New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 590 - Operation Of Comprehensive Psychiatric Emergency Programs › Section 590.6 - Organization and administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
				governing body of the hospital shall be responsible for the overall operation
				and management of the comprehensive psychiatric emergency 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 comprehensive psychiatric emergency
				program without prior approval of the Office of Mental Health.
(b) The hospital shall assure that the
				comprehensive psychiatric emergency program has space, program, staff, policies
				and procedures that are sufficient to meet the requirements of this Part and
				are separately identifiable from any other programs which may be operated by
				the providers.
(c) The governing
				body shall comply with all requirements set forth in 10 NYCRR Part 405 as well
				as requirements established by appropriate local, State and Federal
				standard-setting bodies. In addition, the governing body shall be responsible
				for the following duties:
(1) 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 program director who shall be a member of the professional staff employed
				by the comprehensive psychiatric emergency program. The program director shall
				report to the director of the host hospital or to the Director of
				Psychiatry;
(2) Ensure efforts to
				reduce disparities in access, quality of care and treatment outcomes for
				underserved/unserved marginalized populations, including but not limited to:
				people of color, members of the LBGTQ community, older adults, Veterans,
				individuals who are deaf & hard of hearing, individuals who are Limited
				English Proficient, immigrants, and individuals re-entering communities from
				jails and prisons. 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 or national origin, as well
				as, written policies on affirmative action which are consistent with the
				affirmative action and equal employment opportunity obligations imposed by
				title VII of the Civil Rights Act, Federal Executive Order 11246, the
				Rehabilitation Act of 1973, section 504, as amended, and the Vietnam Era
				Veteran's Readjustment Act;
(3) to develop, approve, 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 policies and
				procedures governing patient records which ensure confidentiality consistent
				with the Mental Hygiene Law, sections 33.13, 33.14 and 33.16, 45 C.F.R. parts
				160 and 164 and which provide for appropriate retention of such records
				pursuant to section
				590.12  of
				this Part; and
(ii) written
				policies that ensure the protection of patients' rights. At a minimum these
				policies shall establish and describe a patient grievance procedure. The
				provider shall post a statement of patients' rights in a conspicuous location
				easily accessible to the public pursuant to section
				590.15 of
				this Part.
(4) To make an
				effort that the comprehensive psychiatric emergency program's staffing matches
				the demographic profile of the persons served, the program regularly uses data
				to set workforce recruitment targets. Efforts to recruit a diverse workforce
				should include all levels of the organization's workforce, including
				management.