New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIV - Office for People With Developmental Disabilities › Part 690 - Day Treatment Services to Persons with Developmental Disabilities › Section 690.5 - Governance, administration, and operations - Principles of compliance

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Governing
				body responsibilities.
(1) There shall
				be a governing body (see glossary) with the policy making authority for the day
				treatment facility and legal responsibility for its operation and management.
				Each member of the governing body shall be identified by name and address in
				the agency/facility (see glossary) records. No one shall serve as both a member
				of the governing body and of the paid staff of the day treatment
				facility.
(2) The governing body
				shall be responsible for the operation of the day treatment facility according
				to the principles and standards established in this Part and other applicable
				rules, regulations, and statutes. This includes, but is not limited to, Parts
				620, 624, 633 and 635 of this Title. Further, it shall:
(i) Ensure that the facility has a plan for a
				management and fiscal audit, and that such audit is conducted at least
				annually. This audit is to ensure that the facility complies with State and
				Federal laws and regulations and the facility's policies and procedures; and
				that it is operating in a fiscally responsible manner. Results of the
				evaluation are to be in writing, including recommendations, plans of correction
				and timeframes, and the names(s) of the party(ies) responsible for those
				corrections. The results of the audit shall be available on request for review
				by OPWDD.
(ii) Delegate the
				continuous day-to-day direction and control of the facility to a specific staff
				member who is referred to in this Part as the administrator (see
				glossary).
(iii) Ensure that the
				facility, and its associated satellite(s), have sufficient qualified
				professionals (see glossary) and direct care staff to deliver the services
				offered in accordance with the intensity, duration and frequency recommended by
				the treating clinician(s) for persons admitted to the facility. This includes
				setting forth procedures (available to and periodically reviewed with staff) to
				address and ensure adequate and appropriate coverage in the event of
				absenteeism (for any reason) by administrative, clinical, and/or direct care
				personnel.
(3) The
				governing body shall ensure the development, implementation, revision when
				necessary, and use of written policies/procedures (see glossary). The
				policies/procedures shall specify the facility's operational procedures and the
				staff titles operationally responsible for various facility activities in at
				least the following areas:
(i) services
				available, treatment planning, service delivery;
(ii) treatment coordination;
(iii) staffing, qualifications, and personnel
				policies;
(iv)
				administration;
(v) admission (see
				glossary) and discharge criteria;
(vi) quality assurance and quality
				improvement, including program and individual service evaluation;
(vii) standing committees;
(viii) program goals;
(ix) recordkeeping and reporting;
				and
(x) budgeting and expenditure
				controls.
(4) In
				addition, there shall be policies/procedures specifying:
(i) Steps to follow in the event of any
				unusual occurrence, including serious illness, accident, impending death or
				death. Such steps would include, as appropriate, notification of the
				correspondent, the residence, the medical examiner. (If an autopsy is performed
				on a person receiving day treatment services, it shall be performed by an
				impartial qualified physician who is not employed by the facility).
(ii) Practices to be followed in the event of
				emergencies. The administrator shall develop a written staff organization plan
				with detailed written procedures for meeting all potential emergencies and
				disasters, such as missing persons, severe weather, power outages, fires,
				floods, bomb threats, strikes and medical emergencies (
e.g.,
epidemics, food poisoning, chemical poisoning, etc.). This plan shall be posted
				at suitable locations throughout the facility and clearly communicated to and
				periodically reviewed with staff.
(5) The governing body shall ensure the
				development and implementation of a written quality assurance program that
				includes a planned and systematic process for monitoring and assessing, on an
				ongoing basis, the quality and appropriateness of treatment and clinical
				performance of staff, as well as the continuing adequacy of the facility's
				physical plant, equipment and supplies.
(i)
				The plan shall include a means to resolve identified problems, pursue
				opportunities to improve the care and treatment provided and incorporate the
				regular, ongoing input of individuals, parents and/or advocates, and other
				relevant service providers.
(ii)
				The plan shall be subject to OPWDD review and approval as part of the process
				for issuing a new operating certificate or the facility's first certification
				subsequent to the effective date of this Part.
(6) To ensure that services are focused on
				developing those skills/capacities that enable each person to exercise
				alternative, less restrictive service choices, and as an integral part of a day
				treatment facility's internal quality assurance plan, a means shall be
				implemented whereby the facility's management can assess:
(i) the appropriateness of the admissions to
				the facility;
(ii) the
				appropriateness of the services provided relative to the presenting and/or
				current needs of persons admitted; and
(iii) the appropriateness of continuing a
				person's current level of participation at the day treatment
				facility.
(7) The
				governing body shall ensure that admission and discharge policies, including
				those pertaining to eligibility for service/treatment and a description of
				available services, are written and made available to staff members, persons
				served and their families, cooperating/referring agencies, and, as requested,
				to the general public.