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 680.7 - Specialty hospital services (see section 680.13 of this Part)
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 680.7
Current through Register Vol. 46, No. 39, September 25, 2024
(a) The specialty hospital shall provide or ensure provision of a planned combination of medical treatment and active programming through the use of preventive, habilitative and rehabilitation programs (see section 680.13). These programs shall be divided into the following categories:
(1) Mandatory (see section
680.13).
Those services which are required for every individual on a daily
basis.
(2) Selective (see section
680.13).
Those services which are available at all times in the specialty hospital, and
required for some individuals in the manner and frequency prescribed by the
person's individual program plan.
(3) Combination. Those mandatory and
selective services which are combined to provide preventive, habilitative and
rehabilitative programs in medical treatment and active programming in a
concerted effort to reduce the health care problems which necessitated the
individual's admission to the specialty hospital.
(b) Mandatory services (see section 680.13 under specific disciplines) include:
(1) medical
services;
(2) nursing
services;
(3) nutrition
services;
(4) recreation services;
and
(5) self-care services.
They shall be provided to each individual every day in accordance with an individual's individual program plan and conform with the following requirements:
(i) Medical
services.
(a) The medical director shall
ensure that the medical staff carries out the following responsibilities
relating to services, as appropriate:
(1)
providing and supervising medical treatment through the delivery of preventive,
habilitative and rehabilitative programs;
(2) providing health care consultation and
referral of individuals to appropriate health care specialists;
(3) developing and amending medical policies
and procedures for matters such as physician visits, emergency coverage,
records, consultations and participation in the interdisciplinary team
processes and services;
(4)
advising the specialty hospital administrator regarding medical and related
problems;
(5) establishing
necessary professional relationships with other institutions and agencies such
as general or special hospitals, medical schools, rehabilitation centers,
nursing homes, health-related facilities, home health agencies, hospital
outpatient departments, diagnostic and treatment facilities, clinics,
laboratories and related resources;
(6) detection and treatment of health
problems, through adequate medical surveillance, periodic inspection and
regular medical examination.
(7)
semi-annual physical examinations that include:
(i) examination of vision and
hearing;
(ii) routine laboratory
examinations, as deemed necessary by the physician; and special studies when
the index of suspicion is high; and
(iii) assessment of the need for a
comprehensive physical therapy evaluation and services for all individuals
including and especially those who are nonambulatory, have cerebral palsy, have
undergone orthopedic surgery or who have other orthopedic problems.
(8) immunization, using as a guide
the recommendations of the United States Public Health Service Advisory
Committee on Immunization Practices and/or the Committee on the Control of
Infectious Diseases of the American Academy on Pediatrics as appropriate to the
specialty hospital's population;
(9) tuberculosis control, in accordance with
the recommendations of the American College of Chest Physicians and/or the
section on diseases of the chest of the American Academy of Pediatrics, as
appropriate to the specialty hospital's population;
(10) reporting of communicable diseases and
infections in accordance with law;
(11) genetic counseling to individuals and
next of kin; and
(12) reviewing and
responding to suggestions of pharmacists and registered nurses for
modifications in individual's medications.
(b) There shall be a formal arrangement for
qualified medical care for the individual, including care for medical
emergencies at all times.
(1) Procedures
shall be established that provide steps to be followed when the primary care
physician is not available.
(2) The
names and telephone numbers of physicians and/or personnel to be called in the
event of an emergency shall be posted.
(c) Upon admission of the individual, a
medication history of prescription and nonprescription drugs shall be obtained
and this information shall be entered in the individual's record.
(d) An individual record shall be maintained
for each individual of all medications (prescription and nonprescription)
dispensed, including the quantities and frequency of refill.
(e) The medical director shall maintain
effective arrangements through which medical services required by the
individuals but not regularly provided within the specialty hospital can be
obtained promptly when needed.
(ii)
Nursing services.
(a) The objectives of nursing services shall
be to evaluate each individual's need for nursing care on a continuing basis,
and to provide such care directly by or under the supervision of a registered
nurse (see section
680.13 of
this Part). Such services shall include:
(1)
development of a written nursing services plan for each person as part of the
individual program plan;
(2)
participation in preventive, habilitative and rehabilitative services to
eliminate, limit or reduce the individual's health related problem;
(3) review of each individual's nursing
services plan in terms of the individual's daily needs, at least quarterly and
more frequently for those with an acute or chronic condition requiring
treatment and/or surveillance by a physician or other health professional level
health care staff;
(4) control of
communicable diseases and infections through:
(i) identification and assessment;
(ii) reporting to medical authorities;
and
(iii) implementation of
appropriate protective and preventive measures.
