§ 680.4 - Organization and administration

Organization and administration

This section establishes organizational and administrative requirements for the governing body and administrator of a 'specialty hospital' under New York Title 14, Part 680, which serves individuals with developmental disabilities under OPWDD oversight. The governing body must adopt written policies covering admission, individual program planning, staffing, rights protection, emergency preparedness, incident reporting, and discharge procedures. The administrator is responsible for maintaining an organizational table, standing committees, policy manuals, transfer agreements with hospitals, and annual management audits to ensure regulatory compliance.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 680.4 - Organization and administration 

 State Regulations 

 Compare

(a)

Organization.

(1)
 The governing
 body (see section
 
680.13
 of this Part) of the
 specialty hospital shall be responsible for the overall operation and
 management of the specialty hospital and may discharge any responsibilities
 hereinafter stated through any body of delegates which is approved by the
 commissioner.

(2)
 The governing
 body shall ensure that the facility and services provided adequately meet the
 health, social and developmental needs of all individuals receiving services
 through preventive, habilitative and rehabilitative programs.

(3)
 The governing body shall ensure that
 there is adequate protection of each person's health, safety, comfort,
 well-being, and civil, human and legal rights.

(4)
 The governing body of the specialty
 hospital shall develop working agreements with other providers, and/or use the
 services the agency is licensed to deliver in its other departments and/or
 units, to ensure delivery to individuals, as appropriate, special diagnostic,
 and medical services which the specialty hospital does not provide.

(5)
 The governing body of the specialty
 hospital shall develop working agreements with the OPWDD and providers of
 services to ensure to the greatest extent possible, that opportunities exist in
 the community for movement of individuals, when appropriate, to less
 restrictive residential settings.

(6)
 Minutes of all official meetings of the
 governing body shall be maintained as permanent record of the decisions made in
 relation to the operation of the specialty hospital.

(7)
 Administrative management of the
 specialty hospital shall be delegated by the governing body to an appropriately
 qualified administrator.

(8)

 Ongoing direction and control of the medical services of the unit shall be
 delegated by the governing body to a physician whose qualifications in
 developmental disabilities are appropriate to the program. For purposes of this
 Part, this person shall be known as the medical director (see section
 
680.13
).

(9)
 The governing body shall develop and
 revise as necessary and provide to OPWDD for review and approval, written
 policies for the quantity, quality, scope, goals, objectives and evaluation of
 all programs (see section
 
680.13
 of this Part); and policies
 for the accomplishment of stated purposes and well-being of individuals. These
 policies shall include, but not be limited to: 
 
(i)
 A statement of the facility's philosophy,
 objectives, and goals, specifying: 
(a)
 the
 specialty hospital's role in the State's comprehensive services for people with
 developmental disabilities;

(b)
 the
 goals for individuals it serves; and

(c)
 the concept of its relationship to the
 parents or correspondents of individuals it serves;

(ii)
 methods for coordinating services for
 every individual between the specialty hospital and other providers of programs
 and services;

(iii)
 policies and
 procedures specifying how and by whom the following functions shall be
 performed: 
(a)
 specification of preadmission
 procedures which include requiring referral services to identify the person's
 specific conditions which necessitate hospitalization, that no other less
 restrictive setting can meet the needs of the individual, and the types of
 rehabilitation therapy requested;

(b)
 an application screening process which: 
 
(1)
 determines appropriateness and medical
 necessity of the admission in accordance with the specialized services
 offered;

(2)
 determines person's
 rehabilitation potential; and

(3)

 includes a procedure requesting the approval of the commissioner prior to the
 admission;

(c)
 an
 admission and process which includes the development of an individual program
 plan (see section
 
680.13
) defining the types of
 therapy services to be provided in accordance with the individual's
 condition(s), measurable outcome expected, and a time frame for attainment of
 each outcome;

(d)
 interdisciplinary
 assessments, preparation of individual service plans (see section
 
680.13
), and periodic reevaluation
 and revision of the plans in coordination with agencies providing day programs
 and treatment to the individuals;

(e)
 
 periodic review as defined in this Part of the appropriateness of
 the person's admission and continued stay in the specialty hospital;

