New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIV - Office for People With Developmental Disabilities
Part 690 - Day Treatment Services to Persons with Developmental Disabilities
Section 690.5 - Governance, administration, and operations - Principles of compliance

(i) Ensure that the facility has a plan for a management and fiscal audit, and that such audit is conducted at least annually. This audit is to ensure that the facility complies with State and Federal laws and regulations and the facility's policies and procedures; and that it is operating in a fiscally responsible manner. Results of the evaluation are to be in writing, including recommendations, plans of correction and timeframes, and the names(s) of the party(ies) responsible for those corrections. The results of the audit shall be available on request for review by OPWDD.

(ii) Delegate the continuous day-to-day direction and control of the facility to a specific staff member who is referred to in this Part as the administrator (see glossary).

(iii) Ensure that the facility, and its associated satellite(s), have sufficient qualified professionals (see glossary) and direct care 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. This includes setting forth procedures (available to and periodically reviewed with staff) to address and ensure adequate and appropriate coverage in the event of absenteeism (for any reason) by administrative, clinical, and/or direct care personnel.

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

(ii) treatment coordination;

(iii) staffing, qualifications, and personnel policies;

(iv) administration;

(v) admission (see glossary) and discharge criteria;

(vi) quality assurance and quality improvement, including program and individual service evaluation;

(vii) standing committees;

(viii) program goals;

(ix) recordkeeping and reporting; and

(x) budgeting and expenditure controls.

(i) Steps to follow in the event of any unusual occurrence, including serious illness, accident, impending death or death. Such steps would include, as appropriate, notification of the correspondent, the residence, the medical examiner. (If an autopsy is performed on a person receiving day treatment services, it shall be performed by an impartial qualified physician who is not employed by the facility).

(ii) 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 persons, severe weather, power outages, fires, floods, bomb threats, strikes 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.

(i) 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, parents and/or advocates, and other relevant service providers.

(ii) The plan shall be subject to OPWDD review and approval as part of the process for issuing a new operating certificate or the facility's first certification subsequent to the effective date of this Part.

(i) the appropriateness of the admissions to the facility;

(ii) the appropriateness of the services provided relative to the presenting and/or current needs of persons admitted; and

(iii) the appropriateness of continuing a person's current level of participation at the day treatment facility.

(i) If the facility serves 50 or more full-time persons on a daily basis, there shall be a full-time administrator. If, however, the administrator is also the physician responsible for the program's medical services, there shall be a full-time assistant administrator (see glossary) on the staff of the facility.

(ii) If the facility serves fewer than 50 full-time persons on a daily basis, there may be an administrator who works on a part-time basis. However, employment may not be less than half-time. In the instances where the administrator is part-time and/or is not assigned on-site, a QIDP shall be designated to be responsible for the day-to-day- administrative direction of the facility when the administrator is absent. If the administrator devotes less than half-time as administrator because he or she is also the physician responsible for the facility's medical services, there shall be a full-time assistant administrator assigned to the facility.

(i) the continuous direction and day-to-day control of the facility;

(ii) designating a QIDP staff member to be responsible for the administrative direction of the facility at all times when the administrator and/or assistant administrator are absent;

(iii) maintaining a current table of organization which shows the services of the facility, the administrative personnel in charge of the services and their lines of authority, responsibility and communication. This table of organization shall identify the party(ies) and/or agencies providing services to admitted persons on a contractual or agreement basis, including staff shared with another provider of service, if any;

(iv) developing working relationships with other providers of service with the object of ensuring, to the greatest extent possible, that opportunities exist in the community for movement to more appropriate program/service settings;

(v) ensuring that the services meet the physical, social and developmental needs of all persons attending the facility, that there is adequate protection of each person's health, safety, comfort, well-being, and civil, human and legal rights and that selection takes account of the person's preferences;

(vi) ensuring that there is a standing committee, or comparable mechanism, to address the issue of infection control. The committee shall maintain minutes of its deliberations including recommendations made and documentation of follow-up actions;

(vii) establishing policies concerning the day-to-day operation of the facility and the well-being of the person's served, in conformance with the philosophy and goals established by the agency's governing body. In accordance with agency administrative practices, the administrator shall ensure the governing body is aware of these policies;

(viii) ensuring that policies and procedures required by this Part are kept up-to-date and that the facility is in compliance with the requirements therein;

(ix) ensuring that the governing body is informed of the regulations governing the operation of the day treatment facility and receives all audit reports of the facility's compliance with this Part;

(x) ensuring that each person to be admitted and his/her correspondent is informed orally and in writing prior to his or her admission, of all services available, personal items provided by the facility, and the financial charges which may be incurred by him or her for these services:

(xi) making arrangements or preparations for persons to obtain additional services needed through other agencies at locations that are accessible to the person, regardless of handicap;

(xii) ensuring that arrangements are made for the provision of appropriate follow-up services pursuant to a discharge plan to persons who leave the program;

(xiii) keeping records as follows:

(xiv) ensuring the means whereby staff, persons and their correspondents may communicate ideas and concerns to the facility's administration without fear of penalty; and

(xv) the administrator shall maintain or cause to be maintained the following records of facility operations:

(i) ensuring that services provided by the facility to appropriately admitted persons are necessary to diagnose, treat, correct or habilitate conditions associated with the person's developmental disability;

(ii) reviewing each person's treatment plan or any substantial revisions within 30 days of its implementation, and indicating by signature that said treatment plan (or its substantial revision) is appropriate and not medically contraindicated;

(iii) facilitating, where appropriate, contact with the person's primary physician or health care provider;

(iv) ensuring that staff of the day treatment facility responsible for planning and/or delivering services are aware of any medical conditions or needs of the person and which are then accounted for, as appropriate, in the person's treatment plan;

(v) providing input at least annually to the interdisciplinary team as to the person's continuing need to receive day treatment services; and

(vi) maintaining the general health conditions of the facility and encouraging appropriate health promotion activities.

