Standards for public agencies

2020 Edition

Mental Health and/or Substance Use Services (PA-MHSU) 2: Personnel

Program personnel have the competency and support needed to provide services and meet the needs of the target population.


Competency can be demonstrated through education, training, experience, or licensure. Support can be provided through supervision or other learning activities to improve understanding or skill development in specific areas.
2020 Edition




Individuals and families who receive Mental Health and/or Substance Use Services improve social, emotional, psychological, cognitive, and family functioning and attain recovery and wellness.
Full Implementation, Outstanding Performance
A rating of (1) indicates that the agency's practices fully meet the standard and reflect a high level of capacity.  
  • All elements or requirements outlined in the standard are evident in practice, with rare or no exceptions: exceptions do not impact service quality or agency performance. 
Substantial Implementation, Good Performance
A rating of (2) indicates that an agency's infrastructure and practices are basically sound but there is room for improvement.
  • The majority of the standards requirements have been met and the basic framework required by the standard has been implemented. 
  • Minor inconsistencies and not yet fully developed practices are noted; however, these do not significantly impact service quality or agency performance.

Partial Implementation, Concerning Performance
A rating of (3) indicates that the agency's observed infrastructure and/or practices require significant improvement.  

  • The agency has not implemented the basic framework of the standard but instead has in place only part of this framework.  
  • Omissions or exceptions to the practices outlined in the standard occur regularly, or practices are implemented in a cursory or haphazard manner.  
  • Service quality or agency functioning may be compromised.  
  • Capacity is at a basic level.
Unsatisfactory Implementation or Performance
A rating of (4) indicates that implementation of the standard is minimal or there is no evidence of implementation at all.  
  • The agency’s observed service delivery infrastructure and practices are weak or non-existent; or show signs of neglect, stagnation, or deterioration.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Table of contents of training curricula
  • Procedures or other documentation relevant to continuity of care and case assignment
  • Sample job descriptions from across relevant job categories
  • Documentation tracking staff completion of required trainings and/or competencies
  • Training curricula
  • Caseload size requirements set by policy, regulation, or contract, when applicable
  • Documentation of current caseload size per worker
  • Interviews may include:
    1. Program director
    2. Relevant personnel
  • Review personnel files

PA-MHSU 2.01

Clinical personnel are qualified by education, training, supervised experience, and licensure or the equivalent as appropriate to the services provided and program design.


Clinical personnel may also include individuals who are license-eligible and supervised by experienced, licensed staff.

PA-MHSU 2.02

Supervisor qualifications are tailored to the services provided and program design, and include: 
  1. an advanced degree in a human services field and a minimum of two years professional experience;
  2. specialized training in supervision; and
  3. certification and/or licensure by the designated authority in their state, as appropriate.


Regarding element (a), supervisors in detoxification treatment programs may have an advanced degree in a medical field.
Examples: Qualifications for supervisors in substance use treatment programs may include training and experience in alcohol and other drug use, diagnosis, and treatment, and/or certification by the designated authority in their state as approved alcohol and/or drug counseling supervisors.

PA-MHSU 2.03

Clinical personnel are trained on, or demonstrate competence in: 
  1. evidence-based practices and other relevant emerging bodies of knowledge;
  2. psychosocial and ecological or person-in-environment perspectives;
  3. criteria to determine the need for more intensive services;
  4. methods of crisis prevention and intervention, including assessing for and responding to signs of suicide risk;
  5. understanding child development and individual and family functioning;
  6. working with difficult to reach or disengaged individuals and families;
  7. recognizing and working with individuals with co-occurring physical health, mental health, and substance use conditions; and
  8. collaborating with other disciplines and services.


When the agency serves military or veteran populations, it is essential that staff have the competencies needed to effectively support and assist service members, veterans, and their families, including sufficient knowledge regarding: military culture, values, policies, structure, terminology, unique barriers to service, traumas and signature injuries, applicable regulations, benefits, and other relevant issues. When providers possess the requisite military competency, they are capable of supporting improved communication and more effective care. 

Signature injuries and co-occurring conditions often found in this population include post-traumatic stress disorder (PTSD), depression, traumatic brain injury (TBI), substance use, and intimate partner violence, which could subsequently increase the risk for suicide. Personnel serving military and veteran populations should have the competencies to identify, assess, and develop a treatment plan for these injuries and conditions.


Element (e) is not applicable to detoxification treatment programs.
Examples: Ecological or person-in-environment perspectives view social, economic, and environmental factors as critical in the development and resolution of personal and family problems. Factors may include: 
  1. poverty and lack of employment opportunities;
  2. local mores;
  3. language and cultural differences; and
  4. alternative medicine and traditional healing processes.

PA-MHSU 2.04

Clinical personnel are trained on, or demonstrate competence in the latest information, theories, and proven practices related to the treatment of alcohol and other drug use disorders, including: 
  1. the signs and symptoms of withdrawal;
  2. addiction as a disease;
  3. relapse prevention; and
  4. interventions that demonstrate respect for sociocultural values, personal goals, life style choices, and complex family interactions.
NA The agency provides mental health services only.

PA-MHSU 2.05

Individuals who provide peer support:
  1. obtain certification, as defined by their state; 
  2. are willing to share their personal recovery stories; 
  3. have a job description and clearly understand the role of a peer support worker; and
  4. have adequate support and appropriate supervision.
NA The agency does not utilize peer support workers.

PA-MHSU 2.06

Individuals who provide peer support receive pre- and in-service training on: 
  1. how to recognize the need for more intensive services and how to make an appropriate referral;
  2. established ethical guidelines, including setting appropriate boundaries and understanding confidentiality; 
  3. wellness support methods, trauma-informed care practices, and recovery resources; and
  4. skills, concepts, and philosophies related to recovery and peer support.
NA The agency does not utilize peer support workers.

PA-MHSU 2.07

The agency minimizes the number of workers assigned to persons served over the course of their contact with the agency by:
  1. assigning a worker at intake or early in the contact; and
  2. avoiding the arbitrary or indiscriminate reassignment of direct service personnel.
NA The agency provides Diagnosis, Assessment, and Referral Services only.

PA-MHSU 2.08

Employee workloads support the achievement of client outcomes and are regularly reviewed.
Examples: Factors that may be considered when determining employee workloads include, but are not limited to:
  1. the qualifications, competencies, and experience of the worker, including the level of supervision needed;
  2. the work and time required to accomplish assigned tasks and job responsibilities; and
  3. service volume, accounting for assessed level of needs of clients.