(f)
 ensuring effective communication between
 staff and individuals and families of individuals, using such means as
 counseling with individuals, problem-solving procedures, family conferences,
 telephone communication and newsletters;

(g)
 ensuring that the rights of all
 individuals are not abridged;

(h)

 the provision of all services required by section
 
680.7
 of this Part. This shall
 include a description of methods to be used for coordinating each service with
 other services and programs provided to the individuals. In addition: 
 
(1)
 policies and procedures regarding medical
 and medically related services (see section
 
680.13
) to individuals shall
 include, but not be limited to, physician visits, emergency coverage,
 hospitalization, consultants and rehabilitative services;

(2)
 policies and procedures regarding dental
 services (see section
 
680.13
) shall include, but not be
 limited to, emergency care; and

(3)

 policies and procedures regarding pharmacy services (see section
 
680.13
 of this Part) and
 consultation to individuals shall include, but not be limited to, the safe
 administration and handling of all medication in accordance with section
 
633.17
 of this
 Title;

(i)
 arrangements
 or preparations for the individuals to obtain additional services needed
 through other agencies;

(j)

 discharge or transfer of a person, including: 
 
(1)
 participation of the staff, the
 individual, where appropriate, the individual's guardian or correspondent, the
 individual's supporter under an applicable supported decision-making agreement,
 the family and the agent responsible for service delivery following discharge
 or transfer;

(2)
 due process for
 discharge or transfer in accordance with the requirements of section
 
633.12
 of this Title as well as
 other requirements set forth by OPWDD; and

(3)
 provision for appropriate follow-up
 services;

(k)
 space
 utilization;

(l)
 planning for
 organization, size and grouping of living units (see section
 
680.13
). 
 
(1)
 The specialty hospital may not group
 individuals of widely divergent ages, developmental levels and social needs in
 close physical or social proximity unless the grouping is planned for the
 concentrated treatment of health problems necessitated by the person's
 admission and there is a specific written plan which includes the rationale for
 this grouping.

(2)
 The specialty
 hospital may not group individuals on the basis of their physical handicaps
 unless the grouping is for concentrated treatment of health problems
 necessitating the individuals' admissions. Otherwise, individuals who are
 mobile, nonambulatory, deaf, blind, who have epilepsy, or who have other
 physical or developmental disabilities shall be grouped with other individuals
 of comparable social and intellectual development;

(m)
 recordkeeping;

(n)
 the management of personal funds in
 accordance with the requirements of sections
 
633.9
 and
 
633.15
 of this Title; 

(o)
 practices to be followed in the event of
 emergencies. The administrator shall develop a written emergency preparedness
 plan with detailed procedures for meeting all potential emergencies and
 disasters, such as missing individuals, severe weather, power outages, fires,
 floods, bomb threats and medical emergencies (
e.g.,
 epidemics,
 pandemics, food poisoning, chemical poisoning, etc.). This plan shall be posted
 at suitable locations throughout the facility and clearly communicated to and
 reviewed at least annually with all facility staff. Such plan shall include at
 least the following: 
(1)
 instructions for
 using alarm systems and signals;

(2)
 assignment of personnel to specific tasks
 and responsibilities;

(3)

 specifications of evacuation routes and procedures which are posted at suitable
 locations throughout the facility;

(4)
 systems for notification of appropriate
 persons and government agencies;

(5)
 location of pertinent equipment,
 including firefighting equipment and personal protective equipment;
 and

(6)
 procedures for continuity
 of operations;

(p)

 notification to individuals' families, advocates, supporters under an
 applicable supported decision-making agreement, or correspondents regarding
 health care problems in accordance with section
 
633.10
 of this Title ;

(q)
 steps to follow in the death of a person.
 In addition to the death reporting requirements in Part 624 of this Title,
 steps must include notification of the medical examiner and arranging for an
 autopsy when required by the local medical examiner; 
 
(1)
 In every case, the medical examiner
 should be immediately notified of a person's death.

(2)
 If the medical examiner releases the body
 to the facility for autopsy, the autopsy shall be performed by an impartial
 qualified physician who is not employed by the specialty hospital.

(3)
 The individual's correspondent shall be
 informed of the autopsy findings if they so desire;

(r)
 reporting and management of incidents in
 accordance with Parts 624 and 625 of this Title:. 
 
