§ 595.6 - Organization and administration

Organization and administration

This section establishes organizational and administrative requirements for the governing body of mental health residential programs licensed under Title 14, Part 595 by the New York Office of Mental Health. The governing body must meet regularly, maintain an organizational plan, adopt written policies covering personnel, admissions, medication, confidentiality, and quality assurance, and ensure cultural and ethnic representation. Providers must also cooperate with local governmental units in planning, conduct annual financial audits, and ensure priority access for individuals enrolled in assisted outpatient treatment programs.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 595.6 - Organization and administration 

 State Regulations 

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(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.

Notes

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

 §
 
595.6

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