New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 580 - Operation Of Psychiatric Inpatient Units Of General Hospitals › Section 580.5 - Organization and administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Organization.
(1) The governing body of the general
				hospital shall be responsible for the overall operation and management of the
				psychiatric inpatient unit, and may discharge any responsibilities hereinafter
				stated through any body of delegates which is approved by the
				commissioner.
(2) The governing
				body shall establish and maintain current a plan of organization for the unit
				which clearly indicates lines of accountability, the nature of professional
				responsibility to be exercised according thereto, and the professional
				qualifications required.
(3) The
				governing body shall develop and revise, as necessary, written policies for the
				quantity, quality, scope, goals, objectives and evaluation of all programs,
				policies for the accomplishment of stated purposes, and personnel policies.
				Personnel policies shall prohibit discrimination on the basis of race, color,
				creed, disability, sex, marital status, age, national origin, or sexual
				orientation. Personnel policies and procedures shall provide for verification
				of employment history, personal references, work record and qualifications.
				Such policies shall also provide for securing a signed sworn statement whether,
				to the best of his/her knowledge, the applicant has ever been convicted of a
				crime in this State or any other jurisdiction.
(4) The governing body shall establish
				written staff development and training policies which address orientation and
				ongoing staff development and training which shall include, but not be limited
				to, behavioral management interventions, techniques and alternative methods of
				safely handling crisis situations and safety and security procedures. In
				addition, in those hospitals serving children, staff training shall include the
				principles of child development, behavioral management interventions,
				techniques, and alternative methods of safely handling crisis situations,
				techniques of group and child management, the laws and regulations governing
				child abuse reporting and the protection of children from child abuse and
				maltreatment. Such training in those hospitals serving children shall include
				preemployment orientation and continuing education.
(5) The governing body shall establish
				written volunteer policies and procedures. Such policies and procedures shall
				provide for screening of volunteers and verification of employment history,
				personal references and work history; supervision of volunteers; training in
				accordance with paragraph (4) of this subdivision. Such policies shall also
				provide for securing a signed sworn statement whether, to the best of his/her
				knowledge, the volunteer has been convicted of a crime in this State or any
				other jurisdiction.
(6) The
				governing body shall establish procedures to assure the health and safety of
				the patients in the program, and shall develop, implement, and regularly
				monitor clinical risk management programs in order to protect the health and
				safety of patients and enhance their quality of care.
(7) The governing body shall meet as often as
				necessary to properly execute its functions, and in no event less often than
				quarterly. 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 psychiatric inpatient unit and shall be made available to the
				office upon request.
(8) Ongoing
				direction and control of the program of the unit shall be delegated by the
				governing body to a physician whose qualifications in psychiatry are
				appropriate to the program. For purposes of this Part, this person shall be
				known as the director.
(9)
				Administrative management of the unit may be delegated by the governing body to
				an appropriately qualified administrator.