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.

MHSU 2: Screening and Intake

The organization’s screening and intake practices ensure that service recipients receive prompt and responsive access to appropriate services. 

Rating Indicators
All elements or requirements outlined in the standard are evident in practice, as indicated by full implementation of the practices outlined in the Practice standards.
Practices are basically sound but there is room for improvement, as noted in the ratings for the Practice standards; e.g.,
  • Minor inconsistencies and not yet fully developed practices are noted, however, these do not significantly impact service quality; or
  • Procedures need strengthening; or
  • With few exceptions procedures are understood by staff and are being used; or
  • Referrals procedures need strengthening; or
  • For the most part, established timeframes are met;
  • Active client participation occurs to a considerable extent.
  • In a few rare instances urgent needs were not prioritized.
Practice requires significant improvement, as noted in the ratings for the Practice standards. Service quality or program functioning may be compromised; e.g.,
  • Procedures and/or case record documentation need significant strengthening; or
  • Procedures are not well-understood or used appropriately; or
  • Urgent needs are often not prioritized, or
  • Services are frequently not initiated in a timely manner; or
  • Applicants are not receiving referrals, as appropriate; or
  • A number of client records are missing important information  or
  • Client participation is inconsistent; or
  • Screening and intake done by referral source and no documentation and/or summary of required information present in case record; or
  • One of the Fundamental Practice Standards received a rating of 3 or 4.
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the Practice standards; e.g.,
  • There are no written procedures, or procedures are clearly inadequate or not being used; or
  • Documentation is routinely incomplete and/or missing; or  
  • Two or more Fundamental Practice Standards received a rating of 3 or 4.

Table of Evidence

Self-Study Evidence On-Site Evidence On-Site Activities
    • Screening and intake procedures
    • List of community-based providers/ referral sources
    • Interview:
      1. Clinical or program director
      2. Relevant personnel
      3. Individuals or families served
    • Review case records

  • MHSU 2.01

    Service recipients are screened at intake and informed about:

    1. how well their request matches the organization’s services; 
    2. what services will be available and when; and
    3. rules and expectations of the program. 

    Interpretation: Screenings will vary based on the program’s target population and services offered and may include information to identify any of the following: trauma history, substance use disorders, mental illness, developmental delays, suicide and self-harm history and current level of risk, and/or risk of harm to others.

    Interpretation: For organizations providing services for substance use disorders, rules and expectations of the program should include any consequences that can result from the verified use of alcohol, drugs, or other substances while participating in the program.

    Interpretation: For residential detoxification treatment programs, rules and expectations could include:

    1. personal items service recipients may bring them; and
    2. items that are discouraged or prohibited. 

    Research Note: Employing electronic, telephonic, or technology-based interventions can minimize geographic barriers and increase the availability of necessary services, particularly for individuals and families living in rural or underserved areas. 

    NA Another organization is responsible for screening, as defined in a contract.

  • FP
    MHSU 2.02

    Prompt, responsive intake practices:

    1. ensure equitable treatment;
    2. give priority to urgent needs and emergency situations;
    3. facilitate the identification of individuals and families with co-occurring conditions and multiple needs;
    4. enable access to a comprehensive assessment process;
    5. support timely initiation of services; and
    6. provide for placement on a waiting list, if desired.

    Interpretation: Screening and intake procedures should direct staff on how to identify and respond to individuals or families experiencing emergency situations to ensure that they receive expedited treatment planning and are connected to more intensive services. For example, individuals discharged from emergency rooms or psychiatric inpatient facilities after a suicide attempt remain a high-risk group post discharge. To reduce the risk of suicide re-attempt, these individuals should be contacted within 24 hours, receive access to services within three to seven calendar days, and active outreach should be initiated in cases of a missed appointment until contact is made. Organizations should have the capacity to refer individuals in crisis to the appropriate services, which may include 24-hour mobile crisis teams, emergency crisis intervention services, crisis stabilization, or 24-hour crisis hotline.

    Urgent situations can also include those in which an individual has a child in the child welfare system.

    Interpretation: Wait times are a major barrier to individuals and families receiving services. Organizations can monitor waitlists and standardize their referral process to improve accessibility. 

    Research Note: Literature indicates that schools are the primary setting for the identification of children and youth with mental health conditions. Symptoms usually begin in early childhood; however, some disorders may develop and present in later adolescence. Organizations that serve children and youth should collaborate with school-based and primary health care settings to identify those with mental health needs and facilitate access to services as early as possible. Early intervention can prevent significant mental health issues from developing and reduce risk behaviors, such as suicide or self-harm, substance use, and involvement with the juvenile justice system.

  • MHSU 2.03

    Service recipients who cannot be served, or cannot be served promptly, are referred or connected to appropriate resources.

    NA The organization accepts all service recipients.

  • MHSU 2.04

    During intake, the organization gathers information to identify critical service needs and/or determine when a more intensive service is necessary, including:

    1. personal and identifying information;
    2. emergency health needs; and
    3. safety concerns, including imminent danger or risk of future harm.

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