§ 594.6 - Organization and administration

Organization and administration

This section establishes organizational and administrative requirements for providers operating licensed mental health housing programs under New York's Title 14, Part 594, as overseen by the Office of Mental Health. Governing bodies must meet quarterly, maintain an organizational plan, ensure policy development (covering personnel, confidentiality, admissions, grievances, and child supervision), and conduct annual financial audits. Providers must also participate in local planning processes, report incidents, and ensure culturally competent services for residents, with specific protections for children and adolescents in placement.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 594.6 - 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.

(b)
 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 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 resident population;

(6)
 to ensure that a child or adolescent
 resident, and where appropriate, his or her family or surrogate family, are an
 integral part of service planning decisions;

(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 or national
 origin;

(ii)
 written personnel
 policies which provide for screening of employees through the New York
 Statewide Central Register of Child Abuse and Maltreatment, 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
 provide for screening of volunteers through the New York Statewide Central
 Register of Child Abuse and Maltreatment, 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 which 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 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 from the program which shall state that no
 person shall be excluded from the program on the basis of race, religion,
 color, sex, sexual orientation, disability, HIV status or national origin.
 However, nothing in this subparagraph shall be interpreted to prevent a
 provider from making admission or discharge decisions based upon the
 functional, clinical and behavioral needs of the applicant which are relevant
 to its functional program;

(viii)

 written policies and procedures that will allow family members or guardians to
 visit the child in the residential program and/or participate in planned
 recreation activities and outings;

(ix)
 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 youth 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 or the parents or guardians of residents;

(x)
 written policies and procedures
 describing a resident grievance process which ensures the timely review and
 resolution of residents' or family members' complaints and which provides a
 process enabling residents or family members to request review by the Office of
 Mental Health when resolution is not satisfactory;

(xi)
 written policies and procedures
 describing a staff supervision plan which identifies the minimum
 skills/competencies necessary for staff to supervise youth in placement
 independent of direct supervision; and

(xii)
 written policies and procedures
 describing general child supervision practices and individual precautions
 designed to ensure a safe environment for all residents.

(8)
 The governing body shall ensure the
 development of, approve and periodically review and revise a written quality
 assurance plan for the licensed housing program. Such plan shall include, but
 not be limited to, the following:
(i)
 Written
 policies and procedures for monitoring the operation of the housing program
 against criteria established in the functional program.

(ii)
 A written utilization review procedure
 to monitor the extent to which residents are receiving appropriate services and
 are being served at an appropriate level of care.

(iii)
 A written procedure for incident
 reporting and incident management.

(c)
 A provider of service shall ensure the
 timely reporting, investigation, review, monitoring and documentation of
 incidents pursuant to the Mental Hygiene Law and Part 524 of this
 Title.

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

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

(f)
 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. At a minimum, such participation shall include: 
 
(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;

(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 (CCCED) providers, which must include referral and admission
 procedures, as well as procedures for crisis clinical back-up.

(g)
 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.

(h)
 The provider of service shall establish
 mechanisms which ensure that the cultural and ethnic backgrounds of residents
 are taken into account such as ethnic representation on the staff and governing
 body, and inclusion of ethnic appropriate content in service
 programs.

(i)
 The provider of
 service shall provide for the fair compensation of residents who are employed
 by the provider. Such employment must meet all applicable requirements of
 Federal and State labor laws. The requirements of this subdivision shall not be
 applicable to the performance of normal household chores.

(j)
 The provider shall submit an annual
 report to the Office of Mental Health. The report shall include annual goals
 and objectives of the program, progress toward meeting the goals, and feedback
 from semi-annual consumer evaluations.

Notes

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

 §
 
594.6

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