N.Y. Comp. Codes R. & Regs. tit. 14 § 595.6

Current through Register Vol. 46, No. 45, November 2, 2024

Section 595.6 - Organization and administration

(a) The provider of service shall identify a governing body which shall have overall responsibility for the operation of the program. The governing body may delegate responsibility for the day-to-day management of the program to appropriate staff pursuant to an organizational plan approved by the Office of Mental Health. No individual shall serve as both member of the governing body and of the paid staff of the program without prior approval of the Office of Mental Health. The owner(s) may serve as the governing body for a proprietary residential program.

(b) The governing body shall establish mechanisms for the participation of current or former recipients of mental health services and family members of recipients of mental health services on the governing body.

(c) The governing body must ensure that its membership reflects the ethnic and cultural diversity in which the residential program is located. It must also effect an appropriate mechanism(s) to facilitate the integration of the program into the community.

(d) The governing body shall be responsible for the following duties:

(1) to meet at least four times a year;

(2) to review, approve and maintain minutes of all official meetings;

(3) to develop an organizational plan which indicates lines of accountability and the qualifications required for staff positions. Such plan may include the delegation of the responsibility for the day-to-day management of the program to an individual who is qualified by training and experience to supervise;

(4) to review the program's compliance with the terms and conditions of its operating certificate, applicable laws and regulations;

(5) to ensure the existence of a residents' council or other appropriate mechanism to provide participation into the formulation of house rules and other matters which affect the operation of the residence;

(6) to ensure that the design and operation of the program is consistent with and appropriate to the ethnic and cultural background of the resident population;

(7) to ensure the development of, approve, and periodically review and revise as appropriate all programmatic and administrative policies and procedures. Such policies and procedures shall include, but are not limited to, the following:

(i) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, sexual orientation, marital status, age, HIV status, military status, genetic predisposition or carrier status or national origin;

(ii) written policies which shall provide for verification of employment history, personal references, work record and qualifications, as well as requesting the office to perform criminal history record checks in accordance with Part 550 of this Title;

(iii) written volunteer policies which shall provide for screening of volunteers, verification of employment history, personal references, work history, and supervision of volunteers, as well as requesting the office to perform criminal history record checks in accordance with Part 550 of this Title;

(iv) written policies that are consistent with the obligations imposed by titles VI and VII of the Civil Rights Act, Federal Executive Order 11246, article 15 of the Executive Law (Human Rights Law), article 15-A of the Executive Law (Minority and Women Business Enterprises Program), section 504 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Act, the Federal Age Discrimination in Employment Act of 1967, the Federal Equal Pay Act of 1963, and the Federal Americans with Disabilities Act;

(v) written policies and procedures concerning, if necessary, the supervision of self administration and storage of medication which shall be consistent with applicable Federal and State laws and regulations;

(vi) written policies and procedures governing resident records which ensure confidentiality consistent with the Mental Hygiene Law, including sections 33.13 and 33.16, 45 CFR parts 160 and 164 (HIPAA), and other applicable State and Federal laws and regulations, which provide for appropriate retention and resident access of such records;

(vii) written criteria for admission and discharge to the program, which shall state: that no person shall be excluded from the residential program on the basis of race, religion, color, age, sex, sexual orientation, physical disability, HIV status or national origin. However, nothing in this subparagraph shall be interpreted to prevent a residential program from making admission or discharge decisions based upon the functional, clinical and behavioral needs of the applicant, which are relevant to its functional program; and

(viii) if a program serves parents with children or adolescents, written policies and procedures regarding the mandatory reporting of child abuse or neglect, reporting procedures and obligations of persons required to report, provisions for taking a child or adolescent into protective custody, mandatory reporting of death, immunity from liability, penalties for failure to report, and obligations for the provision of services and procedures necessary to safeguard the life or health of the child or adolescent. Such policies and procedures shall address the requirements for the identification and reporting of abuse or neglect regarding residents who are children, or who are the parents or guardians of children; and

(8) the governing body shall ensure the development of, approve and periodically review and revise a written Quality Assurance Plan for the residential program. Such plan shall include, but not be limited to, the following:

(i) written policies and procedures for monitoring the operation of the residential program against criteria established in its functional program;

(ii) a written utilization review procedure to monitor the extent to which a resident is receiving appropriate services and is being served at an appropriate level of care;

(iii) a written procedure for incident reporting and incident management; and

(iv) written policies and procedures describing a resident grievance process which ensures the timely review and resolution of residents' complaints and which provides a process enabling residents to request review by the appropriate field office of the Office of Mental Health when resolution is not satisfactory.

(e) A provider of service shall ensure that no otherwise appropriate resident is denied access to services solely on the basis of multiple diagnoses, physical disability, a diagnosis of HIV infection, AIDS, or AIDS-related complex, pregnancy, or solely because the individual has any past involvement with substance abuse or the criminal justice system.

(f) There shall be an emergency evacuation plan and staff shall be knowledgeable about its procedures.

(g) The provider of service shall participate as required with the local governmental unit in local planning processes pursuant to sections 41.05 and 41.16 of the Mental Hygiene Law. The local government may ask the provider of service to provide, at minimum and not limited to, the following information:

(1) provision of budgeting and planning data as requested by the local governmental unit;

(2) identification of the population being served by the program;

(3) identification of the geographic area being served by the program; and

(4) description of the program's relationship to other providers of service including, but not limited to, a description of all written agreements entered into pursuant to this Part; and

(5) for CREDIT programs, in addition to the provisions of paragraph (4) of this subdivision, a description of specific affiliation agreements with designated Comprehensive Care Center for Eating Disorders providers, which must include referral and admission procedures, as well as procedures for crisis clinical back-up.

(h) In programs which are not operated by State or local government, there shall be an annual audit, pursuant to a format prescribed by the Office of Mental Health, of the financial condition and accounts of the program performed by a certified public accountant who is not a member of the governing body or an employee of the program. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements.

(i) The provider of service shall establish mechanisms which ensure that a program provides reasonable accommodations and services which are relevant to the cultural, language and ethnic backgrounds of residents. Such mechanisms, whenever possible and appropriate, shall include ethnic representation on the staff and governing body and inclusion of ethnic appropriate content in service programs.

(j) The provider of service shall provide for the fair compensation of residents who are employed by the provider. Such employment shall meet all applicable requirements of Federal and State labor laws.

(k) The provider of service shall establish mechanisms to ensure priority access by individuals, referred to the provider, who are enrolled in an assisted outpatient treatment program established pursuant to section 9.60 of the Mental Hygiene Law. The provider of service shall cooperate with the local governmental unit or the commissioner, or their authorized representatives, in ensuring priority access by such individuals, and in the development, review and implementation of treatment plans for such individuals. Prior to the discharge by a provider of service of an individual who is also enrolled in an assisted outpatient treatment program, the provider of service shall notify the individual's case manager and the director of the assisted outpatient treatment program. Any and all related information, reports and data which may be requested by the commissioner or the local governmental unit shall be furnished by the provider of service. Any requests for clinical records from persons or entities authorized pursuant to section 33.13 or 33.16 of the Mental Hygiene Law, regarding individuals who are the subject of, or under consideration for, a petition for an order authorizing assisted outpatient treatment shall be given priority attention and responded to without delay.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 595.6