§ 587.6 - Organization and administration

Organization and administration

This section establishes organizational and administrative requirements for outpatient mental health program providers certified by the New York Office of Mental Health under 14 NYCRR Part 587. Governing bodies must meet quarterly, maintain organizational plans, adopt written policies on personnel, medication, records, child abuse reporting, and recipient grievances, and ensure ongoing staff training. Specific provisions address partial hospitalization programs (electroconvulsive therapy approval), prohibition of seclusion and restraint in outpatient settings, utilization review, financial auditing, and priority access for individuals enrolled in assisted outpatient treatment programs.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 587.6 - 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.

(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 as a member of
 the governing body and of the paid staff of the program without prior approval
 of the Office of Mental Health.

(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-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 patient population;

(6)
 to ensure that recipients and their
 families have a mechanism for participating in treatment or psychiatric
 rehabilitation service planning decisions;

(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 personnel
 policies which shall prohibit discrimination on the basis of race, color,
 creed, disability, sex, marital status, age, national origin or sexual
 orientation;

(ii)
 written policies
 which shall provide for verification of employment history, personal
 references, work record and qualifications, as well as securing a signed, sworn
 statement whether, to the best of his or her knowledge, the applicant has ever
 been convicted of a crime in this State or any other jurisdiction and for
 appropriate consideration and confidentiality of such information;

(iii)
 written volunteer policies which shall
 provide for screening of volunteers, verification of employment history,
 personal references and work history, and supervision of volunteers. Such
 policies shall also provide for securing a signed, sworn statement whether, to
 the best of his or her knowledge, the volunteer has ever been convicted of a
 crime in this State or any other jurisdiction, for appropriate consideration
 and confidentiality of such information;

(iv)
 written policies which are consistent
 with the obligations imposed by title VII of the Civil Rights Act, Federal
 Executive Order 11246, the Rehabilitation Act of 1973, section 504, 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 American Disabilities
 Act of 1990;

(v)
 written policies
 and procedures concerning the prescription and administration of medication
 which shall be consistent with applicable Federal and State laws and
 regulations;

(vi)
 written policies
 and procedures governing recipients' records which ensure confidentiality
 consistent with the Mental Hygiene Law, and which provide for appropriate
 retention of such records pursuant to section
 
587.18
 of this Part;

(vii)
 written criteria for admission, and
 discharge from the program;

(viii)

 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

(ix)

 written policies and procedures describing a recipient grievance process which
 ensure the timely review and resolution of recipients' complaints and which
 provides a process enabling recipients to request review by the Office of
 Mental Health when resolution is not satisfactory; and

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

(d)
 A provider of service
 certified as a partial hospitalization program shall ensure that
 electroconvulsive therapy is only used pursuant to a written plan previously
 approved by the Office of Mental Health.

(e)
 The provider of service who provides
 carved-out services to enrollees of a managed care provider in need of such
 services shall enter into agreement(s) with managed care provider(s) in
 accordance with chapter 165 of the Laws of 1991 and the accompanying memorandum
 of agreement. Such agreements are intended to integrate special care and
 managed care within the Medicaid managed care program and the special care
 program based on the agreed upon protocols for the purposes of coordination of
 care and determination of need.

(f)

 A provider of service shall ensure that an outpatient program does not use
 seclusion as a treatment intervention or response to a crisis
 situation.

(g)
 A provider of
 service shall ensure that an outpatient program does not use restraint as a
 treatment intervention or in response to a crisis situation.

(h)
 A provider of service shall ensure that
 recipient participation in research only occurs in accordance with applicable
 Federal and State requirements.

(i)

 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.

(j)
 A
 provider of service shall ensure that no otherwise appropriate recipient is
 denied access to services solely on the basis of multiple diagnoses or a
 diagnosis of HIV infection, AIDS, or AIDS-related complex.

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

(l)
 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 policies
 and procedures shall include provisions insuring that utilization review is
 performed only by professional staff trained to do such reviews, or by staff
 who are otherwise qualified by virtue of their civil service standing, and
 shall ensure to the maximum extent possible that the designated utilization
 review authority functions independently of the clinical staff which is
 treating the recipient under review.

(m)
 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;
 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.

(n)
 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.

(o)
 The provider of service shall establish
 mechanisms for the meaningful participation of recipient 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.

(p)
 The provider of service shall establish
 mechanisms which ensure that the cultural and ethnic backgrounds of recipients
 are taken into account such as participation of ethnic consumers, ethnic
 representation on the staff and board, and inclusion of ethnic appropriate
 content in service programs.

(q)

 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

 §
 
587.6

Amended,
 
New
 York State Register, Volume XXXVI, Issue 22
, effective
 
6/4/2014

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