New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIV - Office for People With Developmental Disabilities › Part 680 - Specialty Hospitals › Section 680.4 - Organization and administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
Organization.
(1) The governing
				body (see section
				680.13  of
				this Part) of the specialty hospital shall be responsible for the overall
				operation and management of the specialty hospital and may discharge any
				responsibilities hereinafter stated through any body of delegates which is
				approved by the commissioner.
(2)
				The governing body shall ensure that the facility and services provided
				adequately meet the health, social and developmental needs of all individuals
				receiving services through preventive, habilitative and rehabilitative
				programs.
(3) The governing body
				shall ensure that there is adequate protection of each person's health, safety,
				comfort, well-being, and civil, human and legal rights.
(4) The governing body of the specialty
				hospital shall develop working agreements with other providers to ensure
				delivery to individuals, as appropriate, special diagnostic and medical
				services which the specialty hospital does not provide.
(5) The governing body of the specialty
				hospital shall develop working agreements with the Developmental Disabilities
				Services Office (see section
				680.13  of
				this Part) and other providers to ensure to the greatest extent possible, that
				opportunities exist in the community for movement of individuals, when
				appropriate, to less restrictive residential settings.
(6) Minutes of all official meetings of the
				governing body shall be maintained as permanent record of the decisions made in
				relation to the operation of the specialty hospital.
(7) Administrative management of the
				specialty hospital shall be delegated by the governing body to an appropriately
				qualified administrator.
(8)
				Ongoing direction and control of the medical services of the unit shall be
				delegated by the governing body to a physician whose qualifications in
				developmental disabilities are appropriate to the program. For purposes of this
				Part, this person shall be known as the medical director (see section
				680.13).
(9) The governing body shall
				develop and revise as necessary, written policies for the quantity, quality,
				scope, goals, objectives and evaluation of all programs (see section
				680.13); and
				policies for the accomplishment of stated purposes and well-being of
				individuals. These policies shall include, but not be limited to:
(i) a statement of the facility's philosophy,
				objectives and goals, specifying:
(a) the
				specialty hospital's role in the State's comprehensive services for people with
				developmental disabilities;
(b) the
				goals for individuals it serves; and
(c) the concept of its relationship to the
				parents or correspondents of individuals it serves;
(ii) methods for coordinating services for
				every individual between the specialty hospital and other providers of programs
				and services;
(iii) policies and
				procedures specifying how and by whom the following functions shall be
				performed:
(a) specification of preadmission
				procedures which include requiring referral services to identify the person's
				specific conditions which necessitate hospitalization and the types of
				rehabilitation therapy requested;
(b) an application screening process which:
(1) determines appropriateness and medical
				necessity of the admission in accordance with the specialized services
				offered;
(2) determines person's
				rehabilitation potential; and
(3)
				includes a procedure requesting the approval of the commissioner prior to the
				admission;
(c) an
				admission and process which includes the development of an individual program
				plan (see section
				680.13) 
				defining the types of therapy services to be provided in accordance with the
				individual's condition(s), measurable outcome expected, and a time frame for
				attainment of each outcome;
(d)
				interdisciplinary assessments, preparation of individual service plans (see
				section
				680.13), and
				periodic reevaluation and revision of the plans in coordination with agencies
				providing day programs and treatment to the individuals;
(e) periodic review of the appropriateness of
				the person's admission and continued stay in the specialty hospital;
(f) ensuring effective communication between
				staff and individuals and families of individuals, using such means as
				counseling with individuals, problem-solving procedures, family conferences,
				telephone communication and newsletters;
(g) ensuring that the rights of all
				individuals are not abridged;
(h)
				the provision of all services required by section
				680.7 
				of this Part. This shall include a description of methods to be used for
				coordinating each service with other services and programs provided to the
				individuals. In addition:
(1) policies and
				procedures regarding medical and medically related services (see section
				680.13)  to
				individuals shall include, but not be limited to, physician visits, emergency
				coverage, hospitalization, consultants and rehabilitative services;
(2) policies and procedures regarding dental
				services (see section
				680.13) 
				shall include, but not be limited to, emergency care;
(3) policies and procedures regarding
				pharmacy services (see section
				680.13)  and
				consultation to individuals shall include, but not be limited to, the safe
				administration and handling of all drugs specifying the following:
(i) criteria and schedule for evaluations and
				treatment recommendations regarding self-administration of medications by the
				person;
(ii) criteria for staff
				training regarding administration of medication by staff. Only appropriately
				trained staff shall be allowed to administer drugs as specified in existing
				State regulations and policy for administration of medication. For direct care
				staff to be allowed to administer drugs, they must complete a training program
				in administration of medication which has the prior approval of the
				commissioner, and drugs administered by such staff must be in unit dose form;
				and
(iii) all medication errors and
				drug reactions shall be reported immediately to the practitioner who ordered
				the drug. Adverse drug reactions shall be reported to the Federal Food and Drug
				Administration;
(i) arrangements or preparations for the
				individuals to obtain additional services needed through other
				agencies;
(j) discharge or transfer
				of a person, including:
(1) participation of
				the staff, the individual, where appropriate, the family and the agent
				responsible for service delivery following discharge or transfer;
(2) due process for discharge or transfer;
				and
(3) provision for appropriate
				follow-up services;
(k)
				space utilization;
(l) planning for
				organization, size and grouping of living units (see section
				680.13).
