C.M.R. 14, 193, ch. 6, SOCIAL CLUB STANDARDS
The following standards constitute all the requirements for the operation of social clubs. By their very nature, social clubs demand special consideration in terms of regulation. Due to this fact, social clubs are the only service that need not comply with the generic standards section of these regulations. Select standards from the core generic standards have been modified and included in the standards below. In addition, a social club task force has developed and included social club-specific requirements.
Access
SC.1 Each club shall have in effect a transportation plan that assures accessibility to the club.
SC.1.A. The agency documents and takes steps to implement a transportation plan that is directed toward assuring reasonable accessibility to all services.
SC.2 The social club will have a process of determining sufficient hours of operation which places a priority on the needs of the members.
SC.2.A. Documentation of the process for determining the hours is available for review.
SC.2.B. Documentation exists that the needs of the members are reviewed annually.
SC.2.C. The club documents what alternative solutions are explored if the need for extended hours requested by the members is limited in any way.
SC.3 The club has documented evidence of membership criteria that minimally includes people with mental illness.
Interpretive Guideline for SC.3
Self report of eligibility is sufficient for membership.
SC.4 Membership will not be denied based on inability to pay dues.
SC.4.A. No individuals will be refused membership due to inability to pay dues. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.5 The social club applies its eligibility criteria equally and consistently to all members.
SC.5.A. Eligibility criteria will be consistently applied in all instances. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.6 There is no discrimination based upon race, color, religion, age, national origin, gender, ancestry, physical or mental handicap, sexual preference, or socioeconomic status.
SC.6.A. There are no substantiated complaints regarding discrimination. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.7 The club has a policy and procedure that explains what resources will be used or what efforts will be made to assure that club activities and information are available in the language chosen by the club member or potential club member.
SC.7.A. There are no substantiated complaints by club members or potential club members citing unavailability of activities or information in their language of preference. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.8 The consumer board or governing body shall ensure that each social club is in compliance with the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act and the Maine Human Rights Act (MRHA).
SC.8.A. There are no substantiated complaints regarding violation of the ADA, MHRA, or Section 504, including lack of handicapped accessibility. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.8.A..1 Social clubs must notify the Division of complaints pursuant to the above cited laws resulting in a reasonable grounds finding by an external regulatory body (MHRC/EEOC).
SC.8.B. The social club has policies and procedures regarding compliance with the ADA, MHRA and Section 504 including how persons with disabilities may access services.
SC.8.C. All plans for new buildings or renovation of existing buildings receive approval from the State Fire Marshal's office or designees for compliance with the ADA and Section 504.
SC.8.D. All existing buildings will receive approval from DMHMR's Affirmative Action Officer for compliance with the ADA and Section 504.
Club Member Records
SC.9 The club shall maintain club member records in a manner that provides security.
SC.9.A. Club records are stored in secure areas such as locked file cabinets.
SC.9.B. Automated record keeping systems have restricted access through access codes or other automated security measures.
SC.9.B.1. There is a back-up system for all automated club member records.
SC.9.C. The club has a policy and procedure regarding personnel who are authorized to have access to records that is in compliance with federal, state, and local laws.
SC.9.D. There is a method for documenting when records are accessed and taken from the area where they are stored (i.e., outguides, logs). This method should minimally document the person's name, title or relation to the club member, date and time taken and returned.
SC.9.E. There are no instances of breaches of confidentiality that result from improper records management. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.10 Social clubs have a policy and procedure on what documentation is to be maintained in club member records.
SC.11 Social clubs maintain club member records per club policy and procedure.
Interpretive Guideline for SC.10
Documents that would be expected to be found in a club member record include, but are not necessarily limited to, the following: application, emergency contact, incident reports, verification that club member was notified of club rules.
SC.12 All documents or entries in the member's record shall be legible, dated and signed (including full name) by the person making the entry, written in ink or typed, and properly corrected as necessary.
Club Member Rights
SC.13 Social clubs comply with Section A of the Rights of Recipients of Mental Health Services.
Social Club Management
SC. 14. Each social club will have a consumer board made up of and elected by the social club membership.
SC.14.A. If the social club is a freestanding agency, the governing body will be elected by the social club membership and will be responsible for compliance with all of the standards in this section. For the purposes of this section, "governing body" will be referred to as "consumer board".
