STATE OF MICHIGAN

GRETCHEN WHITMER DEPARTMENT OF HEALTH AND HUMAN SERVICES ELIZABETH HERTEL

GOVERNOR LANSING DIRECTOR

July 20, 2023

Constance Conklin, Executive Director

Livingston County Community Mental Health Authority
2280 E. Grand River Rd.
Howell, MI 48843

Dear Ms. Conklin,

Attached you will find the results of the revised assessment report completed by MDHHS-ORR staff Janice
Terry and Cynthia Shadeck May 16-18, 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 351 points out of a total of 402 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 was received on July 14, 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
August 31, 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
Katie Snay, Washtenaw Community Mental Health Recipient Rights Director
 OFFICE OF RECIPIENT RIGHTS
2023 RIGHTS SYSTEM ASSESSMENT REPORT

AGENCY: Livingston County Community Mental Health Authority

ASSESSMENT DATES: May 16-18, 2023

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 26 3 78 24 72
2. RIGHTS OFFICE OPERATIONS 16 3 48 15 45
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 18 54
7. COMPLAINT RESOLUTION – CONTENT 30 3 90 26 78
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 14 28
TOTAL SCORE 156 402 141 351

NO APPEALS
MAXIMUM SCORE 402
FULL COMPLIANCE 382
SUBSTANTIAL COMPLIANCE 362
LESS THAN SUBSTANTIAL COMPLIANCE <362
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 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 0 One complaint of retaliation/ REQUIRED ACTION:
behalf of a recipient will be protected from harassment or harassment was received since last Ensure that allegations
retaliation resulting from recipient rights activities. assessment. The investigation was of retaliation/
inadequate in multiple ways. For harassment are
instance, after taking the phone immediately, thoroughly,
complaint from the psychologist who and correctly
had allegedly been retaliated against investigated, in order to
(fired on the same day she reported an ensure that violators are
abuse allegation), the rights held accountable for the
investigator attempted to contact the rights violation and
provider/ employer several times but persons are protected
it took 3 ½ months until a telephone from being retaliated
interview was conducted with the against and/or harassed
accused provider. Additionally, the due to involvement in
complainant’s supervisor (who would the recipient rights
have had relevant knowledge) was not process.
interviewed at all, rather, a written
statement was obtained over four
months after complaint received. The
RIF was not completed until almost
five months after complaint received,
with no apparent reason for the delay.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

Citation Standard SECTION 1 - CMHSP RESPONSIBILITIES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1755(3) (a) 1.3.4 Appropriate disciplinary action was taken if there was 2 2 The one retaliation/ harassment
AR 7035(1) evidence of retaliation and harassment. case described above was not
substantiated.
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 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.
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.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 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 1 In the course of the assessment, it was REQUIRED ACTION:
or suspected rights violations received including a discovered that the integrity of the Ensure that the recipient
mechanism for logging all complaints. complaint record system was not rights complaint record-
adequately maintained. For instance, keeping system,
multiple dates were entered into the including the log, is
data system, that, upon cross- accurate, up to date, and
checking, were found to be inaccurate consistent with dates
when compared to dates observed in contained on recipient
paper files. rights documents.
Specifically, ensure that
all complaints are
correctly responded to in
accordance with the
Mental Health Code and
MDHHS-ORR
requirements.
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 15

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
completed the Basic Skills Training programs within 90 days of
hire.
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.

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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

MHC 1755[5][f] 3.3.1 All individuals employed by the CMHSP, or its contract 2 2 96% 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
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.
SECTION TOTAL 6 6

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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

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 submitted against
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.

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Citation Standard SECTION 6 – COMPLAINT RESOLUTION - PROCESS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1778[1] 6.3.1 The rights office immediately initiated investigation of 2 2
apparent or suspected rights violations involving the death of
a recipient, alleged abuse or neglect of a recipient, or the
alleged retaliation or harassment of an individual using the
rights system.
MHC 1778[1] 6.3.2 The rights office initiated investigation of apparent or 2 2
suspected rights violations in a timely and efficient manner.
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.
MHC 1782[1] 6.6.1 The executive director submitted a written summary report to 2 2
the complainant, recipient if different, guardian/parent of a
minor recipient.
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).
MHC 1784[3] 6.8.1 The rights office advised the appellant that there are advocacy 2 2
organizations available to assist in preparing the written
appeal and offered to make the referral. In the absence of
assistance from an advocacy organization, the rights office
assisted the appellant in meeting the procedural requirements
of a written appeal.
SECTION TOTAL 18 18

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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 involved 2 2 Four NRI/OJ cases were reviewed.
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, the 2 2 This office just recently began using
rights office conducted the intervention in compliance with the the intervention process. The two
standards established by MDHHS and utilizing the intervention cases that were
preponderance of evidence standard. reviewed were adequate.
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 were 2 2
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 2
investigation that were sufficient to provide a detailed inquiry
and systematic examination of the allegation.
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, the 2 2
RMHA/ respondent took disciplinary action which remediated
the violation and took action to prevent recurrence.
MHC 1755[3][b] 7.4.2 On substantiated rights violations not requiring disciplinary 2 0 In three of eight cases that required REQUIRED ACTION:
MHC 1780[1] action, the RMHA/respondent took remedial action to remedy remedial action, there is no evidence Ensure and document
the violation and took action to prevent recurrence. that the promised remedial action that remedial action
was completed. which satisfies the
requirements of the
Mental Health Code is
completed for all
substantiated rights
violations.
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

