Private Organization Accreditation

Sweetser, a Maine non-profit agency operating since 1828, provides comprehensive mental and behavioral health and substance abuse treatment services. Statewide, it serves around 15,000 consumers a year, including children, adults, and families in outpatient, office-based, and residential settings.


Rochelle Haimes, ACSW

Volunteer Roles: Commissioner; Peer Reviewer; Standards Panel Member; Team Leader

Rochelle is a Consultant working with a variety of private organizations to become accredited. Her primary area of expertise is in facilitating the development of PQI systems and activities. Her previous experience with both small and large organizations is the cornerstone for her long-standing volunteer activities as a Peer reviewer and as a Team Leader.
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Individuals and families who receive Services for Mental Health and/or Substance Use Disorders improve social, emotional, psychological, cognitive, and family functioning to attain recovery and wellness.


Services for Mental Health and/or Substance Use Disorders (MHSU) are comprehensive, community-based, and designed to help individuals with diagnosable conditions, including: mental health disorders; disorders relating to the use of alcohol, drugs, or other substances; and co-occurring mental health and substance use disorders.

Based on the needs of the individual, services may address mental health symptoms, diagnoses, and associated functional impairments; resolve issues resulting from the use of alcohol, drugs, or other substances; help manage co-occurring mental health, substance use, and/or health conditions; or provide clinical support for psychosocial adjustments related to life cycle issues. 

Standards Assignment Criteria 

The Services for Mental Health and/or Substance Use Disorders (MHSU) standards apply to organizations providing: 

  • Services for Mental Health and Substance Use Disorders; 
  • Mental Health Services only; or
  • Services for Substance Use Disorders only. 
Organizations offering the following levels of care will be responsible for completing all applicable standards within the service section: 
  • Diagnosis, Assessment, and Referral Services only;  
  • Clinical Counseling; and
  • Detoxification Treatment only. 
The way in which the standards are applied and implemented will depend on the type of service and the level of care. Please refer to the Services for Mental Health and/or Substance Use Disorders (MHSU) - Standards Assignment Criteria Chart for a list of applicable standards by program model.

Interpretation: Services can be offered in a variety of settings within the community including outpatient clinics, schools, and service recipients’ homes. As communication technology continues to evolve, organizations are increasingly utilizing electronic interventions to deliver services. Technologies include videoconferencing, online chat platforms, texting, and mobile applications. 

Research Note: Individuals with a mental health disorder are at increased risk of developing a substance use disorder and vice versa. Given the high prevalence of co-occurring mental health and substance use disorders, state mental health and substance abuse authorities are making efforts to integrate systems and services that address these conditions. Integrated treatment —treatment that addresses mental and substance use disorders simultaneously — is linked to better outcomes for individuals with co-occurring disorders, including improved psychiatric functioning, decreased hospitalization, reduced substance use, and improved quality of life.

Research Note: The Patient Protection and Affordable Care Act (ACA) and the Health Care and Education Reconciliation Act of 2010 build on the Mental Health Parity and Addiction Equity Act of 2008 by requiring coverage of mental health and substance use disorder benefits to be on par with physical health coverage.  

Research Note: The importance of providing trauma-informed care is reinforced by a growing body of research on the impact of adverse childhood experiences. A national network of providers, researchers, peer advocates, and families working collaboratively to raise the standard of care has defined a trauma-informed organization as one in which all programs:

  1. routinely screen for trauma exposure and related symptoms;
  2. use culturally and linguistically appropriate evidence-based assessment and treatment for traumatic stress and associated mental health symptoms;
  3. make resources available to children, families, and providers on trauma exposure, its impact, and treatment;
  4. engage in efforts to strengthen the resilience and protective factors of children and families impacted by and vulnerable to trauma;
  5. address parent and caregiver trauma and its impact on the family system;
  6. emphasize continuity of care and collaboration across child-serving systems; and
  7. maintain an environment of care and provide access to needed services for staff that address, minimize, and treat secondary traumatic stress, and that increase staff resilience.

Note: Organizations providing detoxification treatment will complete MHSU 8 in addition to all other applicable core concepts.

Note: Organizations providing services for substance use disorders in a residential setting will complete Group Living Services (GLS) or Residential Treatment Services (RTX) and MHSU 3, MHSU 4, MHSU 5, MHSU 6, MHSU 7, MHSU 9, and MHSU 13. 

Note: Clinical counseling programs reviewed under Services for Mental Health and/or Substance Use Disorders (MHSU) focus on the treatment of diagnosable conditions where therapeutic, evidence-based interventions are provided by appropriately trained, licensed, and/or credentialed personnel.  

Clinical counseling programs reviewed under MHSU are distinct from counseling programs reviewed under Counseling, Support, and Education Services (CSE), which provide non-clinical types of counseling that offer guidance, coaching, community support, and skills building to individuals, families, and groups. Services reviewed under CSE are provided by non-clinical staff, and while there is a screening and intake process, assessments and service plans are not required.

Note: Please see the MHSU Reference List and Suicide Prevention Reference List for a list of resources that informed the development of these standards.

Services for Mental Health and/or Substance Use Disorders Narrative

Self-Study Evidence
    • Provide an overview of the different programs being accredited under this section. The overview should describe:
      1. the program's approach to delivering services;
      2. the eligibility criteria;
      3. any unique or special services provided to specific populations; and
      4. major funding streams
    • If the elements of the service (e.g., assessments) are provided by contract with outside programs or through participation in a formal, coordinated service delivery system, provide a list that identifies the providers and the service components for which they are responsible. Do not include services provided by referral. 
    • Provide any other information you would like the peer review team to know about these programs.
    • A demographic profile of persons and families served by the programs being reviewed under this service section with percentages representing the following:
      1. racial and ethnic characteristics
      2. gender/gender identity;
      3. age;
      4. major religious groups, as appropriate; and
      5. major language groups
    • As applicable, a list of groups or classes including, for each group or class:
      1. the type of activity/group;
      2. whether the activity/group is short-term or ongoing;
      3. how often the activity/group is offered;
      4. the average number of participants per session of the activity/group, in the last month; and
      5. the total number of participants in the activity/group, in the last month
    • A list of the programs that were opened, merged with other programs or services, or closed.
    • A list or description of program outcomes and outputs being measured.
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