New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 582 - Operation Of Hospitals For Persons With Mental Illness › Section 582.5 - Organization and administration

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
				Organization.
(1) The governing body shall be
				responsible for the overall operation and management of the hospital.
(2) The governing body shall establish and
				maintain current a plan of organization for the hospital 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 and shall include provisions implementing
				criminal history record checks in accordance with Part 550 of this
				Title.
(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 and shall include provisions implementing criminal history
				record checks in accordance with Part 550 of this Title.
(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 is
				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 hospital.
(8) Ongoing direction and control of the
				program of the hospital 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 hospital
				may be delegated by the governing body to an appropriately qualified
				administrator.