Current through Register Vol. 46, No. 39, September 25, 2024
(a) The provider of services
shall identify the individuals who have overall responsibility for the operation of
the residential treatment facility. These individuals shall be known as the
governing body. No individual shall serve as both a member of the governing body and
of the paid staff of the residential treatment facility without the prior approval
of the Office of Mental Health.
(b) The
provider of services shall assure that the residential treatment facility has space,
programs, staff and policies and procedures that are separately identifiable from
any other programs which may be operated by the provider of services.
(c) The governing body shall meet on a regular
basis, in no event less often than quarterly, and shall maintain written minutes of
all meetings as a permanent record of the decisions made in relation to the
operation of the residential treatment facility. The minutes shall be reviewed and
approved by the governing body.
(d) The
governing body shall approve a written plan or plans that, at a minimum, address the
following aspects of the operation of the residential treatment facility:
(1) the goals and objectives of the residential
treatment facility, including the admission and discharge criteria and a statement
of the involvement of the family;
(2)
the plan of organization that clearly indicates lines of responsibility;
(3) a written plan for services and staff
composition which:
(i) includes the qualifications
and duties of each staff position by title, and addresses all essential aspects of
the operation of the residential treatment facility including clinical,
administration, fiscal, clerical, housekeeping, maintenance, dietetic, and
recordkeeping and reporting functions; and
(ii) specifies all services available through the
residential treatment facility including the treatment program and
environment;
(4) the written
quality assurance plan; and
(5) the
written utilization review plan.
(e) The governing body shall approve written
policies and procedures of the residential treatment facility, including but not
limited to:
(1) Admission, transfer, continued stay
and discharge policies and procedures.
(2) 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, gender identity, marital status, age,
national origin, sexual orientation, military status, domestic violence victim
status, disability, pregnancy-related condition, predisposing genetic
characteristics, prior arrest or conviction record or familial status. Personnel
policies and procedures shall provide for verification of employment history,
personal references, work record and qualifications, as well as requesting the
Justice Center for the Protection of Persons with Special Needs to perform criminal
history record checks in accordance with Part 550 of this Title.
(3) Staff training and development policies and
procedures. Such policies and procedures shall address preemployment orientation,
ongoing staff development and training which shall include child or youth abuse
prevention and identification, safety and security procedures, the principles of
child or youth development, use of physical intervention, techniques of group and
child or youth management, the laws and regulations governing the protection of
children from child abuse and maltreatment.
(4) 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
(3) of this subdivision. Such policies shall also provide for requesting the Justice
Center for the Protection of Persons with Special Needs to perform criminal history
record checks in accordance with Part 550 of this Title.
(5) Prescription and administration of medication
policies and procedures. Such policies and procedures shall be consistent with
applicable Federal and State laws and regulations.
(6) Case record policies and procedures. Such
policies and procedures shall ensure confidentiality of patient records in
accordance with the Mental Hygiene Law and shall ensure appropriate retention of
case records.
(f) The
governing body shall review the written plan or plans and policies and procedures
required pursuant to subdivisions (d) and (e) of this section at least annually and
shall make appropriate amendments or revisions.
(g) The governing body may delegate responsibility
for the day-to-day management of the residential treatment facility in accordance
with the written plan of organization provided for in paragraph (d)(2) of this
section.
(1) Ongoing direction may be delegated to
an individual who shall be known as the director and who shall meet the
qualifications specified in section 584.10(d) of this Part.
(2) The director shall be employed by the
residential treatment facility at least one half of the hours of a fulltime
employee.
(3) Administrative direction
may be the responsibility of the director or may be delegated by the governing body
to an individual who shall meet qualifications that are acceptable to the Office of
Mental Health.
(h) The
residential treatment facility shall participate with the local governmental unit in
local planning processes. At a minimum, participation shall include:
(1) provision of budgeting and planning data as
requested by the local governmental unit;
(2) identification of the population being served
by the residential treatment facility;
(3) identification of the geographic area being
served;
(4) description of the
relationship to other providers of services which 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 for
prompt referral, evaluation and, as necessary, admission to cooperating programs,
and for sharing information about residents being served; and
(5) attendance at planning meetings as may
reasonably be required by the local governmental unit.
(i) The residential treatment facility shall
provide for the following:
(1) an annual written
evaluation of the residential treatment facility's attainment of its stated goals
and objectives which indicates any required changes in policies and
procedures;
(2) an annual audit of the
financial condition and accounts of the residential treatment facility performed by
a certified public accountant who is not a member of the governing body or an
employee of the residential treatment facility;
(3) emergency evacuation plans for the building in
which the residential treatment facility is located. Evacuation plans shall address
emergencies resulting from fire as well as potential hazards in the geographic area
in which the residential treatment facility is located; and
(4) up-to-date copies of any regulations,
guidelines, manuals, or other information required by the Office of Mental
Health.