SC.14.B. If the social club is a part of a larger organization, the club will have a consumer board elected by the social club membership and will be responsible for compliance with all of the standards in this section.
SC.15. If the social club is part of a larger organization, the consumer board will be vested with authority for the operation and day-to-day management of the social club.
SC.16. The social club consumer board develops bylaws that address the needs and desires of the membership.
SC.17. The social club consumer board develops documented rules, policies and procedures necessary for the ongoing daily operation of the social club.
SC. 17. A.. The social club rules, policies and procedures will minimally include the following:
SC. 17. A.1. a written mission statement, written by the consumer board or governing body, describing its purpose, the activities it provides and its accessibility and that is reviewed on at least an annual basis;
SC. 17. A.2. a planning process that bases its short and long term goals and objectives for activities on a periodic analysis of the wants and needs of current or potential members;
SC. 17. A.3. a policy and procedure regarding conflict of interest that minimally addresses the definition of conflict of interest and the procedures for resolving these issues; and
SC. 17. A.4. documented criteria and process for suspension of members which should be limited to threats, criminal activity and violent or abusive behavior to self, others or property and which will adhere directly to the "right to due process" with regard to grievances as stated in the Rights of Recipients of Mental Health Services.
SC. 17. A.4.a. There is documented evidence that the rules and suspension criteria are reviewed with each member.
SC. 17. A.4.b. The club will document that members who have been suspended are given the opportunity to engage in the development of a re-entry plan with an authorized representative of the club.
SC. 17. A.4.b.1. All reentry plans will clearly delineate the responsibilities of the re-entering member and the club.
SC.18. The club rules are fairly applied and administered by the consumer board or governing body.
SC. 18. A. There are no substantiated complaints regarding unfair application or administration of rules by the consumer board or governing body. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.
SC.19. If the social club is part of a larger organization, there will be documented evidence of governing body receipt and consideration of the consumer board's input regarding issues and concerns raised by the consumer board and club members.
SC.20. The social club has an organizational chart that defines the lines of authority and responsibility for each position.
SC.21. The social club shall post the original, current license issued by the Department.
SC.22. The social club shall report immediately to the Division, any legal proceedings arising out of circumstances related to the social club.
SC.23. The social club management will provide ongoing and appropriate training to develop and support members as leaders and promote member leadership.
Marketing
SC.24. The social club accurately portrays the scope of their activities in audio, visual, or printed materials.
SC.25. The social club has evidence that its activities are publicized.
SC.25.A. There is evidence that public information activities have been implemented.
Financial Management
SC.26. The governing body is responsible for insuring the establishment and maintenance of sound fiscal practices as evidenced by, the development and periodic review of policies regarding the fiscal practices of the agency.
SC.26.A. The governing body reviews the financial status of the agency on a periodic basis, and minimally reviews the agency's annual audit and approves the annual budget.
SC.27. Where fees are charged, a schedule of fees for services and policies concerning collection of fees shall be made available to each client or their legally responsible party or posted in the facility for public view.
SC.27.A. When the fee schedule is not posted for public view, there is documented evidence that clients and/or the legally responsible party have received notification of the fee schedule.
Interpretive Guideline for SC.26 through SC.26.A
"Periodic is to be defined by the governing body. the club will be evaluated on:
SC.28. Social clubs will have documented annual audits from an independent Certified Public Accountant verifying that generally accepted accounting practices are being maintained.
I
Interpretive Guideline for SC.28
The club must contact the Division for written approval of alternative auditing mechanisms.
SC.29. The social club complies with all applicable health codes.
SC.29.A. There are no substantiated health code violations.
SC.29.B. The social club complies with all health standards in this section.
SC.30. Any social club not using a public water and/or sewer system shall be inspected and approved by the Department of Human Services.
SC.30.A. Any social club without a public water and/or sewer system shall be able to produce a Sanitary Survey report from the Health Engineering Division of the Department of Human Services.
SC.30.B. Any social club without public water and/or sewer system will have Sanitary Surveys conducted at least every 3 years per Department of Human Services Engineering Division regulation.
SC.31. The social club has policies and procedures for managing and controlling infections.
SC.31.A. The social club has documented evidence that they have implemented policies and procedures regarding the management and control of infections.
