New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 680 - Specialty Hospitals
Section 680.4 - Organization and administration
Universal Citation: 14 NY Comp Codes Rules and Regs § 680.4
Current through Register Vol. 47, No. 12, March 26, 2025
(a) Organization.
(1) The governing
body (see section
680.13 of this Part) of the
specialty hospital shall be responsible for the overall operation and
management of the specialty hospital and may discharge any responsibilities
hereinafter stated through any body of delegates which is approved by the
commissioner.
(2) The governing
body shall ensure that the facility and services provided adequately meet the
health, social and developmental needs of all individuals receiving services
through preventive, habilitative and rehabilitative programs.
(3) The governing body shall ensure that
there is adequate protection of each person's health, safety, comfort,
well-being, and civil, human and legal rights.
(4) The governing body of the specialty
hospital shall develop working agreements with other providers to ensure
delivery to individuals, as appropriate, special diagnostic and medical
services which the specialty hospital does not provide.
(5) The governing body of the specialty
hospital shall develop working agreements with the Developmental Disabilities
Services Office (see section
680.13 of this Part) and other
providers to ensure to the greatest extent possible, that opportunities exist
in the community for movement of individuals, when appropriate, to less
restrictive residential settings.
(6) Minutes of all official meetings of the
governing body shall be maintained as permanent record of the decisions made in
relation to the operation of the specialty hospital.
(7) Administrative management of the
specialty hospital shall be delegated by the governing body to an appropriately
qualified administrator.
(8)
Ongoing direction and control of the medical services of the unit shall be
delegated by the governing body to a physician whose qualifications in
developmental disabilities are appropriate to the program. For purposes of this
Part, this person shall be known as the medical director (see section
680.13).
(9) The governing body shall develop and
revise as necessary, written policies for the quantity, quality, scope, goals,
objectives and evaluation of all programs (see section
680.13); and policies for the
accomplishment of stated purposes and well-being of individuals. These policies
shall include, but not be limited to:
(i) a
statement of the facility's philosophy, objectives and goals, specifying:
(a) the specialty hospital's role in the
State's comprehensive services for people with developmental
disabilities;
(b) the goals for
individuals it serves; and
(c) the
concept of its relationship to the parents or correspondents of individuals it
serves;
(ii) methods for
coordinating services for every individual between the specialty hospital and
other providers of programs and services;
(iii) policies and procedures specifying how
and by whom the following functions shall be performed:
(a) specification of preadmission procedures
which include requiring referral services to identify the person's specific
conditions which necessitate hospitalization and the types of rehabilitation
therapy requested;
(b) an
application screening process which:
(1)
determines appropriateness and medical necessity of the admission in accordance
with the specialized services offered;
(2) determines person's rehabilitation
potential; and
(3) includes a
procedure requesting the approval of the commissioner prior to the
admission;
(c) an
admission and process which includes the development of an individual program
plan (see section
680.13) defining the types of
therapy services to be provided in accordance with the individual's
condition(s), measurable outcome expected, and a time frame for attainment of
each outcome;
(d) interdisciplinary
assessments, preparation of individual service plans (see section
680.13), and periodic reevaluation
and revision of the plans in coordination with agencies providing day programs
and treatment to the individuals;
(e) periodic review of the appropriateness of
the person's admission and continued stay in the specialty hospital;
(f) ensuring effective communication between
staff and individuals and families of individuals, using such means as
counseling with individuals, problem-solving procedures, family conferences,
telephone communication and newsletters;
(g) ensuring that the rights of all
individuals are not abridged;
(h)
the provision of all services required by section
680.7 of this Part. This shall
include a description of methods to be used for coordinating each service with
other services and programs provided to the individuals. In addition:
(1) policies and procedures regarding medical
and medically related services (see section
680.13) to individuals shall
include, but not be limited to, physician visits, emergency coverage,
hospitalization, consultants and rehabilitative services;
(2) policies and procedures regarding dental
services (see section
680.13) shall include, but not be
