New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 599 - Clinic Treatment Programs
Section 599.6 - Organization and administration

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 599.6

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.

(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 both as a member of the governing body and of the paid staff of the Mental Health Outpatient Treatment and Rehabilitative Service program without prior written approval of the Office.

(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-today 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 population served. This can include ethnic representation on the staff and board and inclusion of culturally and ethnically relevant content in service programs;

(6) to ensure that planning decisions are based upon input from individuals and, where appropriate, their family members;

(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 criteria for admission, and discharge from the program. Admission policies should include a mechanism for screening individuals at the time of referral and assuring that those referred from inpatient, forensic, or emergency settings, those determined to be at high risk, and those determined to be in urgent need by the Director of Community Services receive services within five business days, and if indicated, are admitted to the Mental Health Outpatient Treatment and Rehabilitative Service program or referred to an appropriate provider of services. The county may establish, subject to the approval of the Office, categories of individuals to be considered in urgent need of services;

(ii) policies and procedures for conducting initial and ongoing risk assessments and for development of plans to address identified areas of elevated risk, including procedures to ensure that any health or mental health issues identified are treated appropriately by the Mental Health Outpatient Treatment and Rehabilitative Service program or that an appropriate referral to a treatment provider and subsequent follow up is made;

(iii) policies and procedures addressing individual/family engagement and retention in treatment, including, at minimum, plans for outreach and re-engagement efforts commensurate with an individual's assessed risk;

(iv) policies and procedures for providing off-site services;

(v) policies to address personal safety of staff and provide appropriate training in de-escalation techniques;

(vi) policies and procedures for age appropriate health monitoring, which describe whether such monitoring will be performed by the provider or, if not, how the provider will seek to ascertain relevant health information. Such policies and procedures must include a requirement that an individual's refusal to provide access to such information be documented in the case record;

(vii) policies and procedures for screening for use of or dependence on alcohol, tobacco or other drugs;

(viii) policies and procedures ensuring that a reasonable effort shall be made to obtain records from prior recent episodes of treatment;

(ix) policies and procedures ensuring that a reasonable effort shall be made to communicate with family members, current service providers, and other collaterals, as appropriate;

(x) written policies and procedures to ascertain whether individuals are currently receiving or are eligible to receive Medicare or Medicaid or other form of reimbursement for services provided. If it is determined that an individual is eligible for any such program but not currently enrolled, the policies and procedures shall include means of facilitating the enrollment of such individual in such program;

(xi) written policies and procedures concerning the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations and which includes procedures for ensuring that individuals are receiving prescribed medications and using them appropriately;

(xii) written policies and procedures governing an individual's records which ensure confidentiality consistent with sections 33.13 and 33.16 of the Mental Hygiene Law and 45 CFR parts 160 and 164, and which provide for appropriate retention of such records pursuant to section 599.11 of this Part;

(xiii) written policies and procedures describing an individual grievance process which ensures the timely review and resolution of individual complaints and which provides a process enabling recipients to request review by the Office when resolution is not satisfactory;

(xiv) written personnel policies which guide efforts to reduce disparities in access, quality of care and treatment outcomes for underserved/unserved and/or marginalized populations, including but not limited to: people of color, members of the LBGTQ+ community, older adults, pregnant persons, Veterans, individuals who are hearing impaired, individuals with limited English proficiency, immigrants, individuals with intellectual/developmental disabilities and all justice system-involved populations ;

(xv) written personnel policies which shall prohibit discrimination on the basis of race or ethnicity, religion, disability, gender identity or sexual orientation, marital status, age, documentation status, 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;

(xvi) written policies for the availability of crisis intervention services at all times. After-hours coverage shall include, at a minimum, the ability to provide brief crisis intervention services provided pursuant to a plan approved by the local governmental unit or the Office. Such services shall be provided either directly or pursuant to a Clinical Services Contract. Such contract shall include, at a minimum, provisions assuring that, in the event of a crisis, the nature of the crisis and any measures taken to address such crisis are communicated to the primary clinician or other designated clinician involved in the individual's treatment at the Mental Health Outpatient Treatment and Rehabilitative Service program, or the individual's primary care or other mental health care provider, if known, on the next business day. At the request of the local governmental unit, State-operated Mental Health Outpatient Treatment and Rehabilitative Service programs shall consult with the local governmental unit or units in their service area in the development of such Mental Health Outpatient Treatment and Rehabilitative Service program's crisis response plan;

(xvii) written policies for the performance of Criminal history information reviews required pursuant to Section 31.35 of the Mental Hygiene Law, Sections 424-a and 495 of the Social Services Law, and 14 NYCRR 550. Such reviews shall be conducted in accordance with such laws and regulations and any guidance issued by the Office. All prospective employees, contractors and volunteers who have the potential for, or may be permitted, regular and substantial unsupervised or unrestricted contact with Recipients shall submit to a criminal history information review. All staff with the potential for regular and substantial contact with Recipients in performance of their duties shall submit to clearance by the New York Statewide Central Register of Child Abuse and Maltreatment. Mental Health Outpatient Treatment and Rehabilitative Service program Staff who have not been screened by the New York Statewide Central Register of Child Abuse and Maltreatment shall not perform duties requiring contact with individuals unless there is another staff member present.

