§ 599.6 - Organization and administration

Organization and administration

This section establishes organizational and administrative requirements for Mental Health Outpatient Treatment and Rehabilitative Service (MHOTRS) programs certified under 14 NYCRR Part 599 in New York. Providers must maintain a governing body with defined responsibilities including policy development, utilization review, risk management, and compliance oversight. Required written policies cover areas such as admission and discharge criteria, medication management, confidentiality, grievance procedures, crisis intervention, criminal history checks, and non-discrimination. Programs must also ensure priority access for individuals in assisted outpatient treatment and those transitioning from ACT services.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 599.6 - Organization and administration 

 State Regulations 

 Compare

(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.

(b)
 In programs operated by
 not-for-profit corporations other than hospitals licensed pursuant to article
 28 of the Public Health Law, no person shall serve both as a member of the
 governing body and of the paid staff of the Mental Health Outpatient Treatment
 and Rehabilitative Service program without prior written approval of the
 Office.

(c)
 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-today management of the program to a designated professional who is
 qualified by training and experience to supervise program staff;

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

(5)
 to ensure that the
 design and operation of the program is consistent with and appropriate to the
 ethnic and cultural background of the population served. This can include
 ethnic representation on the staff and board and inclusion of culturally and
 ethnically relevant content in service programs;

(6)
 to ensure that planning decisions are
 based upon input from individuals and, where appropriate, their family
 members;

(7)
 to develop, 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 criteria for admission, and
 discharge from the program. Admission policies should include a mechanism for
 screening individuals at the time of referral and assuring that those referred
 from inpatient, forensic, or emergency settings, those determined to be at high
 risk, and those determined to be in urgent need by the Director of Community
 Services receive services within five business days, and if indicated, are
 admitted to the Mental Health Outpatient Treatment and Rehabilitative Service
 program or referred to an appropriate provider of services. The county may
 establish, subject to the approval of the Office, categories of individuals to
 be considered in urgent need of services;

(ii)
 policies and procedures for conducting
 initial and ongoing risk assessments and for development of plans to address
 identified areas of elevated risk, including procedures to ensure that any
 health or mental health issues identified are treated appropriately by the
 Mental Health Outpatient Treatment and Rehabilitative Service program or that
 an appropriate referral to a treatment provider and subsequent follow up is
 made;

(iii)
 policies and procedures
 addressing individual/family engagement and retention in treatment, including,
 at minimum, plans for outreach and re-engagement efforts commensurate with an
 individual's assessed risk;

(iv)

 policies and procedures for providing off-site services;

(v)
 policies to address personal safety of
 staff and provide appropriate training in de-escalation techniques;

(vi)
 policies and procedures for age
 appropriate health monitoring, which describe whether such monitoring will be
 performed by the provider or, if not, how the provider will seek to ascertain
 relevant health information. Such policies and procedures must include a
 requirement that an individual's refusal to provide access to such information
 be documented in the case record;

(vii)
 policies and procedures for screening
 for use of or dependence on alcohol, tobacco or other drugs;

(viii)
 policies and procedures ensuring that
 a reasonable effort shall be made to obtain records from prior recent episodes
 of treatment;

(ix)
 policies and
 procedures ensuring that a reasonable effort shall be made to communicate with
 family members, current service providers, and other collaterals, as
 appropriate;

(x)
 written policies
 and procedures to ascertain whether individuals are currently receiving or are
 eligible to receive Medicare or Medicaid or other form of reimbursement for
 services provided. If it is determined that an individual is eligible for any
 such program but not currently enrolled, the policies and procedures shall
 include means of facilitating the enrollment of such individual in such
 program;

(xi)
 written policies and
 procedures concerning the prescription and administration of medication which
 shall be consistent with applicable Federal and State laws and regulations and
 which includes procedures for ensuring that individuals are receiving
 prescribed medications and using them appropriately;

(xii)
 written policies and procedures
 governing an individual's records which ensure confidentiality consistent with
 sections
 
33.13
 and
 
33.16
 of
 the Mental Hygiene Law and 45 CFR parts 
160
 and 
164
, and which provide for
 appropriate retention of such records pursuant to section
 
599.11
 of this Part;

(xiii)
 written policies and procedures
 describing an individual grievance process which ensures the timely review and
 resolution of individual complaints and which provides a process enabling
 recipients to request review by the Office when resolution is not
 satisfactory;

(xiv)
 written
 personnel policies which guide efforts to reduce disparities in access, quality
 of care and treatment outcomes for underserved/unserved and/or marginalized
 populations, including but not limited to: people of color, members of the
 LBGTQ+ community, older adults, pregnant persons, Veterans, individuals who are
 hearing impaired, individuals with limited English proficiency, immigrants,
 individuals with intellectual/developmental disabilities and all justice
 system-involved populations ;