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 2
(a)(b)(c)(d)(e)(f)(g) allegation, citation, and issues, and recommendation sections
of the RIF and provided a summary of the investigative
findings of the rights office. The summary of investigative
findings was sufficient for the potential appellant to
determine if they want to appeal.
MHC 1780 7.5.2 The Summary Report provided detailed information as to the 2 2
action taken (or action planned to be taken) in order to meet
the requirements stated in MHC 1780.
MHC 1782[1][h] 7.5.3 As part of the Summary Report the complainant, recipient, if 2 2
different, guardian or parent of a minor were informed of
their right to appeal, the grounds for filing the appeal, and
information about where to send the appeal.
CMHSP 6.3.2.4 II.D 7.5.4 If the Summary Report included a “Plan of Action,” written 2 0 Four reviewed cases required a REQUIRED ACTION: For
notice was issued to the potential appellants upon completion notice of completion of plan of cases for which the Plan
of the plan. If the action taken was different than the plan, the action. The notice was not of Action is incomplete
notice detailed the action that was taken and the date it completed for any of them. when the Summary
occurred as well as informed potential appellants of the right Report is issued, ensure
to appeal on action only. that the Plan of Action is
completed and that
when it is completed, a
Notice of Completion of
Action is sent to
appellants.
SECTION TOTAL 30 26

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 As noted above for standard 2.4.1, REQUIRED ACTION:
complainant within 5 business days, an acknowledgement of during the assessment it was Ensure that the recipient
receipt and a copy of the complaint. discovered that the integrity of the rights complaint record-
complaint record system was not keeping system,
adequately maintained. This including the log, is
observation resulted in a conclusion accurate, up to date, and
that the data provided for consistent with dates
assessment purposes was unreliable. contained on recipient
When reviewing individual case files rights documents.
and comparing dates on required Specifically, ensure that
documentation with dates entered all complaints are
on the log, multiple inconsistencies correctly responded to in
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CMHSP RIGHTS SYSTEM ASSESSMENT 2023 ASSESSMENT REPORT

were found, including for accordance with the

Acknowledgement Letters. Mental Health Code and
Therefore, no points could be MDHHS-ORR
awarded for this standard. requirements.
CMHSP 6.4.3.2 8.1.2 For each complaint utilizing the intervention process, 2 0 As noted above in standard 8.1.1, REQUIRED ACTION:
responses were provided to the complaint within 30 calendar the data provided for assessment Ensure that the recipient
days. was unreliable. rights complaint record-
keeping system,
including the log, is
accurate, up to date, and
consistent with dates
contained on recipient
rights documents.
Specifically, ensure that
all complaints that are
handled as interventions
are correctly responded
to in accordance with the
Mental Health Code and
MDHHS-ORR
requirements.
MHC 1778 (4) 8.1.3 For each investigation, status reports were issued every 30 2 0 As noted above in standard 8.1.1, REQUIRED ACTION:
days, as required. the data provided for assessment Ensure that the recipient
was unreliable. rights complaint record-
keeping system,
including the log, is
accurate, up to date, and
consistent with dates
contained on recipient
rights documents.
Specifically, ensure that
all required Status
Reports are correctly
written, generated, and
sent out in accordance
with the Mental Health
Code and MDHHS-ORR
requirements.

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Citation Standard SECTION 8 – COMPLAINT RESOLUTION - TIMEFRAMES MAX SCORE FINDINGS REQUIRED ACTION
SCORE
MHC 1778 (1) 8.1.4 Subject to delays involving pending action by external 2 0 As noted above in standard 8.1.1, REQUIRED ACTION:
agencies, the office completed investigations no later than 90 the data provided for assessment Ensure that the recipient
calendar days following receipt. was unreliable rights complaint record-
keeping system,
including the log, is
accurate, up to date, and
consistent with dates
contained on recipient
rights documents.
Specifically, ensure that
all Reports of
Investigative Findings are
correctly written,
generated, and sent out
in accordance with the
Mental Health Code and
MDHHS-ORR
requirements.
MHC 1782 (1) 8.1.5 A written Summary Report was issued for each Report of 2 0 As noted above in standard 8.1.1, REQUIRED ACTION:
Investigative Findings (RIF) within 10 business days after the data provided for assessment Ensure that the recipient
receipt of the RIF. was unreliable rights complaint record-
keeping system,
including the log, is
accurate, up to date, and
consistent with dates
contained on recipient
rights documents.
Specifically, ensure that
all Summary Reports are
correctly written,
generated, and sent out
in accordance with the
Mental Health Code and
MDHHS-ORR
requirements.
SECTION TOTAL 10 0

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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 No appeals received since last
hear appeals of recipient rights matters OR designated the assessment.
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.
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

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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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Citation Standard SECTION 11 – SITE VISITS MAX SCORE FINDINGS REQUIRED ACTION
SCORE
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: May 31, 2023

Janice Terry, Community Rights Specialist, MDHHS-ORR

Report Reviewed by: Date: May 31, 2023

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

Revised 2/10/23 Page 14 of 14