limited to, emergency care;
(3)
policies and procedures regarding pharmacy services (see section
680.13) and consultation to
individuals shall include, but not be limited to, the safe administration and
handling of all drugs specifying the following:
(i) criteria and schedule for evaluations and
treatment recommendations regarding self-administration of medications by the
person;
(ii) criteria for staff
training regarding administration of medication by staff. Only appropriately
trained staff shall be allowed to administer drugs as specified in existing
State regulations and policy for administration of medication. For direct care
staff to be allowed to administer drugs, they must complete a training program
in administration of medication which has the prior approval of the
commissioner, and drugs administered by such staff must be in unit dose form;
and
(iii) all medication errors and
drug reactions shall be reported immediately to the practitioner who ordered
the drug. Adverse drug reactions shall be reported to the Federal Food and Drug
Administration;
(i) arrangements or preparations for the
individuals to obtain additional services needed through other
agencies;
(j) discharge or transfer
of a person, including:
(1) participation of
the staff, the individual, where appropriate, the family and the agent
responsible for service delivery following discharge or transfer;
(2) due process for discharge or transfer;
and
(3) provision for appropriate
follow-up services;
(k)
space utilization;
(l) planning for
organization, size and grouping of living units (see section
680.13).
(1) The specialty hospital may not group
individuals of widely divergent ages, developmental levels and social needs in
close physical or social proximity unless the grouping is planned for the
concentrated treatment of health problems necessitated by the person's
admission and there is a specific written plan which includes the rationale for
this grouping.
(2) The specialty
hospital may not group individuals on the basis of their physical handicaps
unless the grouping is for concentrated treatment of health problems
necessitating the individuals' admissions. Otherwise, individuals who are
mobile, nonambulatory, deaf, blind, epileptic, or who have other physical or
developmental disabilities shall be grouped with other individuals of
comparable social and intellectual development;
(m) recordkeeping;
(n) maintaining a written financial record
for each individual that is available to the individual and the individual's
family (unless the individual is an adult who objects to the disclosure of such
information to his or her family). This record shall include:
(1) written receipts for each individual's
personal possessions and funds received by or deposited with the specialty
hospital; and
(2) written receipts
for all disbursements made to or for the individual;
(o) practices to be followed in the event of
emergencies. The administrator shall develop a written staff organization plan
with detailed written procedures for meeting all potential emergencies and
disasters, such as missing individuals, severe weather, power outages, fires,
floods, bomb threats and medical emergencies (e.g., epidemics,
food poisoning, chemical poisoning, etc.). This plan shall be posted at
suitable locations throughout the facility and clearly communicated to and
periodically reviewed with staff; and shall include at least the following:
(1) instructions for using alarm systems and
signals;
(2) assignment of
personnel to specific tasks and responsibilities;
(3) specifications of evacuation routes and
procedures which are posted at suitable locations throughout the
facility;
(4) systems for
notification of appropriate persons;
(5) location of firefighting equipment;
and
(6) methods of fire
containment;
(p) steps
to follow in the event of any unusual occurrence, including, but not limited to
serious illness, accident or impending death (e.g.,
notification of family;
(q) steps
to follow in the death of a person, including notification of the family and
medical examiner and arranging for an autopsy when required by the local
medical examiner;
(1) In every case, the
medical examiner should be immediately notified of a person's death.
(2) If the medical examiner releases the body
to the facility for autopsy, the autopsy shall be performed by an impartial
qualified physician who is not employed by the specialty hospital.
(3) The individual's correspondent shall be
informed of the autopsy findings if he or she desires;
(r) special review procedures, including but
not limited to:
(1) ensuring that all alleged
violations of policies prohibiting mistreatment, neglect or abuse of an
individual are reported and investigated. The specialty hospital shall have
documentation of the following:
(i) All
alleged violations are reported within 24 hours to the administrator, the
Mental Hygiene Legal Service, the commissioner, the State Office of Health
Systems Management and the State Office of Protective Services for Children or
the corresponding local office (if appropriate given the age of the client
involved).
