New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 679 - Clinic Treatment Facilities
Section 679.3 - Principles of compliance

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 679.3

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

(a) There shall be a governing body (see glossary) with the policy making authority for the clinic treatment facility and legal responsibility for its operation and management. Each member of the governing body shall be identified by name and address in the agency/facility (see glossary under Agency/Facility) records. No one shall serve as both a member of the governing body and of the paid staff of the clinic treatment facility.

(b) The governing body shall be responsible for the operation of the clinic treatment facility according to the principles and standards established in this Part and other applicable rules, regulations and statutes. This includes, but is not limited to, Parts 620, 624, 633 and 635 of this Title.

(c) The governing body shall be responsible for the development, implementation, revisions when necessary, and use of a written policy and procedure (see glossary under Policies/Procedures) manual(s). The manual shall specify the facility's operational procedures and the staff titles operationally responsible for various clinic activities in at least the following areas:

(1) services available, treatment planning, service delivery;

(2) treatment coordination;

(3) staffing, qualifications, and personnel policies;

(4) administration;

(5) admission and discharge criteria;

(6) quality assurance including program and individual service evaluation;

(7) program goals;

(8) recordkeeping and reporting; and

(9) budgeting and expenditure controls.

(d) The governing body shall ensure the development and implementation of a written quality assurance program (subject to OPWDD's approval), that includes a planned and systematic process for monitoring and assessing on an ongoing basis, the quality and appropriateness of the treatment, regardless of service delivery location, and clinical performance of staff. The plan shall include a means to resolve identified problems, pursue opportunities to improve the care and treatment provided, and incorporate the regular, ongoing input of individuals receiving services, collaterals, and referral source representatives. The plan shall be subject to OPWDD review and approval as part of the process for issuing a new operating certificate.

(e) The governing body shall ensure that admission and discharge policies, including those pertaining to eligibility for service/treatment and a description of available services, shall be written and be made available to staff members; persons served and their families; cooperating/referring agencies; and as requested, to the general public.

(f) The governing body of a facility providing medical or dental care in circumstances where such care represents the person's principal source of health care, shall ensure the development of policies and the implementation of related activities which:

(1) assure continuity of care in the area of medical services, including access to emergency medical care;

(2) for medical care, address the parameters associated with managed health care (see section 679.99[e] of this Part);

(3) ensure that its medical/dental practitioners are current in their treatment practices and knowledge, particularly with respect to serving persons with developmental disabilities;

(4) ensure access to specialist care and consultation, when needed;

(5) access outside peer credential review of physicians and dentists;

(6) reinforce the importance of quality hands-on medical/dental care; and

(7) provide opportunities for medical/dental training placements in the clinic treatment facility itself.

(g) Ongoing direction and control of the facility's delivery of services and treatments shall be delegated by the governing body to an appropriately qualified administrator (see glossary) who may also function as the clinic's medical or dental director (see glossary). If the administrator is not a physician/or dentist, he or she shall:

(1) have at least a bachelor's degree from an accredited institution of higher learning; and

(2) have at least one year's post degree experience in a human services setting serving persons with developmental disabilities; and

(3) in a clinic treatment facility providing medical or dental services as principal sources of such health care to appropriately admitted persons, have at least one year's experience in actual health care administration, or a master's degree in health care administration.

(h) An appropriately qualified physician shall be responsible for the ongoing direction of all clinical services. The medical director shall be licensed to practice medicine in New York State and shall be designated as responsible for maintaining the general health conditions and practices of the program. If the clinic provides dental care, the medical director may be a dentist.

(i) The facility shall have sufficient professional (see glossary) staff to deliver the services offered in accordance with the intensity, duration and frequency recommended by the treating clinician(s) for persons admitted to the facility.

(1) The medical director shall be appointed at a sufficient full-time equivalent (FTE) level (based on a 40 hour work week) to provide adequate oversight of the constellation of services offered by the clinic facility for a clinic in operation five days or more per week.
(i) The medical director shall be at least .10 FTE for programs that are required to complete 300 annual physician assessments or less per year (see subdivision [t] of this section for requirements related to physician assessments).

(ii) The medical director shall be at least .20 FTE for programs that are required to complete more than 300 and up to and including 600 annual physician assessments per year.

(iii) The medical director shall be at least .30 FTE for programs that are required to complete more than 600 annual physician assessments per year.

(iv) For programs operating less than five days per week on a regular basis, the medical director coverage shall be at least proportional based on the criteria stated in subparagraphs (i), (ii) and (iii) of this paragraph.

(v) Nothing herein shall preclude the medical director as a physician from delivering appropriate and needed medical services, including the annual physician assessments, for up to one half of his/her assigned time. If the services are not principal source primary medical care, the requirements at subdivisions (f), (k) and (n) of this section need not be met.

(vi) Nothing herein shall preclude the clinic provider from filling the medical director position allocation utilizing more than one physician, as long as only one physician is formally designated as having overall responsibility for the facility's medical direction.

(2) The designated administrator shall be appointed in sufficient amount to cover the hours the clinic is in operation up to one full-time equivalent.

(j) Approved clinical services in a clinic treatment facility certified in accordance with this Part, may include the following types of services delivered by practitioners of the healing arts (see glossary) or otherwise herein authorized parties (see subdivision [l] of this section and glossary):

(1) clinic intake (see glossary);

(2) rehabilitation/habilitation services:
(i) occupational therapy;

(ii) physical therapy;

(iii) psychology;

(iv) rehabilitation counseling;

(v) speech and language pathology; and

(vi) social work;

(3) medical/dental services:
(i) medicine (may include primary care as well as specialties such as psychiatry and physiatry); and

(ii) dentistry (includes services of qualified dental assistants/hygienists operating under the direct supervision of a licensed dentist);

(4) Health care services:
(i) nursing;

(ii) dietetics and nutrition;

(iii) audiology; and

(iv) podiatry.

