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
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 580.5
Current through Register Vol. 46, No. 39, September 25, 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.
(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 policies or services of the
unit.
(2) The governing body shall
maintain a separate set of financial accounts for the operation of the
psychiatric inpatient unit.
(3) The
governing body shall establish 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.
(i) All admission policies shall prohibit
discrimination on the basis of race, creed, sex, age, national origin, sexual
orientation, or physical disability, previous hospitalization in a
State-operated psychiatric facility or ability to pay fees, provided, however,
nothing in this subparagraph shall be interpreted to prevent a facility from
making admission or discharge decisions based upon the functional, clinical and
behavioral needs of a patient which are relevant to its program.
(ii) No facility shall deny care and
treatment to, or otherwise discriminate against, persons who are non-English
speaking, deaf or hard-of hearing, in accordance with section
527.4 of this
Title.
(iii) A facility shall not
deny access to a person who otherwise meets requisite admission criteria solely
on the basis of multiple diagnoses or a diagnosis of HIV infection, AIDS, or
AIDS-related complex.
(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
office.
(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
office. This plan shall provide for review of all incidents in accordance with
Part 524 of this Title and extra-risk procedures administered. Extra-risk
procedures may include, but not be limited to, somatic therapies, experimental
treatment modalities, and restraint or seclusion;
(ii) review and evaluate 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 is 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)
The governing body shall provide for the following in those hospitals which
provide services to children:
(i) procedures
for notification of the child's parent or guardian of incidents as required by
law, including but not limited to Mental Hygiene Law section
33.23; and
(ii) procedures for the proper reporting to
the Statewide Central Register of Child Abuse and Maltreatment of suspected
child abuse or maltreatment by a guardian, caretaker, or other person over the
age of 18 who is responsible for the care of the child.
(7) The governing body shall cause to be
written, made known to all employees and maintained current a plan for
safeguarding all patients in the event of a major natural disaster or civil
disturbance.
(8) The governing body
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:
(i) provision of budgeting and planning data
as requested by the local governmental unit;
(ii) identification of the population being
served by the facility;
(iii)
identification of the geographic area being served by the facility;
(iv) 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; provide for
access to emergency psychiatric services within the geographic area; and
provide a mechanism for sharing information about patients being served;
and
(v) attendance at planning
meetings as may reasonably be required by the local governmental
unit.
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