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 679.4 - Standards of certification

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 679.4

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

(a) OPWDD shall verify (see glossary) that each operator of a Part 679 clinic treatment facility has annually submitted the names and addresses of the current members of its governing body to the commissioner in accordance with the requirements of section 13.39 of the Mental Hygiene Law.

(b) OPWDD shall verify that the governing body has established, maintained, and implemented a plan of organization for the facility which accurately indicates lines of accountability, the nature of professional responsibility to be exercised, and the professional qualifications required.

(c) OPWDD shall verify that since the last survey:

(1) any new/revised policies have been approved by the governing body;

(2) said new/revised policies have been distributed to staff, and they have been advised or trained regarding their responsibilities; and

(3) said staff are knowledgeable regarding their responsibilities under any new/revised policies/procedures.

(d) Minutes of all official meetings of the governing body of other than State operated Part 679 clinic treatment facilities shall be maintained as a permanent record in relation to the policymaking decisions and any decisions made relative to the operation of the facility.

(e) OPWDD shall verify that the facility's staffing plan and actual day-to-day allocation of staff includes provisions for all services to be delivered by or under the direct supervision (see glossary) of practitioners of the healing arts or otherwise herein authorized parties.

(f) At least 25 percent of the full-time equivalent professional staff as identified in section 679.3(l) of this Part, shall have at least one year of full-time treatment experience with persons having developmental disabilities, in programs serving a population with developmental disabilities. If the program has been established to serve a particular group of persons with specialized characteristics/needs, then the staff experience shall be appropriate to serving those with similar needs.

(g) OPWDD shall verify that the facility has assigned a staff member to each person admitted for service, to perform the functions of treatment coordinator and who is the contact point for the person's service coordinator (if applicable). The person's clinical record reflects the activities of this treatment coordination.

(h) OPWDD shall verify that all treatment has been given upon the written order of a physician or dentist, at least annually or when there are significant changes to the ongoing treatment plan, and is delivered under the supervision of a physician, dentist or practitioner of the healing arts (see glossary) subsequent to an intake visit assessment documenting the need for admission to the clinic.

(i) OPWDD shall verify when services have been delivered by students-in-training that:

(1) the facility's plan for supervision of the service where it is delivered, has been implemented consistently and appropriately;

(2) persons receiving services from students-in-training have been so advised and that recipients rejecting such services have not had their rights to services compromised; and

(3) no more than 15 percent of a facility's total billed for units of service are delivered by students-in-training.

(j) OPWDD shall verify that there is a clinical record maintained in a confidential manner for each person admitted to the facility which contains at least:

(1) identification information about the applicant/service recipient and his or her family and services received outside of the clinic (including identification of practitioner or responsible entity);

(2) source of referral, date commencing service/treatment, and the name of the party responsible for treatment coordination;

(3) initial, interim, and/or final diagnosis(es), as applicable, set forth in appropriate official terminology, including those related to the person's developmental disability, other mental disability(ies) if present, and medical condition/diagnoses;

(4) reports of all known, recent (i.e., within the last two years) diagnostic examinations and assessments including findings and conclusions, regardless of source, including reports of any special studies and/or laboratory procedures performed at the clinic's recommendation;

(5) the individual written plan of services for all treatments being recommended and delivered by the clinic; and

(6) treatment notes signed by the professional staff member or treatment coordinator making the note.

(k) There shall be a written plan of services which also documents that the outcomes and/or course of treatment has been reviewed as to the achievement of said outcomes and the need for continued course of treatment pursuant to the following schedule:

(1) as specified by the treating physician or dentist, for medical or dental treatment; and

(2) at least semi-annually by the treating practitioner or treatment coordinator in consultation with the person receiving the service and/or his/her collaterals (unless the person is an adult, has the capacity to object, and does so object to the provision of such services), for all other ongoing rehabilitation/habilitation services (see section 679.3[j][2] of this Part) or health care services (see section 679.3[j][4] of this Part) of six months or longer duration.

(l) OPWDD shall verify that there is a licensed physician or dentist, as appropriate, assigned responsibilities as the medical director for the facility who shall:

(1) if a physician, be board certified by the American Board of Medical Specialties in pediatrics, adult medicine, neurology, family practice medicine, or internal medicine, or be eligible for said certification. Given documentation of the unique or specialized needs of the majority of persons to be served, the clinic, subsequent to OPWDD approval, may employ a candidate with or eligible for an alternative board certified specialization such as psychiatry; or

(2) if a dentist, be board certified in an appropriate specialty (if engaging in any amount of specialized dental practice under the clinic treatment facility's auspices), or be eligible for said certification; and

(3) be qualified pursuant to agency policy for the position by training, experience, and administrative ability.

(m) OPWDD shall verify that the written plan for the facility's quality assurance program describes the program's objectives, organization, responsibilities of all staff members, scope of the program and procedures for overseeing the effectiveness of monitoring, assessment and problem-solving activities and that the plan has been implemented. The quality assurance process shall define methods for the identification and selection of clinical and administrative problems to be reviewed, and include:

(1) the establishment of review criteria developed in accordance with current standards of professional practice for monitoring and assessing the appropriateness of treatment and clinical performance;

(2) regularly scheduled reviews of clinical records, complaints, suggestions from persons served and their collaterals, reported incidents or allegations of abuse, and other documents pertinent to problem identification;

(3) documentation of all quality assurance activities, including but not limited to the findings, recommendations, and actions taken to resolve identified problems; and

(4) the timely implementation of corrective actions and periodic assessments of the results of such actions with adjustments, as appropriate.

(n) OPWDD shall verify that the clinic's administration has reported the findings, conclusions, recommendations, and actions taken as a part of the quality assurance program to the governing body. OPWDD shall verify, that when problems have been identified, the outcomes of the quality assurance program have resulted in one or more of all of the following:

(1) changes in the treatments/services received by persons who have been admitted;

(2) improvements in the efficiency and effectiveness of service delivery;

(3) revision or development of facility policies/procedures; and/or

(4) changes in the granting or renewing of staff privileges, as appropriate.

(o) The agency/facility shall cause to be completed or obtained for every person referred for intake, a developmental/demographic inventory of information on the person's characteristics and needs. Said inventory shall be completed and submitted to OPWDD in a manner and on a schedule acceptable to the commissioner.

(p) OPWDD shall verify that the facility has made persons served at the facility aware of its hours of operation, of the availability and source of emergency services, of phone number(s) of answering services for messages at times when the facility is not in operation, and rights associated with the receipt of services. Such information, and including the provision of assessment and treatment services, shall be provided in a person's primary language and/or in a manner that facilitates communication and understanding.

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