New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 599 - Clinic Treatment Programs › Section 599.6 - 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.
(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 both as a member of the
				governing body and of the paid staff of the Mental Health Outpatient Treatment
				and Rehabilitative Service program without prior written approval of the
				Office.
(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-today 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 population served. This can include
				ethnic representation on the staff and board and inclusion of culturally and
				ethnically relevant content in service programs;
(6) to ensure that planning decisions are
				based upon input from individuals and, where appropriate, their family
				members;
(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 criteria for admission, and
				discharge from the program. Admission policies should include a mechanism for
				screening individuals at the time of referral and assuring that those referred
				from inpatient, forensic, or emergency settings, those determined to be at high
				risk, and those determined to be in urgent need by the Director of Community
				Services receive services within five business days, and if indicated, are
				admitted to the Mental Health Outpatient Treatment and Rehabilitative Service
				program or referred to an appropriate provider of services. The county may
				establish, subject to the approval of the Office, categories of individuals to
				be considered in urgent need of services;
(ii) policies and procedures for conducting
				initial and ongoing risk assessments and for development of plans to address
				identified areas of elevated risk, including procedures to ensure that any
				health or mental health issues identified are treated appropriately by the
				Mental Health Outpatient Treatment and Rehabilitative Service program or that
				an appropriate referral to a treatment provider and subsequent follow up is
				made;
(iii) policies and procedures
				addressing individual/family engagement and retention in treatment, including,
				at minimum, plans for outreach and re-engagement efforts commensurate with an
				individual's assessed risk;
(iv)
				policies and procedures for providing off-site services;
(v) policies to address personal safety of
				staff and provide appropriate training in de-escalation techniques;
(vi) policies and procedures for age
				appropriate health monitoring, which describe whether such monitoring will be
				performed by the provider or, if not, how the provider will seek to ascertain
				relevant health information. Such policies and procedures must include a
				requirement that an individual's refusal to provide access to such information
				be documented in the case record;
(vii) policies and procedures for screening
				for use of or dependence on alcohol, tobacco or other drugs;
(viii) policies and procedures ensuring that
				a reasonable effort shall be made to obtain records from prior recent episodes
				of treatment;
(ix) policies and
				procedures ensuring that a reasonable effort shall be made to communicate with
				family members, current service providers, and other collaterals, as
				appropriate;
(x) written policies
				and procedures to ascertain whether individuals are currently receiving or are
				eligible to receive Medicare or Medicaid or other form of reimbursement for
				services provided. If it is determined that an individual is eligible for any
				such program but not currently enrolled, the policies and procedures shall
				include means of facilitating the enrollment of such individual in such
				program;
(xi) written policies and
				procedures concerning the prescription and administration of medication which
				shall be consistent with applicable Federal and State laws and regulations and
				which includes procedures for ensuring that individuals are receiving
				prescribed medications and using them appropriately;
(xii) written policies and procedures
				governing an individual's records which ensure confidentiality consistent with
				sections 33.13 and
				33.16  of the Mental Hygiene Law
				and 45 CFR parts
				160 and
				164, and which provide for
				appropriate retention of such records pursuant to section
				599.11  of this Part;
(xiii) written policies and procedures
				describing an individual grievance process which ensures the timely review and
				resolution of individual complaints and which provides a process enabling
				recipients to request review by the Office when resolution is not
				satisfactory;
(xiv) written
				personnel policies which guide efforts to reduce disparities in access, quality
				of care and treatment outcomes for underserved/unserved and/or marginalized
				populations, including but not limited to: people of color, members of the
				LBGTQ+ community, older adults, pregnant persons, Veterans, individuals who are
				hearing impaired, individuals with limited English proficiency, immigrants,
				individuals with intellectual/developmental disabilities and all justice
				system-involved populations ;
(xv)
				written personnel policies which shall prohibit discrimination on the basis of
				race or ethnicity, religion, disability, gender identity or sexual orientation,
				marital status, age, documentation status, 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;
(xvi)
				written policies for the availability of crisis intervention services at all
				times. After-hours coverage shall include, at a minimum, the ability to provide
				brief crisis intervention services provided pursuant to a plan approved by the
				local governmental unit or the Office. Such services shall be provided either
				directly or pursuant to a Clinical Services Contract. Such contract shall
				include, at a minimum, provisions assuring that, in the event of a crisis, the
				nature of the crisis and any measures taken to address such crisis are
				communicated to the primary clinician or other designated clinician involved in
				the individual's treatment at the Mental Health Outpatient Treatment and
				Rehabilitative Service program, or the individual's primary care or other
				mental health care provider, if known, on the next business day. At the request
				of the local governmental unit, State-operated Mental Health Outpatient
				Treatment and Rehabilitative Service programs shall consult with the local
				governmental unit or units in their service area in the development of such
				Mental Health Outpatient Treatment and Rehabilitative Service program's crisis
				response plan;
(xvii) written
				policies for the performance of Criminal history information reviews required
				pursuant to Section 31.35  of the Mental Hygiene Law,
				Sections 424-a and 495  of the Social Services Law, and 14 NYCRR 550. Such
				reviews shall be conducted in accordance with such laws and regulations and any
				guidance issued by the Office. All prospective employees, contractors and
				volunteers who have the potential for, or may be permitted, regular and
				substantial unsupervised or unrestricted contact with Recipients shall submit
				to a criminal history information review. All staff with the potential for
				regular and substantial contact with Recipients in performance of their duties
				shall submit to clearance by the New York Statewide Central Register of Child
				Abuse and Maltreatment. Mental Health Outpatient Treatment and Rehabilitative
				Service program Staff who have not been screened by the New York Statewide
				Central Register of Child Abuse and Maltreatment shall not perform duties
				requiring contact with individuals unless there is another staff member
				present.
(xviii) written policies
				regarding the selection, supervision, and conduct of students accepted for
				training in fulfillment of a written agreement between the Mental Health
				Outpatient Treatment and Rehabilitative Service program and a State Education
				Department accredited higher education institution, as well as requesting the
				Office to perform criminal history record checks in accordance with Part 550 of
				this Title;
(xix) written policies
				regarding the employment, supervision and privileging of nurse practitioners
				and physician assistants. Such policies shall ensure that physician assistants
				have responsibilities related to physical health only. Such policies shall
				ensure compliance with Part 550 of this Title concerning the requirement for
				criminal history record checks, for obtaining clearance from the New York State
				Central Register of Child Abuse and Maltreatment for persons who have the
				potential for regular and unsupervised or unrestricted contact with children,
				and for appropriate consideration and confidentiality of such
				information;
(xx) written policies
				which shall establish that contracts with third party contractors that are not
				subject to the criminal history background check requirements established in
				section 31.35  of the Mental Hygiene Law
				include reasonable due diligence requirements to ensure that any persons
				performing services under such contract that will have regular and substantial
				unsupervised or unrestricted contact with patients of the Mental Health
				Outpatient Treatment and Rehabilitative Service program do not have a criminal
				history that could represent a threat to the health, safety, or welfare of the
				patients of the Mental Health Outpatient Treatment and Rehabilitative Service
				program, including, but not limited to, the provision of a signed, sworn
				statement whether, to the best of their knowledge, such person has ever been
				convicted of a crime in this State or any other jurisdiction; and
(xxi) 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
(8) to ensure the establishment
				and implementation of an ongoing training program for current and new employees
				and volunteers that addresses the policies and procedures regarding child abuse
				and neglect described in paragraph (7) of this subdivision.