(1)
 personnel policies and procedures in
 accordance with the requirements of Part 633 of this Title, and also including:
 
(a)
 policies to ensure that employees are
 medically determined to be free of communicable and infectious diseases; and

(b)
 staff schedule for weekdays,
 weekends and holidays in accordance with the staff/individual ratios as
 specified in section
 
680.8
 of this
 Part.

(iv)
 personnel policies and procedures,
 including: 
(a)
 hiring policies reflecting
 conformity to Federal laws governing civil rights and equal employment
 opportunities;

(b)
 job
 descriptions, which specify qualifications, education and skills required,
 description of duties and responsibilities and supervision to be
 provided;

(c)
 authorized procedures
 consistent with due process for suspension and/or dismissal of an employee for
 cause;

(d)
 protection of individual
 rights, including prohibiting mistreatment, neglect or abuse of individuals
 with procedures to be followed in the event that violations of individual
 rights occur;

(e)
 staff training
 program: 
(1)
 job description of an individual
 responsible for staff development and training;

(2)
 orientation procedures;

(3)
 in-service training; and

(4)
 use of community resources and
 consultants;

(f)
 policies
 to ensure that employees are medically determined to be free of communicable
 and infectious diseases;

(g)
 policy
 statements on salaries and increments, accumulation of leave and fringe
 benefits;

(h)
 policy and procedures
 to ensure the complaints by staff can be made without the threat or
 recrimination; and

(i)
 staff
 schedule for weekdays, weekends and holidays in accordance with the
 staff/individual ratios as specified in section
 
680.8
 of this Part.

(10)
 The administrator
 shall ensure that the previously noted policies are incorporated in an
 up-to-date manual of written policies and procedures; and shall further ensure
 that the facility is in compliance with such policies and procedures or has a
 plan of correction for achieving compliance in a timely manner.

(b)

Administration.

(1)
 The specialty hospital administrator
 shall maintain a current table of organization which shows the major operating
 programs of the specialty hospital, the administrative personnel in charge of
 the programs and divisions, and their lines of authority, responsibility and
 communication. This table of organization shall identify the person(s),
 including person(s) in other departments and/or units of the agency who provide
 services delivered under other licenses to individuals at the specialty
 hospital, and/or agencies providing services to the individuals on a
 contractual basis, including shared staff, if any.

(2)
 The specialty hospital administrator
 shall establish an appropriate standing committee to deal with areas such as
 human rights, medication errors, and infection control. Such committees shall
 maintain formal minutes of their activities.

(3)
 The specialty hospital administrator
 shall make available for distribution a summary of the laws, regulations and
 procedures concerning admission, readmission, and discharge of a
 person.

(4)
 The specialty hospital
 administrator shall make arrangements so that an individual is designated as
 responsible for the administrative direction of the facility at all times when
 the administrator is absent.

(5)

 The specialty hospital administrator shall have in effect a transfer agreement
 with one or more hospitals for providing inpatient hospital services not
 available at the specialty hospital to individuals as needed. However, if the
 specialty hospital documents a good faith effort to establish such an
 agreement, but is unsuccessful, then this requirement may be waived if the
 commissioner determines that it is in the public interest and essential to
 providing specialty hospital services to eligible individuals.

(6)
 The specialty hospital administrator
 shall provide adequate, modern administrative support to efficiently meet the
 needs of the individuals. Administrative support includes clerical,
 communication, financial, housekeeping, laundry, personnel, physical plant,
 safety and security, supply, purchasing and transportation services.

(7)
 The specialty hospital administrator
 shall have a plan for a management audit conducted at least annually. This
 audit is to ensure that the specialty hospital complies with State laws and
 regulations and the facility's policy and procedures.

(8)
 The specialty hospital administrator
 shall document the facility's purchasing process and adequately operate its
 inventory control system and stockroom.

Notes

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

 §
 
680.4

Amended
 
New
 York State Register September 21, 2016/Volume XXXVIII, Issue 38
,
 eff. 
9/21/2016

Amended
 
New
 York State Register October 9, 2024/Volume XLVI, Issue 41
, eff.
 
10/9/2024

State regulations are updated quarterly; we currently have two versions available.
 Below is a 
comparison between our most recent version and the prior quarterly release.

