Current through Register Vol. 46, No. 39, September 25, 2024
(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