(5) modification of the nursing services plan
as necessary.
(b) Health
care staff shall monitor effects of medication and make periodic checks to
assure that individuals are taking their medications as prescribed, that
prescriptions are renewed as necessary and that outdated or discontinued drugs
are returned to the pharmacy or disposed of according to the policies of the
appropriate regulatory agency and the facility.
(c) The health care staff shall make periodic
checks to ensure that individuals are maintaining an adequate level of personal
hygiene.
(d) The health care staff
shall secure the services of the individual's physician for illness or injury
and for continuing and preventive health services.
(e) The medical director shall ensure that
written notations are made in the individual's record regarding significant
changes in the individual's program performance, attitudes, feelings and
physical condition which may be the result of medical treatment.
(iii)
Nutrition
services.
(a) The administrator is
responsible for providing or ensuring the provision of meals of adequate
nutrition including medically prescribed diets of suitable quality and adequate
quantity.
(b) Dietary counseling
shall be provided as indicated in each individual's service plan.
(c) Nutrition services shall include:
(1) supervision of individuals during meal
times to ensure that individuals are receiving nutritionally adequate amounts
of food and fluid at proper temperatures;
(2) menu planning:
(i) menus shall be written in advance. Menus
shall provide a sufficient variety of foods served in adequate amounts at each
meal, and shall be different for each day of the week and adjusted for seasonal
change;
(ii) records of menus as
served shall be filed and maintained for at least 30 days; and
(iii) menus shall be planned in such a way as
to meet the food and nutrition needs of individuals in accordance with the
recommended allowances of the Food and Nutrition Board of the National Research
Council, National Academy of Sciences, adjusted for age, sex, activity and
disability. The menu shall provide a nourishing, well-balanced diet unless
contraindicated by medical needs.
(3) establishing specifications for food
purchases and ensuring that such specifications are met. Records of food
purchased for preparation shall be filed and maintained for at least 30
days;
(4) initiating food orders or
requisitions shall be the responsibility of the dietitian (see section
680.13) or
designated supervisor in accordance with established requirements;
(5) storing and handling of food;
(i) Dry or staple food items shall be stored
at least 12 inches above the floor, in a ventilated room not subject to sewage
or waste water backflow, or contamination by condensation, leakage or
vermin.
(ii) Perishable foods shall
be stored at the proper temperature to conserve nutritive values.
(iii) Adequate means of safeguarding foods
against spoilage shall be developed and implemented.
(6) food preparation. A file of tested
recipes, adjusted for appropriate yield, shall be maintained;
(7) food shall be served in conformity with
the following:
(i) Each individual shall be
given the appropriate quantity of food, at an appropriate temperature, in a
form consistent with the developmental level of each individual, and with
appropriate utensils.
(ii) Meals
shall be served at a time comparable to mealtimes existing in the community,
unless medically contraindicated.
(iii) Food served to individuals and not
consumed shall be discarded.
(iv)
Denial of a nutritionally adequate diet shall not be used as
punishment.
(8)
maintaining sanitary standards in compliance with State and local regulations.
Such standards shall include, but not be limited to:
(i) following effective procedures for
cleaning all equipment, work and eating areas;
(ii) providing handwashing faciilties,
including hot and cold water, soap and paper towels adjacent to work
areas;
(iii) ensuring that food
service personnel wear clean clothing. Personnel with long hair shall wear hair
nets and personnel with short hair shall wear clean caps;
(iv) ensuring that there are routine health
examinations for food service personnel; and
(v) ensuring that personnel having symptoms
of communicable diseases or open wounds are not permitted to participate in
food preparation or service.
(9) orientation, training and supervision of
food service personnel.
(d) All individuals, including those who are
mobile nonambulatory, shall eat in dining areas, except when contraindicated
for health reasons or by decision of the team responsible for the individual's
program. Individuals shall eat in an upright position unless medically
contraindicated. Such medical recommendations shall be documented in the
individual's program plan. Individuals shall eat in a manner consistent with
their developmental needs.
