Mission & Governance

Corporate Compliance Program

HIPAA

Client Rights Policies

Accountability to our clients, funders, community, and employees is a core value of MHS, and an integral part of our organizational culture.   We present below the critical standards that govern our conduct as an organization, and evidence of our achievement of those standards.   Here, and throughout this website, we strive to make available to the community the information needed to understand our mission, and evaluate our performance in its fulfillment.

Standard

Our Performance

Identity as a non-profit, charitable organization.

MHS is a tax-exempt organization that meets the requirements described in section 501(c)(3) of the Internal Revenue Code.  MHS is eligible to receive contributions deductible as charitable donations for federal income tax purposes. Documentation of our tax-exempt status may be obtained from Ronald Nowak, Chief Financial Officer; MHS; 1744 Payne Avenue; Cleveland, Ohio 44114-2910. Or, click here to view a PDF of the IRS certification letter to MHS.

Sound governance.

MHS is governed by an independent Board of Trustees who meet monthly, as volunteers, to establish policy and oversee organizational performance. An audit committee meets regularly to analyze financial statements, review the annual audit, and report findings to the board.

Current members of the Board of Trustees of MHS have achieved positions of leadership in for-profit and non-profit organizations. Steven Prengler, former Board President, has worked collaboratively with homeless people, healthcare and social service providers, and government officials to end homelessness in the greater Cleveland area. Current Trustee and Past President Julie Rittenhouse is one of Cuyahoga County's leaders in the planning and utilization management of healthcare and social services. Another Past President, John Urban, had served as a member of the Board of Governors of the Cuyahoga County Community Mental Health Board. We have worked to recruit Trustees who are proportionally representative of the age, race, and ethnicity of the community we serve. Board members include individuals who have been homeless, and those with a personal or immediate family history of mental illness.

Principled leadership.

Leaders of MHS – the Board of Trustees, Executive Director, and Program Directors – define, articulate, and implement our mission and values. They carefully evaluate the needs of the individuals served by MHS, and promote the participation of staff members in the design of programs that can effectively and efficiently meet those needs. They direct and coordinate the services offered by those programs.

MHS leaders have successfully executed a long-range, strategic plan that created a comprehensive continuum of care and services for our homeless and disabled clients, with funding from diversified sources. They have also instituted an agency-wide system of performance improvement based on the collection, organization, and analysis of objective outcome data.

Belief in the capacity of clients to direct their recovery.

A core value of MHS is the conviction that individuals have the capacity to change in ways that allow them to live with independence, dignity, and meaning. With the assistance of caring and supportive services, individuals with chronic and disabling mental disorders can achieve meaningful recovery.

To be in recovery means that you understand the unique features and symptoms of your mental disorder, you accept responsibility for your conduct, you use resources available to you to make thoughtful decisions that improve your life and benefit your community, and you develop the supports and skills needed to achieve the independence that is within your capacity to grasp.

The most compelling evidence that MHS truly values the capacity of clients to recover consists of the outcomes that clients have achieved through their participation in MHS supportive services.

Protection of client rights.

MHS provides services in a manner that respects the rights of clients, and promotes their dignity and independence. These rights are defined by federal and state laws, ODMH administrative rules, and professional codes of ethics. All client rights complaints are reviewed by the MHS Board of Trustees. Performance in the protection of rights is assessed in annual program audits conducted by the Cuyahoga County Community Mental Health Board.

Clients filed 15 client rights complaints during the 2001 fiscal year. In that year, MHS provided 40,759 hours of service for 11,335 individuals. There were 108,126 episodes of service. The proportion of client rights complaints to the number of clients served is 0.001. The proportion of complaints to the number of hours of service is 0.0004.

After investigation by the Client Rights Officer (CRO), two of the 15 complaints were found to be substantiated. Both involved conduct of MHS staff members that was not in accordance with agency policies and procedures. Results of these investigations were reported to the Director of Human Resources, and to program directors, with recommendations for corrective actions. The corrective actions were implemented.

The clients who filed these two complaints were informed of the results of the CRO’s investigation, and of the corrective actions that were taken. The clients who filed the 13 complaints that were not substantiated were also informed of the results of the CRO’s investigations. Some of these complaints concerned another organization, or a governmental office, and the CRO helped clients to file complaints with the proper organization. No client informed us that they wanted to appeal our decision to a local, state, or federal office.

Adherence to professionally-recognized standards of service.

MHS has maintained certification from the Ohio Department of Mental Health (ODMH) since 1989. Certification means that our services for clients and the activities that support those services meet standards adopted by the state. Evidence of our certification is available by sending a written request to Susan Neth, Chief Operating Officer; MHS; 1744 Payne Avenue; Cleveland, Ohio 44114-2910. Or, click here to view the ODMH certification letter to MHS.

Adherence to standards of professional conduct.

MHS maintains and enforces policies that prohibit staff members from activities that would constitute or reasonably create the appearance of personal gain, or conflict of interest. Click here to read the MHS Code of Conduct.