Interpretive Guideline for SC.31 and SC.31.A
The management and control of infection has become on of the most serious issues for society, in general, to address. The management staff should determine the extent to which their agency, clients, employees, and others are at risk for acquiring and transmitting infections. Based on this determination, the agency should develop and implement reasonable policies and procedures to manage and control the potential for acquiring or transmitting infections.
SC.32. Social clubs shall be inspected by the State Fire Marshal or the Fire Marshal's designee to assure compliance with the NFPA 101 Life Safety Code (current edition).
SC.32.A. Social clubs have biennial letters from the State Fire Marshal or the Fire Marshal's designee assuring compliance with NFPA 101 Life Safety Code and safe occupancy.
SC.33. Quarterly fire drills are conducted and documented for non-residential services and monthly for residential services per NFPA 101 Life Safety Code (current edition).
SC.33.A. There is documented evidence that the agency is in compliance with fire drill requirements.
Interpretive Guideline for SC.32 through SC.33
Consult current edition of NFPA 101 Life Safety Code for requirements in each type of occupancy.
SC.34. The agency has a written disaster and evacuation plan specifying procedures for personnel and designating specific tasks and responsibilities.
SC.34.A. The agency disaster plan addresses a variety of pertinent disasters (e.g., fires, power outages, storms).
SC.34.B. The disaster plan addresses staff preparedness, including staff requirements and the designation of roles and functions, particularly in terms of capabilities and limitations.
SC.35. There is documented evidence that staff members receive initial and continuing education concerning disaster and evacuation procedures.
Human Resource Management
SC.36. The social club has written documentation that each person's duties, responsibilities and performance expectations are clearly communicated upon hire.
SC.37. Staff members meet minimum qualifications for their job as determined by the requirements of the Division of Public Education.
SC.38. Each position in the organization has a job description.
SC.38.A. Job descriptions minimally include the following:
SC.38. A.1 title;
SC.38.A.2 supervisor;
SC.38.A.3 supervisees;
SC.38.A.4 duties and responsibilities; and
SC.38.A.5 minimum education, training and experience qualifications
SC.39. The social club has a policy and procedure that addresses the mechanism by which all employees have access to, or receive a copy of, the personnel policies and procedures.
SC.39.A. The social club documents that each employee has reviewed or received a copy of the personnel policies and procedures by way of signature in the employee's personnel file.
Interpretive Guideline for SC.39.A
Documentation may include a form indicating the employee has reviewed policies/procedures or the distribution of personnel policy, handbooks, etc.
SC.40. The social club has policies and procedures for the recruitment, selection, and retention and promotion of employees, volunteers, and students.
SC.41. The social club has a policy and procedure establishing practices for the termination or temporary layoff of employees, including provision for notification or the employee and mechanisms for appeal.
SC.42. The social club has a policy and procedure concerning employee grievances that includes notifying employees of the procedure and maintaining confidential communications and records.
SC.43. Each employee, student and volunteer has a personnel record.
SC.43.A. The social club has a policy and procedure concerning maintaining personnel records for each employee, student or volunteer.
SC.43.B. Personnel records should be maintained similarly and contain documentation pertinent to the employee's, student's or volunteer's work, supervision and training.
SC.44. Each personnel rile contains information documenting and verifying the positions held by the employee, volunteer or student and their qualifications and experience.
SC.44.A. The personnel record minimally contains the individual's:
SC.44.A.1 job description;
SC.44.A.2 copies of appropriate licenses and certifications;
SC.44.A.3 copies of the employee's diplomas, transcripts or documentation of verbal verification from the school officials citing date and school official contacted;
SC.44.A.4 records of employee continuing education and training
Interpretive Guidelines for SC.44.A.4
These record of training may be the form of certificates noting date, title of training, number of hours of CEU's or other listing of training received with content, date, presenter and length of training documented.
SC.45. An individual's need for training and continuing education is assessed with the individual's participation and documented within 6 months of hire or job change and at last annually thereafter.
SC.46. All employees, students and volunteers are given a copy of the Rights of Recipients (Adult and/or Children as appropriate).
SC.46.A There is documented evidence that all employees, students and volunteers review the applicable sections of the Rights of Recipients (Adult and/or Children's editions) before commencing the duties of their job and when there is a change in the Rights regulations.