(xv)

 written personnel policies which shall prohibit discrimination on the basis of
 race or ethnicity, religion, disability, gender identity or sexual orientation,
 marital status, age, documentation status, or national origin, as well as,
 written policies on affirmative action which are consistent with the
 affirmative action and equal employment opportunity obligations imposed by
 title VII of the Civil Rights Act, Federal Executive Order 11246, the
 Rehabilitation Act of 1973, section 504, as amended, and the Vietnam Era
 Veteran's Readjustment Act;

(xvi)

 written policies for the availability of crisis intervention services at all
 times. After-hours coverage shall include, at a minimum, the ability to provide
 brief crisis intervention services provided pursuant to a plan approved by the
 local governmental unit or the Office. Such services shall be provided either
 directly or pursuant to a Clinical Services Contract. Such contract shall
 include, at a minimum, provisions assuring that, in the event of a crisis, the
 nature of the crisis and any measures taken to address such crisis are
 communicated to the primary clinician or other designated clinician involved in
 the individual's treatment at the Mental Health Outpatient Treatment and
 Rehabilitative Service program, or the individual's primary care or other
 mental health care provider, if known, on the next business day. At the request
 of the local governmental unit, State-operated Mental Health Outpatient
 Treatment and Rehabilitative Service programs shall consult with the local
 governmental unit or units in their service area in the development of such
 Mental Health Outpatient Treatment and Rehabilitative Service program's crisis
 response plan;

(xvii)
 written
 policies for the performance of Criminal history information reviews required
 pursuant to Section
 
31.35
 of
 the Mental Hygiene Law, Sections
 
424-a
 and
 
495
 of the
 Social Services Law, and 14 NYCRR 
550
. Such reviews shall be conducted in
 accordance with such laws and regulations and any guidance issued by the
 Office. All prospective employees, contractors and volunteers who have the
 potential for, or may be permitted, regular and substantial unsupervised or
 unrestricted contact with Recipients shall submit to a criminal history
 information review. All staff with the potential for regular and substantial
 contact with Recipients in performance of their duties shall submit to
 clearance by the New York Statewide Central Register of Child Abuse and
 Maltreatment. Mental Health Outpatient Treatment and Rehabilitative Service
 program Staff who have not been screened by the New York Statewide Central
 Register of Child Abuse and Maltreatment shall not perform duties requiring
 contact with individuals unless there is another staff member
 present.

(xviii)
 written policies
 regarding the selection, supervision, and conduct of students accepted for
 training in fulfillment of a written agreement between the Mental Health
 Outpatient Treatment and Rehabilitative Service program and a State Education
 Department accredited higher education institution, as well as requesting the
 Office to perform criminal history record checks in accordance with Part 550 of
 this Title;

(xix)
 written policies
 regarding the employment, supervision and privileging of nurse practitioners
 and physician assistants. Such policies shall ensure that physician assistants
 have responsibilities related to physical health only. Such policies shall
 ensure compliance with Part 550 of this Title concerning the requirement for
 criminal history record checks, for obtaining clearance from the New York State
 Central Register of Child Abuse and Maltreatment for persons who have the
 potential for regular and unsupervised or unrestricted contact with children,
 and for appropriate consideration and confidentiality of such
 information;

(xx)
 written policies
 which shall establish that contracts with third party contractors that are not
 subject to the criminal history background check requirements established in
 section
 
31.35
 of
 the Mental Hygiene Law include reasonable due diligence requirements to ensure
 that any persons performing services under such contract that will have regular
 and substantial unsupervised or unrestricted contact with patients of the
 Mental Health Outpatient Treatment and Rehabilitative Service program do not
 have a criminal history that could represent a threat to the health, safety, or
 welfare of the patients of the Mental Health Outpatient Treatment and
 Rehabilitative Service program, including, but not limited to, the provision of
 a signed, sworn statement whether, to the best of their knowledge, such person
 has ever been convicted of a crime in this State or any other jurisdiction;
 and

(xxi)
 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 into protective custody, mandatory reporting of deaths,
 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. Such policies and procedures shall address the
 requirements for the identification and reporting of abuse or neglect regarding
 recipients who are children, or who are the parents or guardians of children;
 and

(8)
 to ensure the
 establishment and implementation of an ongoing training program for current and
 new employees and volunteers that addresses the policies and procedures
 regarding child abuse and neglect described in paragraph (7) of this
 subdivision.

(d)
 A
 provider of service shall ensure that no individual who is otherwise
 appropriate for admission is denied access to services solely on the basis of
 having a co-occurring non-mental health diagnosis, or a diagnosis of HIV
 infection, AIDS, or AIDS-related complex.

(e)
 The provider of service shall establish
 mechanisms to ensure that priority access is given to 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, in accordance with the following: 
 
(1)
 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.

(2)
 Prior to 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 for the county.

(3)
 Any and
 all related information, reports and data that 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.

(f)
 The provider
 of service shall establish mechanisms to ensure priority access for individuals
 receiving ACT and transitioning, for continuity of care for such individuals,
 including the provision of appropriate services and medications, including
 injectable medications.

