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 680.8 - Staffing

Universal Citation: 14 NY Comp Codes Rules and Regs § 680.8

Current through Register Vol. 46, No. 52, December 24, 2024

(a) A description of and rationale for the specialty hospital's staffing pattern including both mandatory and selective services shall be submitted as part of the application for certification. This description shall specify for each service the programs to be offered and the number of individuals to be served by each staff member. Any changes in the staffing pattern, job descriptions and/or minimum qualifications of the staff must receive the prior approval of OPWDD.

(b) There shall be qualified staff on duty during all hours of each day in sufficient numbers to carry out the policies, responsibilities and programs of the specialty hospital, and to maintain the premises in a safe and sanitary condition. A staff of sufficient size shall be employed so that the specialty hospital does not depend on individuals or volunteers for services. However, interns and students assigned for formal work experience, and volunteers who are registered and have formal duty assignments are encouraged to participate in the program, but are not to be used as substitutes for the staff.

(1) The administrator of the specialty hospital shall have the following qualifications:
(i) a degree of doctor of medicine or a master's degree or its equivalent in hospital administration, public health, science, administrative medicine or business administration when granted for a program in hospital administration, from a college or university approved by the New York State Education Department or whose program is approved by the Association of University Programs of Hospital Administration. Such person shall have a minimum of two years as the administrator, associate or assistant administrator of an accredited hospital or in health service administration acceptable to the commissioner;

(ii) a degree as a registered nurse with a minimum of three years experience as an administrator, associate or assistant administrator of an accredited hospital, or in health services administration acceptable to the commissioner;

(iii) a bachelor's degree from a college or university approved by the Education Department and has served a minimum of five years as an administrator, associate or assistant administrator in an accredited hospital, or in health services administration acceptable to the commissioner;

(iv) is, or has been, prior to January 1, 1968, the administrator of a hospital, or has served a minimum of seven years as an associate or assistant administrator of a hospital with a valid hospital operating certificate; or, prior to February 1, 1966, the administrator of a hospital, or has served a minimum of seven years as an associate or assistant administrator of a hospital which would meet the standards for hospital certification; and

(v) a minimum of two years experience with programs for individuals with developmental disabilities, one of which must be in a supervisory capacity.

(2) The administrator of the specialty hospital shall ensure that there is a qualified physician to serve as medical director of the specialty hospital. This physician shall be a staff member and shall direct and supervise the health and medical care of the individuals and maintain the general health conditions and practices of the specialty hospital.

(3) The administrator of the specialty hospital shall appoint an individual as program director to have overall responsibility for the developmental programming services at the facility. Such person shall, at a minimum, meet the qualifications of professional staff in their respective discipline.

(4) The administrator shall continuously employ an adequate number of appropriately qualified staff to carry out the program of prevention, diagnosis, treatment, habilitation and rehabilitation effectively. A written rationale for the staffing pattern utilized shall be prepared. If the specialty hospital is a unit of a general hospital, then this rationale must clearly specify any regular use of personnel whose primary duty assignments are elsewhere in the general hospital.
(i) The medical director and all staff physicians shall be currently registered and licensed to practice medicine in the State of New York; their qualifications shall be reported to OPWDD at the time of their employment.

(ii) The specialty hospital shall not permit the physicians in training to perform a service for which a license is required by the State of New York except as a part of an approved training program and/or unless authorized on a temporary certificate to practice medicine at the hospital. Such physicians in training or on a temporary permit are to be under the direct control and supervision of a currently registered and licensed physician.
(a) A training program, to be approved, must be accredited by the Council on Medical Education of the American Medical Association, the appropriate specialty boards or any other recognized approval body based on standards acceptable to OPWDD.

(b) With respect to the care of recipients of Federal health insurance and medical assistance only, training programs must comply with the requirements of applicable rules and regulations of the Secretary of Health, Education and Welfare pertaining to resident, intern and medical student training programs enacted to the Health Insurance for the Aged Act.

(iii) All direct service, other than in an emergency, provided by interns, house officers, residents or physicians with equivalent titles must be provided as specified in paragraph (ii) of this subdivision or must be provided by a physician currently registered and licensed to practice in New York State.

(iv) The nursing service shall be under the direction of a professional nurse currently registered and licensed to practice in the State of New York and experienced in the care of individuals with developmental disabilities and in the administration of nursing services.

(v) All staff members providing services as members of professions, the practice of which is by law required to be licensed, certified or registered shall file documentation of compliance with the governing body; this documentation shall be retained on file and made available to OPWDD upon request.

(vi) All staff members providing services as members of professions, the practice of which does not by law require licensure, certification or registration shall file documentation of their training and experience with the governing body. This documentation shall be retained on file and made available to OPWDD upon request.

(vii) All other program staff shall have qualifications appropriate to their assigned responsibilities as set forth in written policies of the governing body and shall be subject to appropriate professional staff supervision.

(5) There shall be at least one licensed physiatrist on the staff of the specialty hospital who is present at the specialty hospital at least a portion of five working days per week and visits at least weekly all individuals requiring physiatric services.

(c) The specialty hospital shall employ and assign to each individual living unit a sufficient number of appropriately qualified and trained personnel to provide health care services and self-care services. Staffing for each living unit shall be based on the severity of disabilities of all individuals.

(1) The required number of qualified physicians on duty or on call shall be as follows:
(i) if the number of individuals is less than 125, one physician on duty at all times shall be required;

(ii) if the number of individuals is less than 200, but greater than 125, then one physician shall be on duty at all times and one physician shall be on call though not necessarily on site;

(iii) if the number of individuals exceeds 200, but is less than 225, two physicians shall be on duty at all times; and

(iv) if the number of individuals is greater than 225, the number of physicians on duty at all times shall be determined by the commissioner.