(1) Dining areas
shall be equipped with tables, chairs, eating utensils and dishes designed to
meet the developmental needs of each individual.
(2) Dining areas shall be adequately
supervised and staffed for the direction of self-help dining procedures, and to
ensure that each individual receives an adequate amount of food.
(3) Individuals shall be provided with
systematic training to develop appropriate eating skills, utilizing appropriate
individualized adaptive equipment when it serves the developmental
process.
(e) As
appropriate, modified diets shall be:
(1)
prescribed by the individual's physician with a record of the prescription kept
on file;
(2) planned, prepared, and
served by persons who have received adequate instruction; and
(3) periodically reviewed and adjusted as
needed, but no less frequently than every 30 days. Such reviews are to be
documented in the individual's program plan.
(f) Staff shall be trained in and shall
utilize proper feeding techniques.
(g) There shall be a sufficient number of
trained and designated personnel to fulfill the food and nutrition needs of
each individual.
(iv)
Recreation services.
(a) Each individual
shall be provided with a planned program of meaningful recreation activities
every day.
(b) The program shall
provide all equipment and supplies necessary for the conduct of the recreation
activities.
(c) The specialty
hospital administrator shall ensure that:
(1)
a program of meaningful activities are planned and conducted, including those
which are intellectually stimulating, augment health maintenance, encourage the
participation of the individuals in the community, and involve appropriate
volunteers and volunteer groups, except for those individuals where there is
documentation that such activities would be medically
contraindicated;
(2) activities are
conducted for each individual during afternoon and evening hours and on
weekends and holidays;
(3) a
current monthly schedule of activities is posted to provide information to
individuals and staff; and
(4)
recreation services are coordinated with individualized health care, medical
treatment and active programming and are derived from the interdisciplinary
team planning process.
(v) Self-care services.
(a) Each individual shall receive
individually planned services and activities designed to improve his or her
ability to independently perform routine activities of daily living, including,
but not limited to, bathing, brushing teeth, shampooing, combing and brushing
hair, shaving and caring for toenails and fingernails. Items for these
activities shall be issued to each individual and marked in a way that will
appropriately identify each individual's items.
(b) A toilet training program shall be
provided for each individual who does not have adequate self-toileting skills
and does not have a documented medical condition which prevents the acquisition
of these skills. Records shall be kept of the progress of each individual
receiving toilet training. Individuals who are incontinent shall be immediately
bathed or cleaned upon voiding or soiling unless specifically contraindicated
by the training program as documented in the individual's program
plan.
(c) Training in the
activities of daily living shall be provided, and coordinated with the
provision of other services to ensure that individuals who are able, develop or
improve independent self-care skills.
(d) The specialty hospital administrator
shall ensure provision of suitable and adequate space appropriately designed
and equipped for the training and practice of activities of daily living.
(c) Selective services (see section 680.13 under specific disciplines) include:
(1)
communication services;
(2) dental
services;
(3) education
services;
(4) occupational therapy
services;
(5) optometric
services;
(6) orthotic
services;
(7) pharmacy
services;
(8) physical therapy
services;
(9) psychology
services;
(10) respiratory
therapy;
(11) social
services;
(12) special medical
services;
(13) special diagnostic
services; and
(14) transportation
services.
Selective services shall be available at all times to individuals who require them. Because a specialty hospital is designed to provide specialized treatment to individuals whose disability prevents movement to a less restrictive treatment alternative, selective services shall be delivered in such a manner as to effect that movement as soon as possible. Therefore, it may be necessary to concentrate on particular types of services throughout an individual's stay at the specialty hospital while the provision of other kinds of habilitative services which a person needs are postponed until the person has reached the treatment goal of movement to a less restrictive placement. Selective services may be provided by staff of the specialty hospital or through contract with other agencies in conformity with the following requirements.
(i)
Communication services.
(a) Communication
services shall be rendered:
(1) directly,
through contract between speech pathologists, audiologists (see section
680.13 under
"Professional Staff") and individuals; and
(2) indirectly, by working with other service
providers in implementing communication improvement programs in the residential
and program setting.
