Standards for public agencies

2020 Edition

Mental Health and/or Substance Use Services (PA-MHSU) 7: Medical Care and Clinical Support Team

Treatment decisions are guided by a qualified clinical team and are made in collaboration with persons served.
NA The agency provides Diagnosis, Assessment, and Referral Services only.

NA The agency provides Clinical Counseling services only.
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.
Note: Medical care includes psychiatric care and treatment.
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
No Self-Study Evidence
  • Job description and resume of qualified health professional and/or formal agreement with a professional or community-based provider
  • Interviews may include:
    1. Program director
    2. Relevant personnel
    3. Persons served
  • Review case records
  • Review personnel record, when applicable

Fundamental Practice

PA-MHSU 7.01

A licensed physician, or another qualified health professional, with experience, training, and competence in engaging, diagnosing, and treating persons with mental health and/or substance use disorders is responsible for the medical aspects of treatment.


When an appropriately qualified health professional is not employed by the agency, their participation on the treatment team should be secured through contract or formal agreement.
Examples: Medical aspects can include: 
  1. prescribing medication and medication management, including appropriate management of pharmacotherapy for individuals with co-occurring conditions; 
  2. providing or reviewing diagnostic, toxicological, and other health related examinations of persons not currently under medical care and supervision; 
  3. review of complicated cases where co-occurring substance use, health, and mental health conditions intersect; and
  4. other medical and psychiatric related issues, such as seizure disorders, psychosomatic disorders, or traumatic brain injury.
Examples: The qualifications and training of the physician may vary as appropriate to the program. For example, agencies that provide mental health services may have a board-eligible psychiatrist who is responsible for the medical aspects of treatment. Qualified health professionals may include: psychiatric or mental health nurse practitioners, physician assistants, or health professionals that are permitted by law in their state to provide medical care and services (e.g., prescribe and monitor medications) without direction or supervision.

Fundamental Practice

PA-MHSU 7.02

In collaboration with the service recipient, a clinical team and a licensed physician, or other qualified health professional, make decisions about level of care, treatment, and aftercare or discharge planning.


PA-MHSU 7.03

Agencies that employ or have formal agreements with telemedicine practitioners, or individuals that provide telehealth services, monitor and share information in a way that ensures privacy and security of confidential information.
NA The agency does not employ or have formal agreements with telemedicine practitioners.