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
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 582.5
Current through Register Vol. 46, No. 39, September 25, 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.
(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 hospital.
(2)
The governing body shall cause to be made an annual audit of the financial
condition and accounts of the hospital by a certified public accountant who is
not a member of the governing body or an employee of the hospital.
(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, 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 Part 524 of this Title and 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)
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 alleged child abuse or
maltreatment involving the child or other incidents as required by law,
including but not limited to Mental Hygiene Law section 33.23; and
(ii) procedures for the proper reporting of
all incidents of alleged child abuse or maltreatment as follows, in accordance
with the Mental Hygiene Law and Part 524 of this Title:
(a) to the Statewide Central Register of
Child Abuse and Maltreatment immediately;
(b) to the appropriate Office of Mental
Health field office, within two weeks, using forms designated by the Office of
Mental Health;
(c) to the
Commission on Quality of Care and Advocacy for Persons with Disabilities within
72 hours; and
(d) to the Mental
Hygiene Legal Service within the next working day.
(7) The governing body shall cause
to be written, made known to all employees and maintain 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; 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.
(c) Education program.
(1) If any children of legal school age are
served, an appropriate instructional program approved by the New York State
Education Department must be made available to them by the hospital.
(2) The treatment program in those hospitals
which provide services to children shall include the means for providing
instruction to patients under the age of 18, and, when required pursuant to an
Individualized Education Plan, to certain patients over the age of 18,
consistent with their age, needs and clinical condition, as well as the needs
and circumstances within the facility or program, in techniques and procedures
which will enable such patients to protect themselves from abuse and
maltreatment.
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