Use of services and treatments having evidence of effectiveness.

Clinical and supportive services provided by MHS homeless assistance programs are evidence-based practices that have been shown to result in improved clinical¹ and housing² outcomes. These components include: staged interventions that are responsive to clinical status and readiness for treatment; assertive outreach to retain clients who may have interrupted or discontinued treatment; motivational interventions to help participants develop and sustain engagement in treatment; counseling to help participants learn skills for symptom management and abstinence; supportive interventions to help participants develop comfort in social interactions and to cultivate a social network; a long-term perspective that recognizes the time and effort required to establish patterns of thought, social perception, and behavior; prompt access to comprehensive health, social, and supportive services; and responsiveness to participants’ cultural values.

Systematic collection, reporting, analysis, and use of outcome data.

MHS has well-established procedures for the collection, analysis, and utilization of outcome data, and these data demonstrate that MHS programs are effective in helping clients achieve meaningful goals. Nine MHS programs for homeless individuals use the Outcomes Management Framework system adopted by the Cleveland and Cuyahoga County Office of Homeless Services. In this system, each program defines and tracks performance targets, interim milestones that describe client progress toward the achievement of the performance target, and verifications that serve as evidence for the achievement of the performance targets and milestones.

MHS case management, Safe Haven, and transitional housing programs also utilize the Ohio Department of Mental Health (ODMH) Consumer Outcomes System. Four consumer outcome domains are measured: (1) clinical status, (2) quality of life, (3) functional status, and (4) safety and health. These instruments are completed upon a client's admission to a program, after 6 and 12 months of service, and at termination. In addition, MHS collects 25 data elements regarding client characteristics and dispositions at admission to services, and at termination of services.

Financial accountability, and responsible use of resources.

An annual audit is conducted by an independent, certified accounting firm, with financial statements prepared with generally-accepted accounting principles. Current audited financial statements are available to anyone, by sending a written request to Ronald Nowak, Chief Financial Officer; MHS; 1744 Payne Avenue; Cleveland, Ohio 44114-2910. You may also click here to view a PDF of our financial statements for the 2005 fiscal year, or the 2006 fiscal year.

Annual audits have concluded that financial resources are used for the sole purpose of supporting program services and activities. There have been no HUD findings or audit findings for any of our programs. In independent audits conducted by Zalick, Torok, Kirgesner, Cook, and Company for the fiscal years ending on 30 June 1999, 2000, and 2001, and by Meiden and Moore, Ltd., for the fiscal years ending on 30 June 2002, 2003, 2004, 2005, and 2006, there were no reportable findings, material or reportable control weakness conditions, material reported noncompliance, or material control weakness conditions reported. The auditors’ reports identified the type of major programs’ compliance opinion as "unqualified."

As a recipient of grants from the U.S. Department of Housing and Urban Development, MHS refrains from lobbying activities described in Title 31 of the United States Code, Section 1352. MHS does not attempt to influence the U.S. Executive or Legislative offices or personnel in connection with any federal grant.

Cultural diversity, and cultural competence standards.

MHS complies with all federal statutes relating to nondiscrimination, organizes and conducts an annual seminar in which all staff members are trained in the conduct of culturally-competent services, and examines service data to determine if critical service characteristics (access to services, service frequency, and service duration) are reliably related to the age, sex, and race of the client.

The racial and ethnic characteristics of MHS employees are similar to those of the residents of Cuyahoga County. Among MHS staff during the 2005 fiscal year, 49% were African-American, 49% were white, 2% were Latino, 1% were Asian, and none were American Indian. Corresponding figures for residents of Cleveland, Ohio, are: 51% African-American, 42% white, 7% Latino, 1% Asian, and less than 1% American Indian.

Community collaboration to achieve continuity of care.

MHS maintains written affiliation agreements with more than 30 community mental health centers, hospitals, and other healthcare providers in Cuyahoga County. These agreements describe collaborative protocols for referral, service provision and collaboration, exchange of information, the protection of confidential health information, and for improving the quality of services.

MHS crafted model language for these protocols, and formulated the final language in a series of meetings with provider representatives and the Cuyahoga County Community Mental Health Board. Protocols described in these agreements allow clients and providers to access our services easily and speedily, and coordinate the care and services provided by MHS with those provided by other organizations. MHS also helped police departments in the county formulate policies that describe how police officers make referrals of child trauma victims.

MHS has also led a group of representatives from community mental health centers in efforts to achieve compliance with the privacy rules of the Health Insurance Portability and Accountability Act of 1996. This workgroup met regularly from June, 2001 until March 2003.

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Mental Health Services for Homeless Persons, Inc. (MHS)
1744 Payne Avenue; Cleveland, Ohio 44114 U.S.A.
216-623-6555 - TTY/TDD: 216-623-6540

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http://www.mhs-inc.org/StandardsandValues.asp
It was most recently updated on 31 May 2007.
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