(xviii) written policies regarding the selection, supervision, and conduct of students accepted for training in fulfillment of a written agreement between the Mental Health Outpatient Treatment and Rehabilitative Service program and a State Education Department accredited higher education institution, as well as requesting the Office to perform criminal history record checks in accordance with Part 550 of this Title;

(xix) written policies regarding the employment, supervision and privileging of nurse practitioners and physician assistants. Such policies shall ensure that physician assistants have responsibilities related to physical health only. Such policies shall ensure compliance with Part 550 of this Title concerning the requirement for criminal history record checks, for obtaining clearance from the New York State Central Register of Child Abuse and Maltreatment for persons who have the potential for regular and unsupervised or unrestricted contact with children, and for appropriate consideration and confidentiality of such information;

(xx) written policies which shall establish that contracts with third party contractors that are not subject to the criminal history background check requirements established in section 31.35 of the Mental Hygiene Law include reasonable due diligence requirements to ensure that any persons performing services under such contract that will have regular and substantial unsupervised or unrestricted contact with patients of the Mental Health Outpatient Treatment and Rehabilitative Service program do not have a criminal history that could represent a threat to the health, safety, or welfare of the patients of the Mental Health Outpatient Treatment and Rehabilitative Service program, including, but not limited to, the provision of a signed, sworn statement whether, to the best of their knowledge, such person has ever been convicted of a crime in this State or any other jurisdiction; and

(xxi) 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

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

(d) A provider of service shall ensure that no individual who is otherwise appropriate for admission is denied access to services solely on the basis of having a co-occurring non-mental health diagnosis, or a diagnosis of HIV infection, AIDS, or AIDS-related complex.

(e) The provider of service shall establish mechanisms to ensure that priority access is given to 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, in accordance with the following:

(1) 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.

(2) Prior to 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 for the county.

(3) Any and all related information, reports and data that 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.

(f) The provider of service shall establish mechanisms to ensure priority access for individuals receiving ACT and transitioning, for continuity of care for such individuals, including the provision of appropriate services and medications, including injectable medications.

(g) The provider of service shall establish mechanisms for the meaningful participation of individuals, family 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.

(h) The provider of service shall develop and make available to recipients and collaterals, a plan which will assure an appropriate response to recipients admitted to the program and their collaterals who need assistance when the program is not in operation. Such plan shall include the ability to speak with a member of the licensed staff of the Mental Health Outpatient Treatment and Rehabilitative Service program or a licensed staff person working under the auspices of the Mental Health Outpatient Treatment and Rehabilitative Service program pursuant to a plan approved by the local governmental unit or, for county-operated providers, by the Office.

(i) A provider of service shall ensure that any Mental Health Outpatient Treatment and Rehabilitative Service program subject to this Part does not:

(1) utilize restraint or seclusion for any purpose, including, but not limited to, as a response to a crisis situation, provided, however nothing in this section shall be construed to prohibit the use of reasonable physical force when necessary to protect the life and limb of any person where alternative procedures and methods have failed ; and

(2) perform electroconvulsive therapy or aversive conditioning therapy for any purpose, including, but not limited to, as a treatment intervention.

(j) A provider of service shall ensure that an individual's participation in research only occurs in accordance with applicable Federal and State requirements.

(k) A provider of service shall ensure the development, implementation and ongoing monitoring of a Risk Management Program that includes the requirements for identification, documentation, reporting, investigation, review, and monitoring of incidents pursuant to the Mental Hygiene Law and Part 524 of this Title.

(l) There shall be emergency procedures including but not limited to an emergency evacuation plan and staff shall be knowledgeable about such procedures.

(m) 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 utilization review procedure shall provide for:

(1) a review of the appropriateness of admission to a Mental Health Outpatient Treatment and Rehabilitative Service program; and

(2) a review of the need for continued treatment in a Mental Health Outpatient Treatment and Rehabilitative Service program within seven months after admission and every six months thereafter unless the individual is:
(i) discharged out of the program and subsequently readmitted, wherein the cycle begins again; or

(ii) receiving psychotropic medication treatment and medication education services only, wherein the need for continued treatment shall be reviewed every 12 months thereafter.

(n) The provider of service shall participate as requested by the local governmental unit in the local planning processes pursuant to article 41 of the Mental Hygiene Law.

(o) The provider of service shall cooperate with the Office and the local governmental unit in monitoring the access to services of individuals or groups determined to be in urgent need of services pursuant to this section.

(p) In programs that are not operated by State government, there shall be an annual audit of the service provider, pursuant to a format prescribed by the Office, and in accordance with Generally Accepted Auditing Principles, of the financial condition and accounts of the provider, or in accordance with requirements established by the Department of Health for programs operated by agencies operated pursuant to article 28 of the Public Health Law. This audit shall be performed by a certified public accountant who is not a member of the governing body or an employee of the program. In addition, the provider is required to submit an annual Consolidated Fiscal Report to the Office of Mental Health, signed by the Chief Executive Officer, and meet all requirements for submission as described in the instructions for this Report. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements. The Office shall utilize the applicable schedules to the annual Consolidated Fiscal Report to the Office of Mental Health to determine provider compliance with the indigent care requirements contained in section 599.15 of this Part.

(q) A provider of services required to comply with the indigent care requirements contained in section 599.15 of this Part shall ensure that no individual who is otherwise appropriate for admission is denied access to services solely because the individual does not have creditable coverage or the means to pay the provider's private pay rates or sliding fee scale.

(r) Programs operated by hospitals, including psychiatric centers operated by the State, or hospitals licensed pursuant to article 31 of the mental hygiene law or article 28 of the public health law, which are Medicare certified and provide outpatient services reimbursed by Medicare, shall ensure services are provided consistent with applicable Medicare certification and coverage standards and policies, in addition to any other requirement contained in this Part.

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