Interpretive Guideline for SC.46.A
Documented evidence may be a statement of other documentation, signed and dated by the employee, student or volunteer that confirms that they have reviewed the Rights of Recipients (Adult and/or Child edition's).
SC.47. The social club has policies and procedures on access to personnel riles that minimally include the following: the employee's right to access, protection of confidential information, secure storage, making record entries, and distribution of information upon staff request.
SC.47.A. The social club has policies and procedures that minimally address the following personnel records issues:
SC.47.A.1 who in addition to the employee, has access to personnel records;
SC.47.A.2 how confidential personnel information is protected;
SC.47.A.3 how personnel records are securely stored;
SC.47.A.4 who in addition to the employee may enter information into the personnel records; and
SC.47.A.5 how and to whom information from personnel records may be disseminated.
SC.48. The social club has a policy and procedure that addresses when a personnel record is considered inactive and what practices are followed in its disposal to assure the employee's confidentiality.
SC.49. The social club has documented processes for addressing employee issues, including policies and procedures on employee recognition, supervision, and discipline.
SC.50. The social club is an Equal Opportunity Employer.
SC.50.A. The governing body or consumer board establishes and adheres to policies and procedures that provide for periodic review and approval of the personnel policies for compliance with federal, state and local laws.
Interpretive Guideline for SC.50.A
The definition of "periodic review" is determined by the governing body. compliance with this standard and the subsequent standard (SC.53.A.1) depend on the definition.
SC.50.B. The social club will follow personnel policies and procedures as required by federal, state or local laws in all instances.
SC.50.C All social clubs must notify DMHMR of discrimination complaints resulting in a reasonable grounds finding by an external regulatory body (MHRC/EEOC.
SC.50.D. The social club has received approval from DMHMR Affirmative Action Officer as an Equal Opportunity Employer.
Volunteers and Students
SC.51. Individuals who work as volunteers for the agency or who are students shall be clearly identified by title as students or volunteers.
SC.52. Student supervision shall include documenting in their personnel record, contact with the person supervising the student's educational progress.
Interpretive Guideline for SC.52
If the school does not designate a liaison, documentation of this should be placed in the student's personnel record.
SC.53. Students or volunteers are supervised by' individuals with licensure, certification, or experience in an area germane to the work assigned.
Supervision
SC.54. The social club shall develop and maintain clear lines of supervision by assuring that each employee, student and volunteer has a supervisor.
SC.54.A. The social club has a table of organization that clearly indicates lines of supervision within the club and if applicable, how the club staff relate to a larger agency.
SC.55. The social club has a policy and procedure and documented evidence that ongoing supervision is provided for employees, students, and volunteers.
SC.56. All supervisory personnel will have documented evidence in their personnel records of training in supervision.
Quality Management
Quality management is broadly defined as management philosophies and behavioral, and statistical tools aimed at improving quality, customer satisfaction, and profitability. Although all effective quality management processes have distinct similarities, each agency must adopt quality management principles and practices that are sensitive to their organizational culture and effective in their particular setting. For this reason, the Department and the Division of licensing does no espouse one particular model of quality management. Therefore, the standards in this section relate to an agency's ability to demonstrate that they have an ongoing and effective quality management process that is customer-focused and strives for customer satisfaction.
SC.57. The agency has a written plan that addresses how the organization currently monitors, evaluates and improves quality.
SC.58. The agency can demonstrate that it identifies, monitors, and attempts to improve areas deemed to be critical to quality client care.
SC.59. There is documented evidence that quality management activities are conducted on an ongoing and regular basis.
SC.60. The effectiveness of quality management is assessed and documented at least annually and involves input from clients, family members, guardians, client representatives, staff, and referral sources.
SC.61. The agency shall have, available for review, insurance policies citing professional and commercial liability coverage for the organization, staff, volunteers, and students.
SC.62. The agency has a policy and procedure regarding the reporting and recording of adverse and potentially adverse occurrences, including the recording of complaints.
Interpretive Guideline for SC.62
Some examples of adverse or potentially adverse occurrences include, but are not limited to the following:
C.M.R. 14, 193, ch. 6, SOCIAL CLUB STANDARDS