(i) If a person manifests a diagnosed medical condition necessitating individual attention by health care staff (see glossary), he or she may be admitted to a day treatment facility if that required period of individualized medical attention is less than three hours, and the facility can meet that person's medical needs.

(ii) Only those persons able to participate in activities at a site other than where they reside, shall be admitted.

(iii) Admission to and participation in a day treatment facility shall be based on a finding of significant deficiency in adaptive behavior (see glossary) or a self-care deficit(s) with or without related physical handicaps. This shall be determined by the interdisciplinary treatment team comprehensive assessment, and documented in a format acceptable to the commissioner. This form shall include specific criteria of impaired functioning.

(i) The person shall participate (unless the person is a capable adult and chooses not to participate), and the person's correspondent shall be invited to actively participate in the development of the individual program plan, unless the person is a capable adult who objects to such correspondents' participation.

(ii) The person shall be given the opportunity to invite additional parties of his/her choice to participate in the program planning process. The facility shall make reasonable efforts for said invitees to actually participate.

(iii) If no correspondent is available, and if the person does not have the capacity himself/herself to knowledgeably select an outside party to participate in the program planning process, an advocate (see glossary) shall be appointed who shall be invited to actively participate.

(iv) The coordinator at the person's residential facility, if applicable, or case manager shall also be invited to attend and participate in all interdisciplinary treatment team meetings.

(i) review current assessments and/or an existing individual program plan, if available. Assessments or plans developed within twelve months by another agency or certified facility prior to enrollment shall be considered acceptable, based on review and approval by the interdisciplinary treatment team; and

(ii) in the absence of current and acceptable assessments and/or an individual program plan, conduct a preliminary screening of the person.

(i) The administrator shall review the material submitted and make the final decision to admit a person, in accordance with the facility's admission policies and procedures.

(ii) Upon making the decision to admit a person, the administrator shall:

(iii) Within the 21 working days after the date of admission, the following shall have completed:

(i) A comprehensive functional assessment which addresses the persons capacities and capabilities in the areas of communication, mobility, learning, independent living, self-care, health care and self-direction. The comprehensive functional assessment shall:

(ii) Treatment plans for a coordinated program of individually designed activities, experiences and services necessary to achieve individual program objectives written in the form of outcomes (see glossary). These plans shall contain, as appropriate, specific medical prescriptions or written direction (i.e., interventions, (see glossary). These plans shall contain, as appropriate, specific medical prescriptions or written direction (i.e., interventions, methodologies or strategies) from the interdisciplinary treatment team for all specified services. Such services, interventions, and methodologies shall be described in terms sufficiently clear to be understood by all parties participating in the implementation of the individual program plan.

(i) independence - the person has opportunities to develop capacities that lessen his/her dependence;

(ii) inclusion - the person has opportunities to engage in experiences and activities with those who are not disabled;

(iii) individualization - the person's self-esteem is developed by ensuring respect, by giving him/her meaningful choices, and by providing services in terms of his/her unique and valued individuality; and

(iv) productivity - the person is provided opportunities to make an increasingly meaningful contribution to his/her living and community environment.

(i) The interdisciplinary treatment team is responsible for reviewing and evaluating each person's individual program plan and developmental progress.

(ii) At least annually, the interdisciplinary treatment team shall meet to review and evaluate each person's individual program plan and developmental progress.

(iii) If the physician is not present, a registered nurse must attend at least the annual review (and any other interdisciplinary treatment team meetings) where it is necessary to interpret the medical assessment and integrate the person's identified health care needs into the individual program plan.

(iv) The physician shall review and sign all reviews for those persons who are self-injurious, require daily individual attention from health care staff, or for whom a physician has determined that there is the need for a physician's review and sign-off due to medication regimen, physical condition, etc.

(i) a change in the person's status;

(ii) the achievement of an identified objective for which the day treatment facility has responsibility;

(iii) a need for a change in the person's overall individual program plan;

(iv) differences in professional judgment concerning the services, activities or interventions to be provided by the respective facilities need to be resolved; or

(v) new assessment or other information becomes available.

(i) orientation for all new employees and all volunteers, including interns and students assigned for formal work experience, to acquaint them with the philosophy, organization, program practices and goals of the agency/facility as well as emergency and first aid procedures. Orientation shall also include familiarization of staff with appropriate laws, regulations, policies and procedures;

(ii) periodic in-service training to update and improve the skills of all employees;

(iii) intensive and ongoing in-service training for employees who have not achieved the desired level of competence;

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

(v) routine and ongoing direct care staff training in the skills and knowledge (including first aid and CPR in accordance with agency policies and procedures) necessary to provide appropriate services to admitted persons.

(i) There shall be a sufficient number of qualified professionals on duty at all times that people are receiving services at the facility. The ratio between persons served at the facility and qualified professional staff, and direct care staff, shall be adequate to meet the individualized needs of each person, as identified by his/her comprehensive functional assessment.

(ii) At least 25 percent of all full-time equivalent qualified professional staff shall meet the standards of QIDP, as defined in section 690.99 of this Part, under "professional staff". The administrator may be counted for that portion of his or her time directly related to program issues (e.g., program development, supervision of service delivery, advocacy for persons in the program, policy and procedure development relating to service delivery). Time spent by the facility administrator in dealing with administrative and support matters is not to be counted in meeting the QIDP percentage requirement.

(iii) All allowable services shall be directly supervised by a QIDP or a qualified professional as defined in section 690.99 of this Part under "professional staff".