New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 595 - Operation Of Residential Programs For Adults › Section 595.6 - 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. The owner(s) may serve as the governing body for a proprietary
				residential program.
(b) The
				governing body shall establish mechanisms for the participation of current or
				former recipients of mental health services and family members of recipients of
				mental health services on the governing body.
(c) The governing body must ensure that its
				membership reflects the ethnic and cultural diversity in which the residential
				program is located. It must also effect an appropriate mechanism(s) to
				facilitate the integration of the program into the community.
(d) 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 an individual who is qualified by
				training and experience to supervise;
(4) to review the program's compliance with
				the terms and conditions of its operating certificate, applicable laws and
				regulations;
(5) to ensure the
				existence of a residents' council or other appropriate mechanism to provide
				participation into the formulation of house rules and other matters which
				affect the operation of the residence;
(6) 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;
(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, military status, genetic
				predisposition or carrier status or national origin;
(ii) written policies which shall provide for
				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 shall
				provide for screening of volunteers, 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 that 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 supervision of self 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 to the program, which shall state: that no
				person shall be excluded from the residential program on the basis of race,
				religion, color, age, sex, sexual orientation, physical disability, HIV status
				or national origin. However, nothing in this subparagraph shall be interpreted
				to prevent a residential program from making admission or discharge decisions
				based upon the functional, clinical and behavioral needs of the applicant,
				which are relevant to its functional program; and
(viii) if a program serves parents with
				children or adolescents, 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 or
				adolescent 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 who are children, or who are the parents or guardians of children;
				and
(8) the governing
				body shall ensure the development of, approve and periodically review and
				revise a written Quality Assurance Plan for the residential program. Such plan
				shall include, but not be limited to, the following:
(i) written policies and procedures for
				monitoring the operation of the residential program against criteria
				established in its functional program;
(ii) a written utilization review procedure
				to monitor the extent to which a resident is receiving appropriate services and
				is being served at an appropriate level of care;
(iii) a written procedure for incident
				reporting and incident management; and
(iv) written policies and procedures
				describing a resident grievance process which ensures the timely review and
				resolution of residents' complaints and which provides a process enabling
				residents to request review by the appropriate field office of the Office of
				Mental Health when resolution is not satisfactory.