(k) Persons receiving medical services from a clinic treatment facility certified pursuant to this Part, and such services constitute the person's principal source of health care, shall have such services delivered pursuant to an individualized managed health care plan which incorporates the requirements at section 679.99(e) of this Part.

(l) The facility's staffing plan shall include the representation of professional staff members qualified in at least four of the following disciplines: dentistry (and dental hygiene services); medicine (including any appropriate specialty); nursing; occupational therapy; physical therapy; psychology; rehabilitation counseling; social work; and speech therapy. As permitted by New York State law pertaining to the practice of disciplines, and/or authorized by this Part, facilities may utilize assistants, physician assistants; nurse practitioners, and applied behavioral sciences specialists (see glossary) to deliver services. Clinics may utilize the services of students-in-training to deliver billable services in accordance with the following requirements:

(1) Medical/dental interns and residents (without a NYS license as a physician or dentist) participating in an accredited medical/dental school program.

(2) Students-in-training in other discipline areas must:
(i) be in a training program operated by an institution of higher learning with an accredited program in the applicable area;

(ii) have completed the majority of their classroom requirements and the purpose of the placement is part of an approved and required internship or clinical training aspect of the degree program;

(iii) have their activities governed in accordance with a written plan for supervision of the student by both the training institution and the clinic treatment facility; and

(iv) be provided onsite supervision when and where the service is delivered, involving a party with licensure/credentials appropriate to the student's clinical area and include face-to-face contact with the student for review of performance, as well as periodic observation of the student's contact with the admitted person.

(3) Any facility policies authorizing the use of students-in-training to provide billable clinical services must include the following provisions:
(i) the service recipient and his or her correspondent or referral agent is notified prior to receipt of care that the service will be provided by a student (nonlicensed/credentialed party) under supervision; and

(ii) the recipient is advised that he or she may reject service provided by a nonlicensed/credentialed party at any time without prejudice or loss of entitlement to service; and

(iii) there is a means to ensure that the licensed/certified professional providing student-in-training supervision, is fully aware that he/she is directly responsible for the quality of care delivered by the supervised student.

(m) All services shall be provided so as to maximize each person's continuity of care. A single professional or otherwise qualified (i.e., holding at least a baccalaureate degree or a license as a registered nurse) staff member of the clinic shall be designated as a treatment coordinator (see glossary) for each person admitted to the clinic. This staff member shall be assigned primary coordination responsibility for all services delivered by the facility to the person. This staff member shall function as the contact point and liaison at the clinic for referral sources and for any outside-of-the-clinic case managers assigned to the person. The treatment coordinator shall ensure that the recommendations of treatment plans developed by the clinic, and implemented as appropriate by the clinic, are communicated, when pertinent, to other caregivers and referral sources.

(n) All clinic treatment facilities providing medical or dental care services as the principal source of medical/dental care to admitted persons, shall have a formal affiliation with a medical/dental school, a teaching hospital or an acute care hospital, accessible as appropriate to meet the emergency medical/dental needs of those persons receiving medical or dental services from the clinic facility.

(o) All services shall be provided in accordance with generally accepted community standards of professional practice. All medical care provided as the principal source of health care to any of the clinic's participants shall be provided within the context of managed health care as defined at section 679.99(e) of this Part.

(p) Any service, appropriate to the needs of the person, meeting the definition of preventative, therapeutic, rehabilitative or palliative services (see section 679.99 of this Part), and delivered within the scope of the practitioner's licensure/certification, shall be allowable, providing said service(s) is identified and described within the proposal approved as part of the facility's certification of need application. New or revised services shall be submitted and approved by OPWDD prior to such services being offered or delivered by the facility.

(q) All treatment plans and referrals for services, regardless of source, shall be reviewed and approved by the medical director or other designated physician/dentist. Such review shall not be interpreted as meaning that a facility certified pursuant to this Part has responsibility for services or treatment plans delivered by others not under its auspices.

(r) Ongoing treatment (see glossary) services shall be provided principally to persons with a diagnosis of developmental disability and, as necessary and appropriate, to their collaterals for the purposes of enhancing treatment results for the person. Persons without a known developmental disability diagnosis may be admitted for the purposes of a clinic intake or diagnostic and evaluation services to determine whether or not a condition of developmental disability diagnosis exists. However, where it can be substantiated through appropriate clinical documentation that because of unique and individual circumstances a diagnosis cannot be made due to maturational delays or the complexities of the condition which make it resistive to diagnoses by available clinical assessment processes, persons up to their eighth birthday may continue to be served where a substantiated suspicion of developmental disability exists.

(1) For persons five years of age or younger, at least a substantiated suspicion of a developmental disability or documented indicator of such risk, shall exist in order for that person to remain eligible for further treatment as a participant with developmental disabilities.

(2) For persons six years of age and older, the clinical assessment shall substantiate a specific developmental disability diagnosis in order for the person to remain eligible for further treatment as a participant with developmental disabilities.

(s) No person shall be admitted for a service unless he/she meets the facility's admission criteria, there is a documented need for the service, and the program has sufficient capacity to provide the service. This shall not be interpreted to preclude conducting a clinic intake for the purposes of determining the appropriateness of someone for admission.

(t) All persons shall be assessed annually by the medical director or other clinic physician as to the person's continuing need to be served by the clinic.

(u) Clinics providing services in NYS Regents designated physician shortage areas, may provide services to persons without a diagnosis of developmental disability in accordance with such person's assessed needs. In such cases, persons with a diagnosis of developmental disability shall receive priority for services whenever the facility's service capacity is limited.

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