(b)
Communication services available to individuals in a specialty hospital shall
include:
(1) development of receptive and
expressive communication skills; and
(2) assessment of hearing loss and receiptive
and expressive language disorders, to include:
(i) comprehensive audiological screening, to
include tests of pure-tone air and bone conduction, speech audiometry, and
other procedures, as necessary, and to include assessment with the use of
visual cues;
(ii) assessment with
the use of amplification; and
(iii)
for individuals who do not speak, assessment of the capability to benefit from
instruction in signing, the use of communication boards or other methods to
increase receptive and expressive language skills.
(3) comprehensive speech and language
remediation of individuals including:
(i)
instruction in signing, use of communication boards and other devices to
increase receptive and expressive language skills;
(ii) procurement, maintenance and replacement
of hearing aids, as specified by a qualified audiologist;
(iii) reading service for individuals who are
blind and interpretive services for individuals who are deaf; and
(iv) space, facilities, equipment and
supplies adequate for providing efficient and effective communication
services.
(ii) Dental services.
(a) Comprehensive dental services shall be
provided by the specialty hospital, or through contract, which include the
following:
(1) a complete extra and intraoral
examination utilizing all diagnostic aids necessary to properly evaluate the
individual's oral condition. Such examination shall occur within one month
following admission, unless such an examination was done within the six months
immediately prior to admission and the results are received and reviewed by the
specialty hospital's medical director and are entered in the individual's
record;
(2) dental treatment as
needed by individuals, including oral surgery, orthodontics, periodontics and
prostheses;
(3) provision for
emergency treatment on a 24-hour-a-day, 7-day-a-week basis by a qualified
dentist (see section
680.13 under
"Professional Staff");
(4) a recall
system that will ensure that each individual is reexamined at specific
intervals in accordance with his or her needs, but at least annually;
(5) a dental hygiene program that includes:
(i) instruction of individuals and staff in
proper oral hygiene methods; and
(ii) instruction of parents or other care
givers in the maintenance of proper oral hygiene, where appropriate.
(6) maintaining a permanent dental
record for each individual. A summary dental progress report shall be entered
in the individual's record at stated intervals; and
(7) all dentists and dental hygienists (see
section
680.13 under
"Other Staff") providing services to the specialty hospital shall be fully
licensed to practice in New York State.
(iii) Educational services.
(a) Educational services shall be provided
for individuals under 21 years of age only when a person's health-related
problems and treatment for them prevent an individual from attending
educational programs in the community and these services are recommended by the
individual's interdisciplinary team. Under these circumstances, educational
services shall be provided as directed by the interdisciplinary team in the
least restrictive and most normalizing manner.
(b) Educational services shall be available
during both afternoon and evening hours and at bedside for those individuals
who require such arrangements.
(c)
Available educational services shall include:
(1) instruction in self-care skills and
activities necessary for self-preservation; and
(2) instruction in pre-academic and
communicative and computational skill areas.
(iv) Occupational therapy services.
(a) Occupational therapy services shall be
provided directly, through personal contact between occupational therapists
(see section
680.13 under
"Professional Staff") and individuals, and indirectly, through contact between
therapists and other persons involved with the individual.
(b) Occupational therapy staff shall provide
treatment and training programs that are designed to:
(1) preserve and improve abilities for
independent functioning, including activities of daily living; and
(2) prevent, insofar as possible, irreducible
or progressive disabilities, through means such as the use of orthotic and
prosthetic appliances, assistive and adaptive devices, positioning, behavior
adaptation and sensory stimulation.
(c) The therapist shall function closely with
the individual's primary physician, other health care specialists and program
staff.
(d) The therapist shall
ensure integration of these services with all other aspects of the individual's
program plan.
(v)
Optometric services.
(a) Optometric services
shall be provided by a licensed ophthalmologist either directly by the
specialty hospital or through written contract with another agency.
(b) These services shall include:
(1) assessment of vision and/or visual
disability;
(2) provision and
repair of glasses, contact lenses and any other visual prosthetic devices
needed by the individual;
(3)
ophthalmologic treatment as needed by individuals including surgery and/or
medication; and
(4) a recall system
that will ensure that each individual is reexamined at specific intervals in
accordance with his or her needs, but at least annually.
(vi) Orthotic services.
