C.M.R. 14, 193, ch. 6, THE LISCENSURE PROCESS
All agencies that are found in substantial compliance with the core standards will be issued a Mental Health Agency License. The license will list each of the service-specific standards with which the agency will have been found to be in substantial compliance in the operation of services and/or programs. The decision as to which service-specific standards are to be applied to which programs or services will be made jointly by the Division of Licensing and the agency in preparation for the licensure survey.
It is the Division of Licensing's intention to make the licensure process as fair and consistent as possible for all applicants pursuing mental health licensure. In order to achieve this, we have developed the following protocols to assist all applicants toward this end.
Technical assistance is offered to all applicants on an informal and formal basis and provides agencies with education and consultation through a variety of means. Technical assistance tools have been prepared for this purpose. We provide technical assistance through on-site meetings and training sessions, telephone consultation and written correspondence.
New applicants and agencies preparing to deliver a new service are permitted a six month period from the receipt of their application until actual licensure. Technical assistance is provided in order to clarify licensing requirements and assist in preparation for the site review. All agencies are held accountable for compliance with all licensing standards.
Agencies that currently hold a Mental Health Agency License will be notified of the availability of technical assistance six months prior to the license expiration date. Three months before the license expires, Licensing will forward an application packet to the agency. Upon receipt of the completed application packet, Licensing will contact the agency to set up the actual site review.
While all agencies are required to comply with, all regulatory requirements, protocols have been established to allow agencies to apply for waivers of one or more of these requirements. These protocols include a waiver process, deemed status and affiliated service agreements.
Upon completion of the licensure survey, Licensing will prepare a site review report that includes recommendations regarding licensure status. The license which will accompany the report will be signed by the Director of the Division of Licensing and the Commissioner of the Department of Mental Health and Mental Retardation. The Commissioner holds the ultimate authority to issue or deny licensure and to award deemed status. The Commissioner also is authorized to exempt certain programs from these standards and to waive specific requirement except those provisions which are otherwise required by law or judicial decree.
The site review report is a comprehensive document that contains agency identifying information, services and programs reviewed, services to be listed on the license, a list of deficiencies, consultative comments and commendations. All items will address regulatory requirements. New providers achieving an initial license will be issued a provisional license, for a maximum of one year. Providers found in significant non-compliance with the standards will be issued a conditional license for a maximum of one year, pursuant to 34-B-MRSA, at the end of which time they will either achieve substantial compliance or face the loss of the license.
The completed site review report will be forwarded to the agency's Executive Director as well as the governing body President. Accompanying the report will be a plan of correction form for the agency to complete and return to Licensing. The process is designed to insure that deficiencies are resolved in a timely manner and to enable Licensing to provide, if indicated, technical assistance regarding the agency's corrective actions.
Also accompanying the site review report is a Satisfaction Survey. This survey is designed to identify both strengths and weaknesses in the licensing process, standards and reviewers. The responses are forwarded directly to the Director of the Division of Quality Management in order to enable agencies to comment freely about the licensing process. Information from these questionnaires is entered into a database and de-identified reports are periodically produced in order to review and improve all aspects of the licensing process.
Providers who find themselves in disagreement with either a finding of the Division of Licensing or the interpretation of it licensing standard are encouraged to request an appeal of the finding. The opportunity exists a formal review by the Commissioner of the Department of Mental Health and Mental Retardation.
The Division will continue to develop and review policies and procedures, review standards for current appropriateness and work to improve the licensing process. Consultative comments from all interested persons will be considered in our ongoing effort to continue to be as fair and consistent as possible.
C.M.R. 14, 193, ch. 6, THE LISCENSURE PROCESS