Service Standards for Mental Health Services

Approved on May 5, 2020



Prepared by

Service Standards and Integrated Care Plan Committee of the 

Middlesex-Somerset-Hunterdon HIV Health Services Planning Council

Mental Health Services Definition:


HRSA definition: Mental health services are the provision of outpatient psychological and psychiatric screening, assessment, diagnosis, treatment and counseling services offered to clients living with HIV. Services are based on a treatment plan, conducted in an outpatient group or individual session, and provided by a mental health professional licensed or authorized within the state to render such services. Such professionals typically include psychiatrists, psychologists, and licensed clinical social workers. 


Source: HIV/AIDS Bureau Policy Clarification Notice (PCN) #16-02 (2018)


This TGA will acknowledge Master’s Level Licensed Clinical Social Workers (LCSW) and Licensed Professional Counselors.  Mental Health treatment programs in the Middlesex-Somerset-Hunterdon Ryan White Part A TGA design and deliver comprehensive services for outpatient individuals who are experiencing the effects of mental health disorders stemming from or exacerbated by HIV/AIDS.  Our goal is to stabilize and increase the level of functioning of those accessing mental health services through a continuum of mental health treatment options in order to meet the full spectrum of client needs. (US Public Health Guidelines) 


Treatment plans are tailored to meet the needs of each individual client using four basic modalities: Individual, Group, Couple, and Family Therapy, as well as linkages to psychiatric care.  


These services include:

Staff Service Standards

(Mental Health Services)

Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism
1.1Staff hiringStaff will have necessary skills and experience determined by
*Written application
*Personal interview

100% of staff have an application, resume, and communication with personal references documented in personnel files.
1.2Staff qualificationsStaff have appropriate licensing certifications documented in personnel files.*See detailed qualifications on page 6.

100% of staff possess appropriate licensing or credential requirements.

1.3Staff job descriptionsStaff will be given a written job description. The job description includes definition of mental health services

100% of staff has a job description and service standard documented in the personnel file.

1.4Staff trainingStaff are trained and knowledgeable on:
*HIV/AIDS and the affected tri county community including disease process, co-morbidities and psychosocial effects of the disease.
*Cultural humility
*Entitlement programs, benefits to clients, and community resources/support services
*Client confidentiality, client rights, agency grievance procedures

100% personnel files document training.
1.5Staff continuing educationStaff participate in at least one continuing education training per year that is available and appropriate.

100% of training documented in personnel files.

1.6Staff supervisionSupervision is documented in personnel files.
100% of supervisors are knowledgeable about the RW program.

1.7Policies and proceduresSigned form is documented in the personnel file.

100% of staff agrees to follow agency policies and procedures.

1.8Staff evaluationStaff evaluations are documented in personnel files.
100% of staff is evaluated on their performance annually.

1.9DocumentationStaff will keep written documents of contact with clients in accordance with RW data collection procedures.

100% of all contacts are documented in client files.

Client Service Standards

(Mental Health Services)

Activity/IssueMinimum Acceptable Threshold of Service

Accountability Mechanism

2.1Client EligibilityIn order to be eligible for services, individuals must meet the following:
*Residing or receiving services in the Middlesex, Somerset, Hunterdon TGA
*Income no greater than 500% of the Federal Poverty Level

90% of clients have documentation of HIV + status, residence, and income.

2.2(a)General Provider IntakeReferrals will be seen within ten business days of submission. The intake should contain the following elements and is completed on client at the time of provider intake which includes:
*Date of birth
*Sexual orientation
*Proof of HIV status
*Non-Psychiatric needs assessment
*Current living conditions
*Family, medical & psychiatric history
*Clinician preference
*Every provider will have an authorization and/or consent form for treatment signed by each client on file
90% of clients will have an intake completed.

2.2(b)Assessment of needThe assessment of need will contain the following elements:
*Presenting problem
*Mental status assessment
*Depression screening
*Substance use screening
*Trauma history
*Strengths and weaknesses
*Limitations assessment

90% of clients will have a completed assessment.

2.3Design a comprehensive treatment plan for each client

Each treatment plan will contain the diagnoses, identification of short-term and long-term goals as well as interventions to be used. Plans are kept in the client’s file.

The treatment plan will reflect changes in client’s diagnoses and/or progress. The treatment plan is updated quarterly within the first year; every six months for every subsequent year of treatment.

90% of all clients will have a completed treatment plan in place by the end of the 3rd session (whether face to face or via telehealth) but not to exceed the 5th session or within 60 days of intake, whichever comes first. All completed treatment plans will contain the client’s consent/signature.

2.4Treatment plan goalsTreatment plan goals are individualized for the client. Goals may include (but are not limited to):
*Mental health treatment adherence
*Mental health medication adherence

90% of charts have clearly stated goals for treatment.

2.5Implement treatment plan, which will include providing comprehensive counseling to individuals as needed, as part of the coordinated continuum of HIV/AIDS services in this TGA

Record all progress notes and discussions with the client in the client's file.

All medications that are prescribed as part of mental health treatment are documented and monitored.
(APN and/or Psychiatric services only)

Treatment team (meetings) kept in each client’s file. Any treatment intervention between the client and medical professionals (nurse, physician, psychiatrist, etc.) will be documented and kept in the client's file.

Treatment reviews will justify continuation of all appropriate treatment.

90% of client files will have documented progress of treatment plan goals every 3 months for the first year and every 6 months for subsequent years.

90% of client files contain detailed descriptions of monitoring of any medications prescribed by mental health staff.
(APN and/or Psychiatric services only)

90% of client files will have evidence of goal progress assessment or reasons of lack thereof completion within specified timeframe.

90% of client charts will show justification of ongoing treatment.

2.6Medication monitoring and educationMental health staff will provide medication monitoring to clients who are directly prescribed psychiatric medications. Patients will be provided education towards adherence.

90% of charts for clients directly prescribed medications will show evidence of monitoring.
2.7Coordination between HIV Healthcare providers or Primary Care Physicians

Initial report from Primary Care Physician (PCP) or requesting agency completed at time of intake.

Mental health agency requests ongoing report from Primary Care Physician (PCP) over the course of services.

90% of charts for clients include signed consent to communicate with treating healthcare professionals.

90% of charts for clients include documentation of communication with HIV care providers kept on file.
2.8Referral to higher level of mental health care

Mental health staff will provide referrals to clients who need a higher level of care.90% of referral to a higher level of care and linkages are documented.

2.9DischargeWhen treatment goals have been completed, clients will be discharged from services.

90% Reason for discharge documented on file.

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