 More comparison features will be added as we have more versions to compare.

(a)
 
 Organization.
 
(1)
 The governing body (see section 
680.13
 of this Part) of the specialty hospital shall be responsible for the overall operation and management of the specialty hospital and may discharge any responsibilities hereinafter stated through any body of delegates which is approved by the 
commissioner
.
 
(2)
 The governing body shall ensure that the facility and services provided adequately meet the health, social and developmental needs of all individuals receiving services through preventive, habilitative and rehabilitative programs.
 
(3)
 The governing body shall ensure that there is adequate protection of each person's health, safety, comfort, well-being, and civil, human and legal rights.
 
(4)
 The governing body of the specialty hospital shall develop working agreements with other providers to ensure delivery to individuals, as appropriate, special diagnostic and medical services which the specialty hospital does not provide.
 
(5)
 The governing body of the specialty hospital shall develop working agreements with the Developmental Disabilities Services 
Office
 (see section 
680.13
 of this Part) and other providers to ensure to the greatest extent possible, that opportunities exist in the community for movement of individuals, when appropriate, to less restrictive residential settings.
 
(6)
 Minutes of all official meetings of the governing body shall be maintained as permanent record of the decisions made in relation to the operation of the specialty hospital.
 
(7)
 Administrative management of the specialty hospital shall be delegated by the governing body to an appropriately qualified administrator.
 
(8)
 Ongoing direction and control of the medical services of the unit shall be delegated by the governing body to a physician whose qualifications in developmental disabilities are appropriate to the program. For purposes of this Part, this person shall be known as the medical director (see section 
680.13
).
 
(9)
 The governing body shall develop and revise as necessary, written policies for the quantity, quality, scope, goals, objectives and evaluation of all programs (see section 
680.13
); and policies for the accomplishment of stated purposes and well-being of individuals. These policies shall include, but not be limited to: 
(i)
 a statement of the facility's philosophy, objectives and goals, specifying: 
(a)
 the specialty hospital's role in the State's comprehensive services for people with developmental disabilities;
 
(b)
 the goals for individuals it serves; and
 
(c)
 the concept of its relationship to the parents or correspondents of individuals it serves;

(ii)
 methods for coordinating services for every individual between the specialty hospital and other providers of programs and services;
 
(iii)
 policies and procedures specifying how and by whom the following functions shall be performed: 
(a)
 specification of preadmission procedures which include requiring referral services to identify the person's specific conditions which necessitate hospitalization and the types of rehabilitation therapy requested;
 
(b)
 an application screening process which: 
(1)
 determines appropriateness and medical necessity of the admission in accordance with the specialized services offered;
 
(2)
 determines person's rehabilitation potential; and
 
(3)
 includes a procedure requesting the approval of the 
commissioner
 prior to the admission;

(c)
 an admission and process which includes the development of an individual program plan (see section 
680.13
) defining the types of therapy services to be provided in accordance with the individual's condition(s), measurable outcome expected, and a time frame for attainment of each outcome;
 
(d)
 interdisciplinary assessments, preparation of individual service plans (see section 
680.13
), and periodic reevaluation and revision of the plans in coordination with agencies providing day programs and treatment to the individuals;
 
(e)
 periodic review of the appropriateness of the person's admission and continued stay in the specialty hospital;
 
(f)
 ensuring effective communication between staff and individuals and families of individuals, using such means as counseling with individuals, problem-solving procedures, family conferences, telephone communication and newsletters;
 
(g)
 ensuring that the rights of all individuals are not abridged;
 
(h)
 the provision of all services required by section 
680.7
 of this Part. This shall include a description of methods to be used for coordinating each service with other services and programs provided to the individuals. In addition: 
(1)
 policies and procedures regarding medical and medically related services (see section 
680.13
) to individuals shall include, but not be limited to, physician visits, emergency coverage, hospitalization, consultants and rehabilitative services;
 
(2)
 policies and procedures regarding dental services (see section 
680.13
) shall include, but not be limited to, emergency care;
 
(3)
 policies and procedures regarding pharmacy services (see section 
680.13
) and consultation to individuals shall include, but not be limited to, the safe administration and handling of all drugs specifying the following: 
(i)
 criteria and schedule for evaluations and treatment recommendations regarding self-administration of medications by the person;
 