(a) Orthotic services shall be provided
either directly by the specialty hospital or through written contract with
another agency.
(b) These services
shall include:
(1) assessment of each
individual's need for 24-hour adaptive equipment;
(2) design, construction, modification and
repair of all adaptive equipment needed by individuals; and
(3) design, construction, modification and
repair of all adaptive equipment that a individual requires to move from the
specialty hospital to a less restrictive setting.
(vii) Pharmacy services.
(a) Pharmacy services shall be provided by an
appropriately registered pharmacy (i.e. current registration
with the New York State Board of Pharmacy, and the New York State Department of
Health, as appropriate) under the direction of a licensed pharmacist (see
section
680.13 under
"Professional Staff"). These services shall be provided either directly by the
specialty hospital or through written contract with another agency. Such
services shall include provision for emergency service.
(b) A pharmacist or registered nurse shall
regularly review the record of each individual on medication for potential
adverse reactions, allergies, interactions, contraindications, rationality and
laboratory test modifications, and advise the physician of any recommended
changes, with reasons and with an alternative drug regimen.
(c) Each drug shall be identified up to the
point of administration. Medications shall not be used for any person other
than the one for whom they were prescribed.
(d) Drugs that are stored on the premises
shall be stored under proper conditions of sanitation, temperature, light,
moisture, ventilation, segregation and security.
(1) All drugs shall be kept under lock and
key, unless authorized personnel are in attendance.
(2) The security requirements of Federal and
State laws shall be satisfied in storerooms and pharmacies.
(3) Poisons, drugs used externally and drugs
taken internally shall be stored on separate shelves or in separate cabinets at
all locations.
(4) Medications that
are stored in a refrigerator containing things other than drugs shall be kept
in a separate locked compartment.
(5) If there is a drug storeroom separate
from the pharmacy, there shall be a perpetual inventory of receipts and issues
of all drugs from such storeroom.
(e) There shall be automatic stop orders on
all drugs.
(f) There shall be an
emergency kit available to each living unit and program site and constituted so
as to be appropriate to the needs of the individuals. The approved stock of
antidotes and other emergency drugs shall be maintained in the pharmacy and in
personal care areas.
(g)
Authoritative and recent antidote information, as well as the phone number of
the regional poison control center, should be prominently displayed in the area
where drugs are stored.
(h) If
pharmacy services are provided directly by the specialty hospital, there shall
be:
(1) a current pharmacy manual that
includes policies and procedures and defines the functions and responsibilities
relating to pharmacy services. This manual shall be developed by the
responsible pharmacist, physician, nurse and other professional staff, as
appropriate to the specialty hospital. The pharmacy manual shall be revised as
often as necessary, but at least annually, to keep abreast of current
developments in services and management techniques. This manual shall include,
but not be limited to, policies and procedures governing:
(i) filling prescriptions and maintaining
drug supplies. The substitution of generic drugs for brand name drugs shall be
mandatory unless the prescription specifically states that the brand name drug
prescribed must be used;
(ii)
maximum intervals allowed for prescriptions of antibiotics; anticoagulants;
anti-inflammatory agents with a high liability for causing serious adverse
reactions; Schedule II, III, IV and V Controlled Substances prescribed for
stated administration intervals; Schedule II, III, IV and V Controlled
Substances prescribed for p.r.n. administration; steroids and hormones;
sulfonamides; and other medications. Such maximum intervals shall reflect New
York State Department of Health regulations;
(iii) a drug recall procedure that can be
readily implemented and includes provision for returning the following to the
pharmacy for proper disposition: all discontinued and outdated drugs and
containers with illegible or missing labels;
(iv) disposal of excess, contaminated, and
partial doses of parenteral controlled substances. Such disposal procedures
shall be in accordance with the New York State Public Health Laws, and the
Comprehensive Drug Abuse and Prevention Act of 1970; and
(v) control of syringes and
needles.
(2) a formulary
system approved by the medical director and pharmacist, and by other
appropriate specialty hospital staff. Copies of the program's formulary and of
the American Hospital Formulary Service shall be located and available, as
appropriate, at the specialty hospital;
(3) quality specifications established by the
pharmacist for drugs purchased. The pharmacy shall ensure that these
specifications are met. The compounding, packaging, labeling and dispensing of
drugs shall be done by the pharmacist or under his supervision, with proper
controls and records. Samples and investigational drugs shall not be used.
