CMS established Conditions of Participation (CoPs) for the Community Mental Health Centers (CMHCs) effective October 29, 2014 (78 Fed. Reg. 64603, Oct. 29, 2013). The CMHC COPs are located at 42 CFR 485.904 through 42 CFR 485.918. The CMHC COPS include:
§485.904: Personnel qualifications: All professionals who furnish services directly, under an individual contract, or under arrangements with a CMHC, must be legally authorized (licensed, certified or registered) in accordance with applicable Federal, State and local laws, and must act only within the scope of their State licenses, certifications, or registrations. All personnel qualifications must be kept current at all times. (Additional qualifications for personnel of certain disciplines (such as administrator, clinical psychologist, etc.) are enumerated in the COP.)
§485.910: Client rights: The client has the right to be informed of his or her rights. The CMHC must protect and promote the exercise of these client rights.
§485.914: Admission, initial evaluation, comprehensive assessment, and discharge or transfer of the client: The CMHC must ensure that all clients admitted into its program are appropriate for the services the CMHC furnishes in its facility.
§485.916: Treatment team, person-centered active treatment plan, and coordination of services: The CMHC must designate an interdisciplinary treatment team that is responsible, with the client, for directing, coordinating, and managing the care and services furnished for each client. The interdisciplinary treatment team is composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and therapeutic needs of CMHC clients.
§485.917: Quality assessment and performance improvement: The CMHC must develop, implement, and maintain an effective, ongoing, CMHC-wide data-driven quality assessment and performance improvement program (QAPI). The CMHC’s governing body must ensure that the program reflects the complexity of its organization and services, involves all CMHC services (including those services furnished under contract or arrangement), focuses on indicators related to improved behavioral health or other healthcare outcomes, and takes actions to demonstrate improvement in CMHC performance. The CMHC must maintain documentary evidence of its quality assessment and performance improvement program and be able to demonstrate its operation to CMS.
§485.918: Organization, governance, administration of services, and partial hospitalization services: The CMHC must organize, manage, and administer its resources to provide CMHC services, including specialized services for children, elderly individuals, individuals with serious mental illness, and clients of its mental health service area who have been discharged from an inpatient mental health facility.