(ii)
 criteria for staff training regarding administration of medication by staff. Only appropriately trained staff shall be allowed to administer drugs as specified in existing State regulations and policy for administration of medication. For direct care staff to be allowed to administer drugs, they must complete a training program in administration of medication which has the prior approval of the 
commissioner
, and drugs administered by such staff must be in unit dose form; and
 
(iii)
 all medication errors and drug reactions shall be reported immediately to the practitioner who ordered the drug. Adverse drug reactions shall be reported to the Federal Food and Drug Administration;

(i)
 arrangements or preparations for the individuals to obtain additional services needed through other agencies;
 
(j)
 discharge or transfer of a person, including: 
(1)
 participation of the staff, the individual, where appropriate, the family and the agent responsible for service delivery following discharge or transfer;
 
(2)
 due process for discharge or transfer; and
 
(3)
 provision for appropriate follow-up services;

(k)
 space utilization;
 
(l)
 planning for organization, size and grouping of living units (see section 
680.13
). 
(1)
 The specialty hospital may not group individuals of widely divergent ages, developmental levels and social needs in close physical or social proximity unless the grouping is planned for the concentrated treatment of health problems necessitated by the person's admission and there is a specific written plan which includes the rationale for this grouping.
 
(2)
 The specialty hospital may not group individuals on the basis of their physical handicaps unless the grouping is for concentrated treatment of health problems necessitating the individuals' admissions. Otherwise, individuals who are mobile, nonambulatory, deaf, blind, epileptic, or who have other physical or developmental disabilities shall be grouped with other individuals of comparable social and intellectual development;

(m)
 recordkeeping;
 
(n)
 maintaining a written financial record for each individual that is available to the individual and the individual's family (unless the individual is an adult who objects to the disclosure of such information to his or her family). This record shall include: 
(1)
 written receipts for each individual's personal possessions and funds received by or deposited with the specialty hospital; and
 
(2)
 written receipts for all disbursements made to or for the individual;

(o)
 practices to be followed in the event of emergencies. The administrator shall develop a written staff organization plan with detailed written procedures for meeting all potential emergencies and disasters, such as missing individuals, severe weather, power outages, fires, floods, bomb threats and medical emergencies (
e.g.,
 epidemics, food poisoning, chemical poisoning, etc.). This plan shall be posted at suitable locations throughout the facility and clearly communicated to and periodically reviewed with staff; and shall include at least the following: 
(1)
 instructions for using alarm systems and signals;
 
(2)
 assignment of personnel to specific tasks and responsibilities;
 
(3)
 specifications of evacuation routes and procedures which are posted at suitable locations throughout the facility;
 
(4)
 systems for notification of appropriate persons;
 
(5)
 location of firefighting equipment; and
 
(6)
 methods of fire containment;

(p)
 steps to follow in the event of any unusual occurrence, including, but not limited to serious illness, accident or impending death (
e.g.,
 notification of family;
 
(q)
 steps to follow in the death of a person, including notification of the family and medical examiner and arranging for an autopsy when required by the local medical examiner; 
(1)
 In every case, the medical examiner should be immediately notified of a person's death.
 
(2)
 If the medical examiner releases the body to the facility for autopsy, the autopsy shall be performed by an impartial qualified physician who is not employed by the specialty hospital.
 
(3)
 The individual's correspondent shall be informed of the autopsy findings if he or she desires;

(r)
 special review procedures, including but not limited to: 
(1)
 ensuring that all alleged violations of policies prohibiting mistreatment, neglect or abuse of an individual are reported and investigated. The specialty hospital shall have documentation of the following: 
(i)
 All alleged violations are reported within 24 hours to the administrator, the Mental Hygiene Legal Service, the 
commissioner
, the State 
Office
 of Health Systems Management and the State 
Office
 of Protective Services for Children or the corresponding local 
office
 (if appropriate given the age of the client involved).
 
(ii)
 The administrator shall ensure that each alleged violation is investigated thoroughly.
 
(iii)
 The results of each investigation shall be reported to the administrator, 
commissioner
, the Mental Hygiene Legal Service, the Commission on Quality of Care and Advocacy for Persons with Disabilities and the State 
Office
 of Health Systems Management within 24 hours of the report of the alleged violation.
 
