Current through Register Vol. 46, No. 39, September 25, 2024
(a) The
governing body of the hospital shall be responsible for the overall operation
and management of the comprehensive psychiatric emergency 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. No individual shall serve as both member of the
governing body and of the paid staff of the comprehensive psychiatric emergency
program without prior approval of the Office of Mental Health.
(b) The hospital shall assure that the
comprehensive psychiatric emergency program has space, program, staff, policies
and procedures that are sufficient to meet the requirements of this Part and
are separately identifiable from any other programs which may be operated by
the providers.
(c) The governing
body shall comply with all requirements set forth in 10 NYCRR Part 405 as well
as requirements established by appropriate local, State and Federal
standard-setting bodies. In addition, the governing body shall be responsible
for the following duties:
(1) 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 program director who shall be a member of the professional staff employed
by the comprehensive psychiatric emergency program. The program director shall
report to the director of the host hospital or to the Director of
Psychiatry;
(2) Ensure efforts to
reduce disparities in access, quality of care and treatment outcomes for
underserved/unserved marginalized populations, including but not limited to:
people of color, members of the LBGTQ community, older adults, Veterans,
individuals who are deaf & hard of hearing, individuals who are Limited
English Proficient, immigrants, and individuals re-entering communities from
jails and prisons. 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 or national origin, as well
as, written policies on affirmative action which are consistent with the
affirmative action and equal employment opportunity obligations imposed by
title VII of the Civil Rights Act, Federal Executive Order 11246, the
Rehabilitation Act of 1973, section 504, as amended, and the Vietnam Era
Veteran's Readjustment Act;
(3) to develop, approve, 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 policies and
procedures governing patient records which ensure confidentiality consistent
with the Mental Hygiene Law, sections 33.13, 33.14 and 33.16, 45 C.F.R. parts
160 and 164 and which provide for appropriate retention of such records
pursuant to section
590.12 of
this Part; and
(ii) written
policies that ensure the protection of patients' rights. At a minimum these
policies shall establish and describe a patient grievance procedure. The
provider shall post a statement of patients' rights in a conspicuous location
easily accessible to the public pursuant to section
590.15 of
this Part.
(4) To make an
effort that the comprehensive psychiatric emergency program's staffing matches
the demographic profile of the persons served, the program regularly uses data
to set workforce recruitment targets. Efforts to recruit a diverse workforce
should include all levels of the organization's workforce, including
management.
(d)
Comprehensive psychiatric emergency programs review demographic data for the
program's catchment area to determine the cultural and linguistic needs of the
population. Staff is trained to be aware and respond appropriately to the
cultural and linguistic needs of the catchment area.
(e) Comprehensive psychiatric emergency
programs review available demographic data to identify disparities of access to
treatment and should implement policy and procedures to address such
disparities.
(f) Comprehensive
psychiatric emergency programs shall ensure provision of language assistance
services to individuals who are Limited English Proficient and/or have other
communication needs (e.g., deaf or hard of hearing) at no cost to them to
facilitate timely access to all health care and services. Language access
services will be made available in such a way that assessment or treatment
activities will not be delayed.
(1) The
comprehensive psychiatric emergency program shall make all necessary documents
available in the individual's preferred language (e.g. releases). The program
shall inform all individuals of their right to receive language assistance
services clearly and in their preferred language, verbally and in
writing.
(2) The comprehensive
psychiatric emergency program provides easy-to-understand print and multimedia
materials and signage in the languages commonly used by the populations in the
service area, with a focus on the varied reading levels among the service user
population.
(3) Efforts are made to
provide the individuals identified as collaterals with language assistance
services translated into their preferred language, verbally and in
writing.
(4) Efforts are made to
employ staff that are proficient in the most prevalent languages spoken by
services users.
(5) Ensures the
competence of individuals providing language assistance, recognizing that the
use of untrained individuals and/or minors as interpreters should be
avoided.
(g) Incidents
(1) The hospital shall ensure the timely
reporting, investigation, review, monitoring and documentation of incidents
pursuant to the Mental Hygiene Law and Part 524 of this Title. Additionally,
such records and any related information shall be made available to the
Department of Health, at their request.
(a)
The comprehensive psychiatric emergency program shall utilize New York Incident
Management Reporting System reports or other available incident/data analysis
program reports to assist in risk management activities and compile and analyze
incident data for the purpose of identifying and addressing possible patterns
and trends to improve service delivery.
(2) Incident Training
(a) All new staff shall receive training
which must include at a minimum, the definition of incidents, reporting
procedures, an overview of the review process, and the role of risk
management.
(b) Refresher incident
reporting training shall be conducted at least annually for all staff and
evidence of such training must be recorded in the staff personnel
file;
(3) The Hospital's
incident review committee shall review incidents, make recommendations and
ensure implementation of action plans with the comprehensive psychiatric
emergency program's administrator.
(h) The hospital shall ensure that no
otherwise appropriate patient is denied access to services solely on the basis
of multiple diagnoses or a diagnosis of HIV infection, AIDS, or AIDS-related
complex.
(i) The hospital shall
participate 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.
(j) 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. Documents and
fiscal information provided by the certified public accountant shall be relied
upon by the Office of Mental Health in determining whether to issue, modify or
renew the program's license and any associated contracts. Government-operated
programs shall comply with applicable laws concerning financial accounts and
auditing requirements. The audit may be program specific or may be performed as
a part of any overall hospital audit.
(k) The hospital shall ensure the posting of
notices of recipients' rights pursuant to section
527.5
of this Title.
(l) The
comprehensive psychiatric emergency center shall ensure the posting of notices
displaying the availability of on-site peer counseling/self-help services and
the address and telephone number of local off-site peer counseling/self help
services.