(2) There shall be on duty to provide nursing services during the first and second shift one registered nurse for every 20 individuals; during the third shift, through the hours when individuals are sleeping, there shall be on duty one registered professional nurse for every 30 individuals. The calculation of this ratio shall exclude nurses who serve as supervisors.

(3) There shall be at least one qualified dietitian to direct nutrition services.

(4) There shall be least one therapeutic recreation therapist (see section 680.13 of this Part under "Professional Staff") or leisure time specialist for every 60 individuals. These staff members shall work only during afternoon and evening hours except for weekends and holidays when they shall be available during the full span of the majority of individuals' waking hours.

(5) The specialty hospital shall employ and maintain sufficient direct care staff to ensure that the following numbers shall be present and on duty:
(i) during the hours of the day and evening when individuals are awake, there shall be one staff member for every four individuals; and

(ii) during sleeping hours there shall be one staff member for every 12 individuals.

(6) All supervisors of direct care staff shall be registered nurses, licensed practical nurses (see section 680.13 under "Professional Staff"), or qualified professionals from other clinical professions.

(7) The ratio of qualified professional staff to individuals shall be at least 1:3 within both mandatory and selective services.

(8) The administrator of the specialty hospital shall ensure that a minimum of 25 percent of the full-time equivalent staff shall meet the qualifications of professional staff.

(9) There shall be a qualified intellectual disabilities professional (QIPD) who is responsible for supervising the implementation of each individual's individual program plan, integrating the various services received by each individual, recording each individual's progress and initiating periodic review of each individual program plan as stipulated by this regulation. All professionals assigned this responsibility shall have it clearly identified in their job descriptions with the number of hours allocated to this task.

(d) The following professional staff shall be available full time either as employees of the specialty hospital or through written contract with another agency:

(1) communications therapist(s):
(i) at least one audiologist; and

(ii) at least one speech pathologist for every 20 individuals requiring communication services.

(2) at least one dental hygienist;

(3) at least one developmental specialist (see section 680.13 under "Professional Staff") for every six individuals requiring educational services;

(4) at least one occupational therapist for every 20 individuals requiring occupational therapy;

(5) a specialist in orthotics (see section 680.13 under "Other Staff") who shall have the necessary resources in available staff, equipment and funds to design, construct, modify and repair adaptive equipment to meet the needs of individuals;

(6) a registered pharmacist;

(7) at least one physical therapist for every 20 individuals requiring physical therapy;

(8) at least one certified psychologist for all individuals requiring psychological services. Additional master's level psychologists may be used under the supervision of a certified psychologist at a ratio of 1:50 for individuals requiring psychological services;

(9) at least one social worker for every 40 individuals;

(10) the specialty hospital shall employ sufficient mid-level supervisors (see section 680.13) to ensure that there will be one such person present and on duty for each 24 individuals on both the day and evening shifts, and one such person present and on duty for each 48 individuals during the night shift;

(11) personnel and vehicles to transport individuals comfortably and safely; and

(12) if shortages of personnel exist in a particular clinical discipline for programs and services offered by the specialty hospital, and the specialty hospital has made a good faith effort to recruit replacements, OPWDD shall assist the hospital in recruiting and hiring of personnel when individuals in the facility demonstrate the need for this clinical expertise.

(e) The specialty hospital shall employ sufficient qualified staff and support personnel to accurately process, check, index, file and retrieve records and to record data promptly.

(1) The specialty hospital shall employ or contract for an adequate housekeeping staff to meet the housekeeping needs of the facility.

(2) The specialty hospital shall employ or contract for an adequate maintenance and engineering staff to provide for a preventive and emergency maintenance program.

(3) The specialty hospital shall employ a sufficient number of trained and experienced personnel to perform purchase, supply and property control functions.

(f) There shall be a staff training program provided to all employees that includes:

(1) orientation for all new employees, volunteers and interns to acquaint them with the philosophy, organization, program practices and goals of the facility and emergency and first-aid procedures;

(2) periodic (at least semi-annual) in-service training to update and improve the skills of all employees in addition to intensive and continuous in-service training for employees who have not achieved the desired level of competence in accordance with specified job performance criteria;

(3) supervisory and management training for all employees in or candidates for supervisory positions;

(4) direct care staff shall be trained in the following areas:
(i) developmental disabilities;

(ii) positioning and handling individuals;

(iii) proper feeding techniques;

(iv) detecting signs of illness and dysfunction that warrant medical or nursing intervention;

(v) basic skills required to meet the health needs and problems of the individuals; and

(vi) first aid for accident or illness.

(5) records shall be maintained which document the names of staff participating in the orientation and in-service programs, and the content and frequency of these programs; and

(6) if a specialty hospital lacks sufficient resources to conduct an in-service training program, it shall make arrangements with another appropriate community resource or training facility to provide such training.

(g) All professional program staff shall spend a majority of their working hours in direct interaction with and observation of individuals and staff in areas where programs are taking place. Emphasis shall also be placed on training and supervision of staff occurring through direct interaction rather than in settings where individuals are not present.

(1) Interdisciplinary team meetings where individuals and/or the families of individuals are present may be considered as a portion of time spent in direct interaction with the individual.

(2) Every effort shall be made by professional staff to be actively engaged with individuals during the hours individuals are scheduled for active programming. Whenever possible, meetings, report writing and other administrative tasks shall take place during the hours when individuals are not scheduled for active programming.

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