(ii) The administrator
shall ensure that each alleged violation is investigated thoroughly.
(iii) The results of each investigation shall
be reported to the administrator, commissioner, the Mental Hygiene Legal
Service, the Commission on Quality of Care and Advocacy for Persons with
Disabilities and the State Office of Health Systems Management within 24 hours
of the report of the alleged violation.
(iv) The commissioner may require a separate
investigation of an alleged violation to be carried on by staff of OPWDD, the
district attorney's office or other law enforcement officials.
(v) A written report of incidents, with the
investigation results, shall be sent to the Professional Advisory Board (see
section 680.13) within 30 days of the
incident, for all Willowbrook class members.
(vi) A written report of completed
investigations at the specialty hospital shall be shared with the State Office
of Health Systems Management.
(vii)
If the alleged violation is verified, the administrator shall impose an
appropriate penalty;
(2)
ensuring that appropriate corrective action is taken to prevent similar
accidents in the future;
(iv) personnel policies and procedures,
including:
(a) hiring policies reflecting
conformity to Federal laws governing civil rights and equal employment
opportunities;
(b) job
descriptions, which specify qualifications, education and skills required,
description of duties and responsibilities and supervision to be
provided;
(c) authorized procedures
consistent with due process for suspension and/or dismissal of an employee for
cause;
(d) protection of individual
rights, including prohibiting mistreatment, neglect or abuse of individuals
with procedures to be followed in the event that violations of individual
rights occur;
(e) staff training
program:
(1) job description of an individual
responsible for staff development and training;
(2) orientation procedures;
(3) in-service training; and
(4) use of community resources and
consultants;
(f)
policies to ensure that employees are medically determined to be free of
communicable and infectious diseases;
(g) policy statements on salaries and
increments, accumulation of leave and fringe benefits;
(h) policy and procedures to ensure the
complaints by staff can be made without the threat or recrimination;
and
(i) staff schedule for
weekdays, weekends and holidays in accordance with the staff/individual ratios
as specified in section
680.8 of this Part.
(10) The administrator
shall ensure that the previously noted policies are incorporated in an
up-to-date manual of written policies and procedures; and shall further ensure
that the facility is in compliance with such policies and procedures or has a
plan of correction for achieving compliance in a timely manner.
(b) Administration.
(1) The specialty hospital administrator
shall maintain a current table of organization which shows the major operating
programs of the specialty hospital, the administrative personnel in charge of
the programs and divisions, and their lines of authority, responsibility and
communication. This table of organization shall identify the person(s) and/or
agencies providing services to the individuals on a contractual basis,
including shared staff, if any.
(2)
The specialty hospital administrator shall establish appropriate standing
committees to deal with areas such as human rights, aversive conditioning,
research review, medication errors and infection control. Such committees shall
maintain formal minutes of their activities.
(3) The specialty hospital administrator
shall make available for distribution a summary of the laws, regulations and
procedures concerning admission, readmission and release of a person.
(4) The specialty hospital administrator
shall make arrangements so that an individual is designated as responsible for
the administrative direction of the facility at all times when the
administrator is absent.
(5) The
specialty hospital administrator shall have in effect a transfer agreement with
one or more hospitals for providing inpatient hospital services not available
at the specialty hospital to individuals as needed. However, if the specialty
hospital documents a good faith effort to establish such an agreement, but is
unsuccessful, then this requirement may be waived if the commissioner
determines that it is in the public interest and essential to providing
specialty hospital services to eligible individuals.
(6) The specialty hospital administrator
shall provide adequate, modern administrative support to efficiently meet the
needs of the individuals. Administrative support includes clerical,
communication, financial, housekeeping, laundry, personnel, physical plant,
safety and security, supply, purchasing and transportation services.
(7) The specialty hospital administrator
shall have a plan for a management audit conducted at least annually. This
audit is to ensure that the specialty hospital complies with State laws and
regulations and the facility's policy and procedures.
(8) The specialty hospital administrator
shall document the facility's purchasing process and adequately operate its
inventory control system and stockroom.
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