own rights system are visited with
the frequency necessary for protection of rights but in no case
less than annually.
MHC 1755 (5)(e) 11.2.3 The Agency ensured that for site reviews of LPHs and other 2 2
providers that have their own rights system, the review
contained all elements required by Code, Rules, Contract and
MDHHS-ORR standards.

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 CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

MHC 1755 (5)(e) 11.2.4 The Agency ensured that, for each site review of LPHs and 2 2
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) 11.2.5 The Agency ensured that the recipient rights policies of LPHs 2 2
and other providers that have their own rights system are
reviewed, and that the reviews are done in compliance with
applicable standards for rights policy reviews.
SECTION TOTAL 14 14

Report Prepared by: Date: 10/18/2023

Janice Terry, Community Rights Specialist, MDHHS-ORR

Report Reviewed by: Date: 10/31/2023

Andrew Silver, Director, Education, Training and Compliance, MDHHS-ORR

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