Whenever possible, drugs that require dosage measurement shall be dispensed by
the pharmacist in a form ready to be administered to the individual.
(viii) Physical therapy
services.
(a) Physical therapy services shall
be provided directly, through personal contact between physical therapists (see
section
680.13) and
individuals, and indirectly, through contact between therapists and other
persons involved with the individual.
(b) Physical therapy staff shall provide
treatment and training programs that are designed to:
(1) preserve and improve abilities for
independent functioning, such as range of motion, strength, tolerance and
coordination; and
(2) prevent,
insofar as possible, irreducible or progressive disabilities, through means
such as the use of orthotic and prosthetic appliances, assistive and adaptive
devices, positioning, behavior adaptation and sensory stimulation.
(c) The therapist shall function
closely with the individual's primary phycician, other health care specialists
and program staff.
(d) The
therapist shall ensure integration of these services with all other aspects of
the individual's program plan.
(ix) Psychology services.
(a) Psychology services shall be rendered:
(1) directly, through contact between
psychologists (see section
680.13 under
"Professional Staff") and individuals; and
(2) indirectly, through contact between
psychologists, other staff members providing services to the individuals and
their families.
(b)
Psychologists shall participate, when appropriate, in the continuing
interdisciplinary assessment of individuals for the purposes of planning,
implementation and monitoring of individual program plans.
(c) Psychologists shall participate in staff
training, program development and program evaluation.
(d) Psychologists shall design and
participate in therapies which assist individuals with orientation and
adjustment to their disabilities, as well as providing compensatory mechanisms
for their disabilities.
(x) Respiratory services.
(a) Respiratory therapy services shall be
available to individuals in need of such aid and shall include, but not be
limited to:
(1) routine treatment of chronic
lung disorders, including appropriate inhalation therapy;
(2) physical respiratory therapy, such as
postural drainage; and
(3)
mechanical ventilation.
(b) Respiratory therapy services shall be
delivered according to the prescription of the physician.
(c) The respiratory therapist shall function
closely with the individual's primary physician, other health care specialists
and program staff.
(d) Space,
equipment and supplies shall be adequate to provide efficient and effective
respiratory therapy.
(xi) Social services.
(a) Social services shall be provided
directly by or under the supervision of certified social workers (see section
680.13 under
"Professional Staff").
(b) Social
workers shall arrange for the use of other community resources, coordinate and
provide liaison between the individual and community resources, including the
day program, services of generic hospitals (see section
680.13), and
other generic health care settings (see section
680.13), nursing homes, home health agencies, community social agencies and other
service resources.
(c) Social
services, as part of an interdisciplinary spectrum of services, shall be
provided to the individuals through the use of social work methods directed
toward:
(1) facilitating the movement of each
individual to a less restrictive alternative placement within the time frames
specified prior to admission;
(2)
maximizing the social functioning of each individual;
(3) enhancing the coping capacity of staff
providing services and programs to the individual;
(4) enhancing the coping capacity of the
individual's family; and
(5)
asserting and safeguarding the human and civil rights of people with
developmental disabilities and their families and fostering the human dignity
and personal worth of each person.
(d) Social workers shall participate, when
appropriate, in the continuing interdisciplinary evaluation of individual
individuals for the purposes of implementation, monitoring and follow-up of
individual program plans.
(xii) Special medical services. The medical
director shall arrange for special medical services ordered by authorized
practitioners for individuals, by promptly:
(a) ensuring that such services as the
specialty hospital is able to provide directly are performed; and
(b) sending individuals to an approved agency
for services that the facility does not provide.
(xiii) Special diagnostic services. The
medical director shall arrange for special diagnostic services ordered by
authorized practitioners for individuals, by promptly:
(a) ensuring that such services as the
specialty hospital is able to provide directly are performed; and
(b) sending individuals to an approved agency
for services that the facility does not provide.
(xiv) Transportation services.
(a) The specialty hospital shall ensure the
provision of appropriate transportation of individuals to and from all other
sites of programs, services and activities. The facility shall provide
transportation if no other form of appropriate transportation is
available.
(b) Vehicles used shall
be appropriate to the age and condition of individuals so as to ensure their
comfort and safety.
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