(1) The specialty hospital may not group
				individuals of widely divergent ages, developmental levels and social needs in
				close physical or social proximity unless the grouping is planned for the
				concentrated treatment of health problems necessitated by the person's
				admission and there is a specific written plan which includes the rationale for
				this grouping.
(2) The specialty
				hospital may not group individuals on the basis of their physical handicaps
				unless the grouping is for concentrated treatment of health problems
				necessitating the individuals' admissions. Otherwise, individuals who are
				mobile, nonambulatory, deaf, blind, epileptic, or who have other physical or
				developmental disabilities shall be grouped with other individuals of
				comparable social and intellectual development;
(m) recordkeeping;
(n) maintaining a written financial record
				for each individual that is available to the individual and the individual's
				family (unless the individual is an adult who objects to the disclosure of such
				information to his or her family). This record shall include:
(1) written receipts for each individual's
				personal possessions and funds received by or deposited with the specialty
				hospital; and
(2) written receipts
				for all disbursements made to or for the individual;
(o) practices to be followed in the event of
				emergencies. The administrator shall develop a written staff organization plan
				with detailed written procedures for meeting all potential emergencies and
				disasters, such as missing individuals, severe weather, power outages, fires,
				floods, bomb threats and medical emergencies (
e.g.,
epidemics,
				food poisoning, chemical poisoning, etc.). This plan shall be posted at
				suitable locations throughout the facility and clearly communicated to and
				periodically reviewed with staff; and shall include at least the following:
(1) instructions for using alarm systems and
				signals;
(2) assignment of
				personnel to specific tasks and responsibilities;
(3) specifications of evacuation routes and
				procedures which are posted at suitable locations throughout the
				facility;
(4) systems for
				notification of appropriate persons;
(5) location of firefighting equipment;
				and
(6) methods of fire
				containment;
(p) steps
				to follow in the event of any unusual occurrence, including, but not limited to
				serious illness, accident or impending death (
e.g.,
notification of family;
(q) steps
				to follow in the death of a person, including notification of the family and
				medical examiner and arranging for an autopsy when required by the local
				medical examiner;
(1) In every case, the
				medical examiner should be immediately notified of a person's death.
(2) If the medical examiner releases the body
				to the facility for autopsy, the autopsy shall be performed by an impartial
				qualified physician who is not employed by the specialty hospital.
(3) The individual's correspondent shall be
				informed of the autopsy findings if he or she desires;
(r) special review procedures, including but
				not limited to:
(1) ensuring that all alleged
				violations of policies prohibiting mistreatment, neglect or abuse of an
				individual are reported and investigated. The specialty hospital shall have
				documentation of the following:
(i) All
				alleged violations are reported within 24 hours to the administrator, the
				Mental Hygiene Legal Service, the commissioner, the State Office of Health
				Systems Management and the State Office of Protective Services for Children or
				the corresponding local office (if appropriate given the age of the client
				involved).
(ii) The administrator
				shall ensure that each alleged violation is investigated thoroughly.
(iii) The results of each investigation shall
				be reported to the administrator, commissioner, the Mental Hygiene Legal
				Service, the Commission on Quality of Care and Advocacy for Persons with
				Disabilities and the State Office of Health Systems Management within 24 hours
				of the report of the alleged violation.
(iv) The commissioner may require a separate
				investigation of an alleged violation to be carried on by staff of OPWDD, the
				district attorney's office or other law enforcement officials.
(v) A written report of incidents, with the
				investigation results, shall be sent to the Professional Advisory Board (see
				section
				680.13) 
				within 30 days of the incident, for all Willowbrook class members.
(vi) A written report of completed
				investigations at the specialty hospital shall be shared with the State Office
				of Health Systems Management.
(vii)
				If the alleged violation is verified, the administrator shall impose an
				appropriate penalty;
(2)
				ensuring that appropriate corrective action is taken to prevent similar
				accidents in the future;
(iv) personnel policies and procedures,
				including:
(a) hiring policies reflecting
				conformity to Federal laws governing civil rights and equal employment
				opportunities;
(b) job
				descriptions, which specify qualifications, education and skills required,
				description of duties and responsibilities and supervision to be
				provided;
(c) authorized procedures
				consistent with due process for suspension and/or dismissal of an employee for
				cause;
(d) protection of individual
				rights, including prohibiting mistreatment, neglect or abuse of individuals
				with procedures to be followed in the event that violations of individual
				rights occur;
(e) staff training
				program:
(1) job description of an individual
				responsible for staff development and training;
(2) orientation procedures;
(3) in-service training; and
(4) use of community resources and
				consultants;
(f)
				policies to ensure that employees are medically determined to be free of
				communicable and infectious diseases;
(g) policy statements on salaries and
				increments, accumulation of leave and fringe benefits;
(h) policy and procedures to ensure the
				complaints by staff can be made without the threat or recrimination;
				and
(i) staff schedule for
				weekdays, weekends and holidays in accordance with the staff/individual ratios
				as specified in section
				680.8  of this
				Part.
(10)
				The administrator shall ensure that the previously noted policies are
				incorporated in an up-to-date manual of written policies and procedures; and
				shall further ensure that the facility is in compliance with such policies and
				procedures or has a plan of correction for achieving compliance in a timely
				manner.