New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 594 - Operation Of Licensed Housing Programs For Children And Adolescents With Serious Emotional Disturbances › Section 594.6 - Organization and administration

Current through Register Vol. 46, No. 28, July 10, 2024
(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.