New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 511 - Early Periodic Screening, Diagnostic and Treatment Services for Children › Subpart 511-2 - Children's Mental Health Rehabilitation Services Program › Section 511-2.10 - 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 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-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 design and
				  operate services 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 the child and, where
				  appropriate, their family members;
(7) to develop, approve, and periodically
				  review and revise, as appropriate, all program and service 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.
(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 or that an
				  appropriate referral to a treatment provider and subsequent follow up is
				  made;
(iii) policies and procedures
				  addressing child engagement and retention in treatment, including, at minimum,
				  plans for outreach and re-engagement efforts commensurate with a child's
				  assessed risk;
(iv) policies and
				  procedures for screening for abuse or dependence on alcohol or other
				  substances;
(v) policies and
				  procedures ensuring that a reasonable effort shall be made to obtain records
				  from prior recent episodes of treatment;
(vi) policies and procedures ensuring that a
				  reasonable effort shall be made to communicate with family members, current
				  service providers, and other collaterals, as appropriate;
(vii) written policies and procedures
				  describing an individual grievance process which ensures the timely review and
				  resolution of child complaints and which provides a process enabling the child
				  to request review by the office when resolution is not satisfactory;
(viii) written personnel policies which shall
				  prohibit discrimination on the basis of race, color, creed, disability, sex,
				  marital status, age, national origin or sexual orientation, HIV status,
				  military status, predisposing genetic characteristics and the applicable
				  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; the Americans with Disabilities Act of
				  1990; and the State Human Rights Law (Executive Law, Article 15);
(ix) for programs that will provide services
				  to minors, written policies which shall 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.
(x) written
				  volunteer policies which shall 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 checks, in accordance with Part 550 of this Title.
(xi) written policies regarding the
				  selection, supervision, and conduct of students accepted for training in
				  fulfillment of a written agreement between the agency 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.
(xii) 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 of the program do not
				  have a criminal history that could represent a threat to the health, safety, or
				  welfare of a child in the program, including, but not limited to, the provision
				  of a signed, sworn statement whether, to the best of his or her knowledge, such
				  person has ever been convicted of a crime in this State or any other
				  jurisdiction; and
(xiii) written
				  policies and procedures regarding the mandatory reporting of child abuse or
				  neglect, reporting procedures and obligations of persons required to report,
				  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 individuals who are children, or who are the
				  parents or guardians of children; and
(xiv) to ensure the establishment and
				  implementation of training for current and new employees and volunteers that
				  addresses the policies and procedures regarding child abuse and
				  neglect.
(8) A provider
				  of service shall ensure that no child who is otherwise appropriate for
				  admission is denied access to services solely on the basis of having a
				  co-occurring non-mental health diagnosis, or a diagnosis of HIV infection,
				  AIDS, or AIDS-related complex.
(9)
				  Written policies and procedures governing the child'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.
(10) The provider of service shall establish
				  mechanisms for the meaningful participation of child and/or family
				  representatives either through direct participation on the governing body, or
				  through the creation of an individual advisory board. If an individual advisory
				  board is used, the provider of service shall ensure a mechanism for the
				  individual advisory board to make recommendations to the governing
				  body.
(11) The provider of service
				  shall develop and make available to individuals and collaterals, a plan which
				  will assure an appropriate response to individuals admitted to the agency and
				  their collaterals who need assistance when the program is not in
				  operation.
(12) A provider of
				  service shall ensure that any program subject to this Part does not:
(i) utilize restraint or seclusion for any
				  purpose, including, but not limited to, as a response to a crisis situation,
				  provided, however, that in situations in which alternative procedures and
				  methods not involving the use of physical force cannot reasonably be employed,
				  nothing in this section shall be construed to prohibit the use of reasonable
				  physical force when necessary to protect the life and limb of any person;
				  and
(ii) perform electroconvulsive
				  therapy or aversive conditioning therapy for any purpose, including, but not
				  limited to, as a treatment intervention.
(13) A provider of service shall ensure that
				  individual participation in research only occurs in accordance with applicable
				  Federal and State requirements.
(14) A provider of service shall ensure the
				  development, implementation and ongoing monitoring of a risk management program
				  that includes the requirements for identification, documentation, reporting,
				  investigation, review, and monitoring of incidents pursuant to the Mental
				  Hygiene Law.
(15) A provider of
				  service has written emergency preparedness and response plan for all of its
				  services and locations that includes responses to environmental and natural
				  disasters and staff shall be trained about it procedures.
(16) A provider of service has written
				  protocols to address personal safety of staff and provides appropriate training
				  in de-escalation techniques
(17)
				  There shall be a written utilization review procedure to ensure that the child
				  is receiving appropriate services and are being served at an appropriate level
				  of care. Such policies and procedures shall include provisions ensuring that
				  utilization review is performed and shall be performed only by professional
				  staff trained to do such reviews, or by staff who are otherwise qualified by
				  virtue of their civil service standing, and shall ensure to the maximum extent
				  possible that the designated utilization review authority functions
				  independently of the clinical staff that is treating the individual under
				  review. Such utilization review procedure shall provide for:
(i) a review of the appropriateness of
				  admission to services; and
(ii) a
				  review of the need for continued treatment