N.Y. Comp. Codes R. & Regs. tit. 14 § 594.6

Current through Register Vol. 46, No. 45, November 2, 2024

Section 594.6 - Organization and administration

(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.

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