New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES
Part 810 - Establishment, Incorporation and Certification Of Providers of Substance Use Disorder Services
Section 810.7 - Standards for approval of an application requiring full or administrative review

Universal Citation: 14 NY Comp Codes Rules and Regs § 810.7

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

(a) To approve a project requiring either full or administrative review, the Office must find the application meets all of the following:

(1) that there is a public need for the services at the time and place and under the circumstances proposed;

(2) that there are no facilities or services available which serve as alternatives or substitutes, for the services and facilities proposed;

(3) that there are no substantiated negative findings as to the character, competence and standing in the community of the applicant;

(4) that the available financial resources and the sources of future revenues are adequate to meet all necessary and proper capital and operating expenses;

(5) that services will be provided in compliance with applicable laws and regulations, including, but not limited to, the regulatory requirements of this Title;

(6) that ten percent of the owners or principals of the applicant have demonstrated, and can substantiate, prior substantial experience directly providing or managing substance use disorder treatment services, as determined by criteria established by the Office and will maintain such experience while Certified;

(7) that the owners or principals of the applicant have received a criminal history information review pursuant to the provisions of Part 805 of this Title, and the applicant has been subsequently approved by the office.

(b) In determining whether the requirements of subdivision (a) of this section are met, the office shall consider the extent to which:

(1) the services and facilities conform to local and statewide plans, including but not limited to plans for Medicaid managed care;

(2) existing similar services are able to meet or exceed regulatory compliance; and

(3) there exist any other matters determined to be in the public interest.

(1) A management level staff person is identified to be responsible for coordinating all requirements relating to diversity, equity, and inclusion, consistent with all rules and regulations issued by the Office;

(2) the services and facilities will meet the particular needs of the community to be served, based on a needs assessment of the catchment area to be serviced, including the identification of unserved and underserved marginalized communities, uninsured and underinsured persons, and is reflective of the cultural and linguistic needs of the community;

(3) the provider of services is affirmatively addressing opportunities to overcome systemic barriers to accessing care for the communities and persons identified as part of the needs assessment.

(d) If an application involves construction, the office may require the applicant to demonstrate, through the submission of detailed architectural schematic drawings, that the following requirements are met:

(1) that the proposed construction ensures patient confidentiality including gender neutral restroom facilities;

(2) that there is no more efficient architectural solution to the proposed construction, except that providers may include creation of gender neutral restroom facilities;

(3) that the proposed construction will not adversely affect the costs of providing services;

(4) that the proposed construction conforms to applicable Federal, State and local laws and regulations; and

(5) that the proposed construction ensures patient confidentiality.

(e) Criteria and procedures for approval of leases.

(1) If an applicant proposes to lease a facility in which all or part of the proposed services are to be provided, the lease agreement shall include, but is not limited to, the following language: "The landlord acknowledges that the rights of reentry into the premises as set forth in this lease do not confer on the landlord the authority to operate an addiction services program. The landlord agrees to give the New York State Office of Addiction Services and Supports at least thirty (30) day's notice by certified mail of the intent to re-enter the premises or to initiate dispossess proceedings and at least sixty (60) days notice of expiration of the lease."

(2) Lease terms must be for a term sufficient to ensure program continuity with an option to renew for an additional term of years. Longer terms may be required if financial support is provided for a capital project by the office. Month-to-month lease terms shall not be deemed sufficient.

(f) Amendment of an application.

Any amendment to an application, other than technical or minor amendment, that changes the application during the process of review to such an extent that it requires, in the opinion of the commissioner, a reinitiation of a full or administrative review in accordance with this Part must include a written explanation as to the reason for such amendments.

(g) Failure to notify of changes.

Failure to provide the office with information about changes in an application or to obtain prior approval when required by this section may constitute grounds for the denial of authorization to provide services and revocation, limitation or amendment of any operating certificate previously granted for that application.

(h) Withdrawal of an application by the applicant.

An application made to the office in accordance with this Part may be voluntarily withdrawn by written notice from the applicant at any time prior to the decision of the Commissioner.

(i) Criteria and procedures for approval of certificates of incorporation.

(1) Not-for-profit corporations. An entity incorporated or proposed to be incorporated under the Not-for-Profit Corporation Law shall provide the commissioner with a proposed certificate of incorporation or certificate of amendment that conforms with the requirements of the Not-for-Profit Corporation Law and the Mental Hygiene Law. The board of directors of a not-for-profit corporation shall:

(i) include qualified members, broadly representing the community, who have sufficient independence from senior management of such corporations and who will provide the board with expertise to oversee the agency's programmatic and fiscal operations, and any other criteria determined by the office;

(ii) the board shall include members from the community in which the services are to be provided;

(iii) board members shall avoid conflicts of interest, including but not limited to self dealings;

(iv) Reimbursement to board members shall be documented and shall be limited to their reasonable costs and expenses in a manner which ensures that the integrity of the not-for-profit corporation will not be compromised;

(v) no compensated employee or consultant of the corporation shall be a corporate director of such board; however, such employee or consultant of the corporation may be an ex officio corporate member without the right to vote;

(vi) family members of senior management of the not-for-profit corporation shall be prohibited from serving on the board unless it can be sufficiently demonstrated to the office that the independence of the board will not be compromised by such appointment;

(vii) board members shall review on a regular basis the not-for-profit's operation, including but not limited to the performance and compensation of senior executives, the financial operations of the provider of services and implementation of corrective actions to ensure compliance with applicable rules and regulations governing such provider;

(viii) There shall be members of the board that can demonstrate and substantiate prior substantial experience directly providing or managing addiction services and maintain such experience going forward, unless the corporation is an Article 28 facility co-licensed by the New York State Department of Health and defined in Article 28 of the Public Health Law.

(2) Business corporations. For purposes of this paragraph, the term business entity shall mean any entity incorporated or proposed to be incorporated or organized under the Business Corporation Law or the Limited Liability Company Law.

(i) If the business entity is an individual practitioner, partnership of practitioners, a professional service limited liability company, or a professional service corporation of practitioners licensed and currently registered by the New York State Education Department in one of the health professions which is authorized to provide addiction services, it is exempt from the requirement of needing an operating certificate from the office so long as all the following conditions are met:

(a) the business entity employs only persons licensed by the New York State Education Department in the same profession to provide professional services;

(b) the business entity practices under a name that does not indicate an intent, ability or willingness to operate an addiction program; and

(c) a professional service corporation, limited liability company and any stockholder or member thereof has obtained all required approvals from the New York State Education Department and the Department of State.

(ii) If the business entity is not an exempt entity under subparagraph (i) of this paragraph, then it shall provide the Commissioner with a proposed certificate of incorporation or certificate of amendment that conforms to the requirements of the Business Corporation Law and the Mental Hygiene Law.

(iii) Board of directors requirements. For all business entities not exempt under subparagraph (i) of this paragraph, the board of directors shall include members with a diversity of experience sufficient to ensure competent direction and control; and

(a) if any such board member is or has been an incorporator, board member, partner or stockholder in an entity which has operated a hospital, or any other type of residential facility certified by the State Department of Health or a residential facility for the developmentally disabled within the last 10 years, the name of each such facility and any interest such individual held or currently holds therein shall be reported to the commissioner;

(b) all stock or ownership certificates of a corporation shall contain a statement that no person shall own 10 percent or more of the stock of the corporation unless such person has been approved for ownership by the Commissioner. The stock or ownership certificate shall also contain a statement that any transfer, assignment or other disposition of 10 percent or more of the stock or of 10 percent or more of the voting rights there under must receive the prior approval of the Commissioner;

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