Issue 22: Quality Assurance for Community-Based Mental Health Programs

Goal: Fully implement and maintain an integrated quality assurance program for community-based mental health, developmental disabilities and infant learning programs.


The Division of Mental Health and Developmental Disabilities has begun to develop of an integrated quality assurance program covering mental health, developmental disabilities and infant learning services. A Steering Committee with representatives from consumers, providers, advocacy organizations and the State has overseen the development of integrated program standards. The standards include both general administrative standards that apply equally to mental health, developmental disabilities and infant learning, and specific service delivery standards that apply uniquely to each program area.

The next stage in the integrated community quality assurance effort will be to implement the actual program site reviews. Review teams consisting of a contract facilitator and consumer, State, advocate and provider representatives will conduct reviews of programs throughout the state. The program standards will provide the foundation for the reviews, and the reviews will include interviews with consumers, family members, staff and interagency personnel, in addition to a review of agency records. A primary focus of both the reviews (and the standards) will be consumer and family member satisfaction with various aspects of service provision.

Reviews will occur a minimum of every other year and whenever possible, the review team will review the mental health, infant learning and developmental disabilities programs within the given community during a single site visit. Medicaid compliance will also be incorporated into the site review process. Upon completion of the program review, the program will be given a written report detailing its strengths and weaknesses in relationship to the program standards, and will have an opportunity to respond and propose actions to ensure future compliance. An emphasis will also be placed on arranging and/or providing technical assistance to programs to address any major areas of deficiency in relationship to the standards or other concerns identified in the review process.


293. Initiate and maintain program reviews with the broad-based representation described above. The inclusion of consumers, family members and advocates as part of the review teams is particularly important.

294. Ensure that the program reviews address the concerns and perspective of consumers who receive services from the program, and their family members.

295. Through the review process, identify key issues for training and technical assistance and provide resources to address major areas of concern. Depending on the issue, training and technical assistance may be provided at the community, regional or statewide level.

296. Maintain the Steering Committee for the integrated community quality assurance effort to assist in overseeing implementation of the program review process.

297. Begin integration of the community quality assurance effort with the API quality assurance effort (described in Issue 21 in this section). An emphasis should be placed on developing a unified, overall quality assurance system that addresses both community-based and institutional services.

298. Ensure that any identified system-level concerns relating to consumers and family members are communicated with the Consumer Affairs position to be located within the Division of Mental Health and Developmental Disabilities.
Responsible Party (actions 1-6): Division of Mental Health and Developmental Disabilities