Current through Register Vol. 46, No. 39, September 25, 2024
(a) The operator shall collect and maintain
such information, records or reports as determined by the department to be
necessary.
(b) The department or
its designee may examine the books and records of any facility to determine the
accuracy of the annual financial statement, or for any other reason deemed
appropriate by the department to effectuate the purposes of these regulations.
The Justice Center shall have access to any residential care facility within
its jurisdiction and adult care facilities in which a resident received mental
health services as described in section
487.7(d)(8)(iv),
(9)(ii), and (10) of this Part, and to
information, reports or records in such facility's possession as needed to
carry out the functions, powers and duties of the Justice Center, and shall
have such access related to the investigation of deaths concerning patients of
adult care facilities in which a resident who received mental health services
as described in section
487.7(d)(8)(iv),
(9)(ii), and (10) of this Part and mental
hygiene facilities who resided at such facilities at the time of their death or
were former residents of such facilities, and for which the Justice Center
determines that such information, report or record is necessary for the
completion of its investigation. The department and the Justice Center shall,
when required by law, or when so directed by the department or the Justice
Center and except as otherwise prohibited by law, be permitted to share
information obtained in their respective investigations of incidents.
(c)
Resident records.
(1) The operator shall maintain complete,
accurate and current records for each resident.
(2) These records shall be maintained in the
facility and shall be available for review and inspection by department staff
designees.
(3) Records shall be
maintained in a manner which assures resident privacy and accessibility to
staff to use in the provision of routine and emergency services.
(4) At a minimum, the operator shall
maintain:
(i) financial records for each
resident which contain, at a minimum, a copy of the current admission
agreement, documentation of the status of the resident's payment account,
personal fund account, and a current inventory of any personal property held in
custody for the resident by the operator;
(ii) personal records for each resident which
contain, at a minimum: personal data, including identification of the
resident's next of kin, family and sponsor; the name and address of the person
or persons to be contacted in the event of emergency; copies of the resident's
medical evaluations and other medical information, copies of the resident's
mental health evaluations, summaries of the social evaluations; and details of
referral and such other correspondence and papers as are available to document
the physical, mental and social status of the resident; and
(iii) records which are readily available to
food service staff and enable staff to plan for and accommodate prescribed
dietary regimens, allergies and individual food
preferences.
(d)
Facility records.
(1) The operator shall maintain complete,
accurate and current records which document operation and maintenance of the
facility in accord with applicable law and regulation.
(2) These records shall be maintained in the
facility, unless written authorization is given by the department for record
retention in another location, and shall be available for review and inspection
by department staff and designees.
(3) Records must be maintained in a manner
which assures individual residents' rights to confidentiality and privacy,
provided that confidential HIV-related information concerning residents must be
maintained in accordance with section
485.11(g)(9)-(15)
of this Title.
(4) Confidential
HIV-related information concerning employees, volunteers, applicants for
employment and prospective residents must be maintained in accordance with
section 485.11(g)(9)-(15)
of this Title.
(5) At a minimum,
the operator shall maintain:
(i) individual
resident records as stipulated in subdivision (c) of this section;
(ii) resident records stipulated elsewhere in
these regulations, including daily census reports and incident
reports;
(iii) a chronological
admission and discharge register, consisting of a listing of residents
registered in and discharged from such facility by name, age, sex of resident,
and place from or to which the resident is registered or discharged;
(iv) program records, including service
procedures, activities schedules, agreements with external service providers,
emergency plans and records of evacuation drills;
(v) food service records, including menus and
food purchase records;
(vi) records
of maintenance of the physical plant and environmental standards;
(vii) staff records, including personnel
procedures, job descriptions, staffing schedules and payment records;
(viii) certificates or reports issued by
local and other State jurisdictions related to the facility operations, on file
and readily accessible for department review, or posted, if required;
and
(ix) records documenting the
development, implementation and, at a minimum, the bi-annual updating of plans
for quality assurance activities for each area of facility operation. These
must include, at a minimum, the development and maintenance of performance
standards including infection control, measurement of adherence to such
standards and to applicable state and local laws and regulations,
identification of performance failures, design and implementation of corrective
action. Each plan must also include the creation of a quality improvement
committee that is charged with meeting periodically, at least once every six
months, to review summary findings from monitoring implementation of the
facility's plan, evaluating the effectiveness of corrective action policies,
and identifying trends and improvement activities. While reviewing facility
performance, the committee shall not examine personally identifiable resident
incidents. Such committee shall include the administrator or operator of the
facility, the resident council president or other resident representative, and
representatives from frontline employees from each area of
operation.
