New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter IV - Regulation And Quality Control
Subchapter D - Operation Of Facilities
Part 85 - Operation Of Outpatient Facilities For The Mentally Disabled
Section 85.5 - Organization and administration
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 85.5
Current through Register Vol. 46, No. 39, September 25, 2024
(a) Organization.
(1) The certificate holder
shall identify individually by name a group of persons responsible for the
overall operation and management of the outpatient service. For purposes of
this Part, this group shall be known as the governing body.
(2) The governing body shall establish and
maintain current a plan of organization for the outpatient facility 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, and 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, creed, sex, age or national origin.
(4) 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 outpatient facility.
(5) Ongoing direction and control of the
program of the facility shall be delegated by the governing body to an
appropriately qualified professional. For the purposes of this Part this person
shall be known as the director.
(6)
Administrative management of the facility may be delegated by the governing
body to an appropriately qualified administrator.
(7) No person shall serve as both a member of
the governing body and of the paid staff of the facility without the prior
approval of the commissioner.
(b) Administration.
(1) The governing body shall cause to be made
an annual written evaluation of the total program to assess effectiveness and
efficiency and to indicate any required changes in policy or service of the
facility.
(2) The governing body
shall cause to be made an annual audit of the financial condition and accounts
of the facility by a certified public accountant who is not a member of the
governing body or an employee of the facility.
(3) Admission policies, including those
pertaining to eligibility for service, and a description of available services
which shall be written and made available to staff members, persons served and
their families, cooperating agencies and the general public. All admission
policies shall prohibit discrimination on the basis of race, creed, sex, age,
or national origin.
(i) Criteria of
suitability for admission to any program shall be based upon clearly defined
factors appropriate to the purposes of the program.
(ii) Admission policies shall provide for
appropriate referral of those persons applying for admission who do not meet
the pre-established criteria for admission to any program.
(4) The governing body shall cause to be
procured and maintained for reference by the governing body and staff members
an up-to-date copy of this Part and copies of any guideline instruction or
information manuals or other communications as may be prescribed by the
department.
(5) The governing body
shall appoint a special review committee, including members of the professional
clinical staff which shall:
(i) Develop a
written special review plan subject to approval by the governing body and the
department. This plan shall provide for review of all untoward incidents which
may occur and extra risk procedures administered. (Untoward incidents may
include, but not be limited to, serious drug reactions, suicides and sudden
deaths, assaults, accidents, and terminations of service against professional
advice. Extra risk procedures may include, but not be limited to, behavior
modification, somatic therapies, and experimental treatment
modalities),
(ii) Review and
evaluate untoward incidents and extra risk procedures in accordance with the
plan,
(iii) Determine the facts in
any incident reviewed, review ongoing practices and procedures in relation to
such incidents and extra risk procedures and recommend changes in policies,
practices or procedures which may be indicated.
(iv) Include either on a regular membership
basis or by special arrangement as indicated the participation of appropriately
qualified and experienced physicians, and
(v) Meet as often as necessary to properly
execute its functions and in no event less often than quarterly, keeping
written minutes of its deliberations and submitting reports to the governing
body as necessary.
(6)
(i) The governing body of a facility
providing services to the mentally ill pursuant to an operating certificate
issued by the Office of Mental Health shall require staff of the facility to
participate with the local governmental unit in local planning processes as
required by sections 41.05 (e) and
41.16 of the Mental Hygiene Law. Such
participation must be documented in the approved local services or unified
services plan of each local governmental unit served by the facility. At a
minimum, facility participation shall include:
(a) provision of budgeting and planning data
as requested by the local governmental unit;
(b) identification of the population being
served by the facility;
(c)
identification of the geographic area being served by the facility;
(d) description of the facility's
relationship to other providers of services who serve the same geographic area,
including, but not limited to, written agreements to ensure expeditious access
to programs by persons who need them. At a minimum, these agreements shall
provide a process for prompt referral, evaluation, and, as necessary, admission
to cooperating programs; specify mechanisms for coordinated development of
service plans for patients being served by more than one program; and provide a
mechanism for sharing information about patients being served; and
(e) attendance at planning meetings as may
reasonably be required by local governmental unit.
(ii) For facilities issued operating
certificates by the Office of Mental Health, the Regional Director shall
determine, after hearing if necessary, whether the facility has participated in
the planning process in good faith and reasonable conformity with the goals and
objectives of the statewide comprehensive plan for services.
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