(g)
 The
 provider of service shall establish mechanisms for the meaningful participation
 of individuals, family representatives either through direct participation on
 the governing body, or through the creation of a recipient advisory board. If a
 recipient advisory board is used, the provider of service shall ensure a
 mechanism for the recipient advisory board to make recommendations to the
 governing body.

(h)
 The provider of
 service shall develop and make available to recipients and collaterals, a plan
 which will assure an appropriate response to recipients admitted to the program
 and their collaterals who need assistance when the program is not in operation.
 Such plan shall include the ability to speak with a member of the licensed
 staff of the Mental Health Outpatient Treatment and Rehabilitative Service
 program or a licensed staff person working under the auspices of the Mental
 Health Outpatient Treatment and Rehabilitative Service program pursuant to a
 plan approved by the local governmental unit or, for county-operated providers,
 by the Office.

(i)
 A provider of
 service shall ensure that any Mental Health Outpatient Treatment and
 Rehabilitative Service program subject to this Part does not: 
 
(1)
 utilize restraint or seclusion for any
 purpose, including, but not limited to, as a response to a crisis situation,
 provided, however nothing in this section shall be construed to prohibit the
 use of reasonable physical force when necessary to protect the life and limb of
 any person where alternative procedures and methods have failed ; and

(2)
 perform electroconvulsive therapy or
 aversive conditioning therapy for any purpose, including, but not limited to,
 as a treatment intervention.

(j)
 A provider of service shall ensure that
 an individual's participation in research only occurs in accordance with
 applicable Federal and State requirements.

(k)
 A provider of service shall ensure the
 development, implementation and ongoing monitoring of a Risk Management Program
 that includes the requirements for identification, documentation, reporting,
 investigation, review, and monitoring of incidents pursuant to the Mental
 Hygiene Law and Part 524 of this Title.

(l)
 There shall be emergency procedures
 including but not limited to an emergency evacuation plan and staff shall be
 knowledgeable about such procedures.

(m)
 There shall be a written utilization
 review procedure to ensure that all recipients are receiving appropriate
 services and are being served at an appropriate level of care. Such utilization
 review procedure shall provide for:
(1)
 a
 review of the appropriateness of admission to a Mental Health Outpatient
 Treatment and Rehabilitative Service program; and

(2)
 a review of the need for continued
 treatment in a Mental Health Outpatient Treatment and Rehabilitative Service
 program within seven months after admission and every six months thereafter
 unless the individual is:
(i)
 discharged out
 of the program and subsequently readmitted, wherein the cycle begins again;
 or

(ii)
 receiving psychotropic
 medication treatment and medication education services only, wherein the need
 for continued treatment shall be reviewed every 12 months thereafter.

(n)
 The provider of
 service shall participate as requested by the local governmental unit in the
 local planning processes pursuant to article 41 of the Mental Hygiene
 Law.

(o)
 The provider of service
 shall cooperate with the Office and the local governmental unit in monitoring
 the access to services of individuals or groups determined to be in urgent need
 of services pursuant to this section.

(p)
 In programs that are not operated by
 State government, there shall be an annual audit of the service provider,
 pursuant to a format prescribed by the Office, and in accordance with Generally
 Accepted Auditing Principles, of the financial condition and accounts of the
 provider, or in accordance with requirements established by the Department of
 Health for programs operated by agencies operated pursuant to article 28 of the
 Public Health Law. This audit shall be performed by a certified public
 accountant who is not a member of the governing body or an employee of the
 program. In addition, the provider is required to submit an annual Consolidated
 Fiscal Report to the Office of Mental Health, signed by the Chief Executive
 Officer, and meet all requirements for submission as described in the
 instructions for this Report. Government-operated programs shall comply with
 applicable laws concerning financial accounts and auditing requirements. The
 Office shall utilize the applicable schedules to the annual Consolidated Fiscal
 Report to the Office of Mental Health to determine provider compliance with the
 indigent care requirements contained in section
 
599.15
 of this Part.

(q)
 A provider of services required to comply
 with the indigent care requirements contained in section
 
599.15
 of this Part shall ensure
 that no individual who is otherwise appropriate for admission is denied access
 to services solely because the individual does not have creditable coverage or
 the means to pay the provider's private pay rates or sliding fee
 scale.

(r)
 Programs operated by
 hospitals, including psychiatric centers operated by the State, or hospitals
 licensed pursuant to article 31 of the mental hygiene law or article 28 of the
 public health law, which are Medicare certified and provide outpatient services
 reimbursed by Medicare, shall ensure services are provided consistent with
 applicable Medicare certification and coverage standards and policies, in
 addition to any other requirement contained in this Part.

Notes

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

 §
 
599.6

Amended
 
New
 York State Register October 21, 2020/Volume XLII, Issue 42
, eff.
 
10/21/2020

Amended
 
New
 York State Register November 23, 2022/Volume XLIV, Issue 47
, eff.
 
11/23/2022

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.

 No prior version found.

 State Regulations Toolbox