(6) The
records and reports required to be maintained by the operator pursuant to this
subdivision shall not be posted or otherwise made available to the
public.
(e)
Facility reports.
The operator shall submit to the department:
(1) Annual financial statement.
(i) The operator of an adult home or
residence shall file an Annual Financial Statement (DSS-2963)
with the department on or before the 15th of day of the sixth calendar month
after the close of its fiscal year. Such statement shall clearly set forth all
financial information pertaining to the operation of such facility in
accordance with generally accepted accounting principles, including but not
limited to revenues and expenses by categories during such fiscal year,
together with such other information as may be required by the department, and
shall, for all facilities with a capacity of 10 or more residents, be
accompanied by an opinion signed by an independent licensed accountant that
such financial statement represents the financial operations and position of
the facility.
(ii) The operator of
a not-for-profit adult home which submits a charitable organization annual
report to the Secretary of State or the residential health care facilities
annual report to the Department of Health may submit copies of those reports,
together with such other data as may be necessary to satisfy the requirement in
subparagraph (i) of this paragraph.
(iii) An operator shall maintain and make
available all such books and records as may be required by the department to
determine the accuracy of any and all information contained in the financial
report filed by the operator.
(2) A quarterly statistical information
report.
(3) For facilities with a
certified capacity of 80 beds or more in which twenty percent or more of the
resident population are persons with serious mental illness as defined in
section 487.2(c) of this
Part, a quarterly statistical information report which must:
(i) identify the quarter being reported
on;
(ii) contain a census report,
which shall include a roster of residents who are persons with serious mental
illness as defined in section
487.2(c) of this
Part;
(iii) for any residents
admitted during the quarter reported on, the prior residence, and for any
residents discharged during the quarter being reported on, the discharge
location; and
(iv) contain the
number of resident deaths which occurred during the quarter being reported
on.
(4) For facilities
with a certified capacity of 80 beds or more in which twenty percent or more of
the resident population are persons with serious mental illness as defined in
section 487.2(c) of this Part, including Transitional Adult Homes as defined in
section 487.13 of this Part, a monthly admissions report identifying all
persons admitted to the facility during the prior calendar month.
For the purpose of calculating the reporting threshold in
this subdivision, if the facility has ever reported an individual as having
Serious Mental Illness, such facility must continue to report that individual
as having Serious Mental Illness until the department or its designee has
conducted a mental health evaluation of that individual to confirm a change in
status, and communicates written approval to the facility to discontinue
reporting such individual as having Serious Mental Illness. Nothing in this
paragraph shall require the department, or its designee, to conduct an
independent mental health evaluation for an individual who resides in an adult
home that is not defined as a transitional adult home as of January 1,
2022.
(5) For all
facilities, a roster of all residents shall be submitted to the department on a
quarterly basis in the manner prescribed by the department.
(f)
Mandated forms.
The department mandates utilization of the following
forms:
(1)
Personal Data
Sheet (DSS-2949).
(2)
Daily Census Record (DSS-2900).
(3)
Incident Report
(DSS-3123).
(4)
Medical
Evaluation (DSS-3122).
(5)
Inventory of Resident Property (DSS-3027).
(6) The following personal allowance account
forms must be used unless prior written authorization for substitutions has
been given by the department:
(i)
Statement of Offering (DSS-2853).
(ii)
Personal Allowance
Summary (DSS-2855).
(iii)
Personal Allowance Ledger.
(7) Mental Health
Evaluation.
(g) The
operator shall post the following documents:
(1) the operating certificate;
(2) the inspection report for the most recent
complete or summary inspection, with any related follow-up inspection
reports;
(3) statement of rights of
residents;
(4) weekly
menus;
(5) monthly activities
schedules;
(6) evacuation
procedures;
(7) notice prohibiting
employee acceptance of remuneration, tips or gratuities;
(8) schedule of times residents may have
access to their personal allowance accounts; and
(9) procedures for presenting grievances and
recommendations.
(h)
Records retention.
(1) Records
required by the department, excepting financial records of the previous
operator, shall be retained in the facility upon change of operator.
(2) Records relating to an individual shall
be retained for three years after death or discharge of a resident.
(3) Program records, business records and
records relating to application or renewal for an operating certificate shall
be retained for seven years.
(i) Except as otherwise prohibited by law,
the operator of a facility, as defined in section
488
(4) of the Social Services Law and who is not
otherwise subject to article six of the Public Officers Law, shall make records
available for public inspection and copying to the extent required by
subdivision six of section
490 of the
Social Services Law and regulations of the Justice Center.
