New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 587 - OPERATION OF OUTPATIENT PROGRAMS › Section 587.6 - 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.
(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.