(iv)
 The 
commissioner
 may require a separate investigation of an alleged violation to be carried on by staff of OPWDD, the district attorney's 
office
 or other law enforcement officials.
 
(v)
 A written report of incidents, with the investigation results, shall be sent to the Professional Advisory Board (see section 
680.13
) within 30 days of the incident, for all Willowbrook class members.
 
(vi)
 A written report of completed investigations at the specialty hospital shall be shared with the State 
Office
 of Health Systems Management.
 
(vii)
 If the alleged violation is verified, the administrator shall impose an appropriate penalty;

(2)
 ensuring that appropriate corrective action is taken to prevent similar accidents in the future;

(iv)
 personnel policies and procedures, including: 
(a)
 hiring policies reflecting conformity to Federal laws governing civil rights and equal employment opportunities;
 
(b)
 job descriptions, which specify qualifications, education and skills required, description of duties and responsibilities and supervision to be provided;
 
(c)
 authorized procedures consistent with due process for suspension and/or dismissal of an employee for cause;
 
(d)
 protection of individual rights, including prohibiting mistreatment, neglect or abuse of individuals with procedures to be followed in the event that violations of individual rights occur;
 
(e)
 staff training program: 
(1)
 job description of an individual responsible for staff development and training;
 
(2)
 orientation procedures;
 
(3)
 in-service training; and
 
(4)
 use of community resources and consultants;

(f)
 policies to ensure that employees are medically determined to be free of communicable and infectious diseases;
 
(g)
 policy statements on salaries and increments, accumulation of leave and fringe benefits;
 
(h)
 policy and procedures to ensure the complaints by staff can be made without the threat or recrimination; and
 
(i)
 staff schedule for weekdays, weekends and holidays in accordance with the staff/individual ratios as specified in section 
680.8
 of this Part.

(10)
 The administrator shall ensure that the previously noted policies are incorporated in an up-to-date manual of written policies and procedures; and shall further ensure that the facility is in compliance with such policies and procedures or has a plan of correction for achieving compliance in a timely manner.

(b)
 
Administration.
 
(1)
 The specialty hospital administrator shall maintain a current table of organization which shows the major operating programs of the specialty hospital, the administrative personnel in charge of the programs and divisions, and their lines of authority, responsibility and communication. This table of organization shall identify the person(s) and/or agencies providing services to the individuals on a contractual basis, including shared staff, if any.
 
(2)
 The specialty hospital administrator shall establish appropriate standing committees to deal with areas such as human rights, aversive conditioning, research review, medication errors and infection control. Such committees shall maintain formal minutes of their activities.
 
(3)
 The specialty hospital administrator shall make available for distribution a summary of the laws, regulations and procedures concerning admission, readmission and release of a person.
 
(4)
 The specialty hospital administrator shall make arrangements so that an individual is designated as responsible for the administrative direction of the facility at all times when the administrator is absent.
 
(5)
 The specialty hospital administrator shall have in effect a transfer agreement with one or more hospitals for providing inpatient hospital services not available at the specialty hospital to individuals as needed. However, if the specialty hospital documents a good faith effort to establish such an agreement, but is unsuccessful, then this requirement may be waived if the 
commissioner
 determines that it is in the public interest and essential to providing specialty hospital services to eligible individuals.
 
(6)
 The specialty hospital administrator shall provide adequate, modern administrative support to efficiently meet the needs of the individuals. Administrative support includes clerical, communication, financial, housekeeping, laundry, personnel, physical plant, safety and security, supply, purchasing and transportation services.
 
(7)
 The specialty hospital administrator shall have a plan for a management audit conducted at least annually. This audit is to ensure that the specialty hospital complies with State laws and regulations and the facility's policy and procedures.
 
(8)
 The specialty hospital administrator shall document the facility's purchasing process and adequately operate its inventory control system and stockroom.

Notes

N.Y. Comp. Codes R. & Regs. Tit. 
14
 § 
680.4

Amended 
New York State Register September 21, 2016/Volume XXXVIII, Issue 38
, eff. 
9/21/2016

 State Regulations Toolbox