New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 587 - OPERATION OF OUTPATIENT PROGRAMS
Section 587.6 - Organization and administration

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 587.6

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

(a) The provider of service shall identify a governing body which shall have overall responsibility for the operation of the program. The governing body may delegate responsibility for the day-to-day management of the program to appropriate staff pursuant to an organizational plan approved by the Office of Mental Health.

(b) In programs operated by not-for-profit corporations other than hospitals licensed pursuant to article 28 of the Public Health Law, no person shall serve as a member of the governing body and of the paid staff of the program without prior approval of the Office of Mental Health.

(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 ensure that the design and operation of the program is consistent with and appropriate to the ethnic and cultural background of the patient population;

(6) to ensure that recipients and their families have a mechanism for participating in treatment or psychiatric rehabilitation service planning decisions;

(7) to develop, approve, and periodically review and revise as appropriate all programmatic and administrative policies and procedures. Such policies and procedures shall include, but are not limited to, the following:
(i) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, marital status, age, national origin or sexual orientation;

(ii) written policies which shall provide for verification of employment history, personal references, work record and qualifications, as well as securing a signed, sworn statement whether, to the best of his or her knowledge, the applicant has ever been convicted of a crime in this State or any other jurisdiction and for appropriate consideration and confidentiality of such information;

(iii) written volunteer policies which shall provide for screening of volunteers, verification of employment history, personal references and work history, and supervision of volunteers. Such policies shall also provide for securing a signed, sworn statement whether, to the best of his or her knowledge, the volunteer has ever been convicted of a crime in this State or any other jurisdiction, for appropriate consideration and confidentiality of such information;

(iv) written policies which are consistent with the 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, and the American Disabilities Act of 1990;

(v) written policies and procedures concerning the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations;

(vi) written policies and procedures governing recipients' records which ensure confidentiality consistent with the Mental Hygiene Law, and which provide for appropriate retention of such records pursuant to section 587.18 of this Part;

(vii) written criteria for admission, and discharge from the program;

(viii) written policies and procedures regarding the mandatory reporting of child abuse or neglect, reporting procedures and obligations of persons required to report, provisions for taking a child into protective custody, 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 recipients who are children, or who are the parents or guardians of children; and

(ix) written policies and procedures describing a recipient grievance process which ensure the timely review and resolution of recipients' complaints and which provides a process enabling recipients to request review by the Office of Mental Health when resolution is not satisfactory; and

(8) to ensure the establishment and implementation of an ongoing training program for current and new employees and volunteers which address the policies and procedures regarding child abuse and neglect described in subparagraph (7)(viii) of this subdivision.

(d) A provider of service certified as a partial hospitalization program shall ensure that electroconvulsive therapy is only used pursuant to a written plan previously approved by the Office of Mental Health.

(e) The provider of service who provides carved-out services to enrollees of a managed care provider in need of such services shall enter into agreement(s) with managed care provider(s) in accordance with chapter 165 of the Laws of 1991 and the accompanying memorandum of agreement. Such agreements are intended to integrate special care and managed care within the Medicaid managed care program and the special care program based on the agreed upon protocols for the purposes of coordination of care and determination of need.

(f) A provider of service shall ensure that an outpatient program does not use seclusion as a treatment intervention or response to a crisis situation.

(g) A provider of service shall ensure that an outpatient program does not use restraint as a treatment intervention or in response to a crisis situation.

(h) A provider of service shall ensure that recipient participation in research only occurs in accordance with applicable Federal and State requirements.

(i) A provider of service shall ensure the timely reporting, investigation, review, monitoring and documentation of incidents pursuant to the Mental Hygiene Law and Part 524 of this Title.

(j) A provider of service shall ensure that no otherwise appropriate recipient is denied access to services solely on the basis of multiple diagnoses or a diagnosis of HIV infection, AIDS, or AIDS-related complex.

(k) There shall be an emergency evacuation plan and staff shall be knowledgeable about its procedures.

(l) There shall be a written utilization review procedure to ensure that all recipients are receiving appropriate services and are being served at an appropriate level of care. Such policies and procedures shall include provisions insuring that utilization review is 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 which is treating the recipient under review.

(m) The provider of service shall participate as required with the local governmental unit in local planning processes pursuant to sections 41.05 and 41.16 of the Mental Hygiene Law. At a minimum, such 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 program;

(3) identification of the geographic area being served by the program; and

(4) description of the program's relationship to other providers of service including, but not limited to, a description of all written agreements entered into pursuant to this Part.

(n) In programs which are not operated by State or local government, there shall be an annual audit, pursuant to a format prescribed by the Office of Mental Health, of the financial condition and accounts of the program performed by a certified public accountant who is not a member of the governing body or an employee of the program. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements.

(o) The provider of service shall establish mechanisms for the meaningful participation of recipient representatives either through direct participation on the governing body, or through the creation of a recipient advisory board. If a recipient advisory board is used, the provider of service shall ensure a mechanism for the recipient advisory board to make recommendations to the governing body.

(p) The provider of service shall establish mechanisms which ensure that the cultural and ethnic backgrounds of recipients are taken into account such as participation of ethnic consumers, ethnic representation on the staff and board, and inclusion of ethnic appropriate content in service programs.

(q) The provider of service shall establish mechanisms to ensure priority access by individuals, referred to the provider, who are enrolled in an assisted outpatient treatment program established pursuant to section 9.60 of the Mental Hygiene Law. The provider of service shall cooperate with the local governmental unit or the commissioner, or their authorized representatives, in ensuring priority access by such individuals, and in the development, review and implementation of treatment plans for such individuals. Prior to the discharge by a provider of service of an individual who is also enrolled in an assisted outpatient treatment program, the provider of service shall notify the individual's case manager and the director of the assisted outpatient treatment program. Any and all related information, reports and data which may be requested by the commissioner or the local governmental unit shall be furnished by the provider of service. Any requests for clinical records from persons or entities authorized pursuant to section 33.13 or 33.16 of the Mental Hygiene Law, regarding individuals who are the subject of, or under consideration for, a petition for an order authorizing assisted outpatient treatment shall be given priority attention and responded to without delay.

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