N.Y. Comp. Codes R. & Regs. tit. 14 § 582.5

Current through Register Vol. 46, No. 51, December 18, 2024

Section 582.5 - Organization and administration

(a) Organization.

(1) The governing body shall be responsible for the overall operation and management of the hospital.

(2) The governing body shall establish and maintain a current plan of organization for the hospital which clearly indicates lines of accountability, the nature of professional responsibility to be exercised according thereto, and the professional qualifications required.

(3) The governing body shall develop, and revise as necessary, written policies for the quantity, quality, scope, goals, objectives and evaluation of all programs, policies for the accomplishment of stated purposes, and personnel policies. Personnel policies shall prohibit discrimination on the basis of race or ethnicity, religion, color, creed, disability, sex, marital status, age, national origin, gender identity or sexual orientation. Such policies shall include but not be limited to:

(i) Policies governing affirmative action that are consistent with the affirmative action and equal employment opportunity obligations imposed by title VII of the Civil Rights Act, Federal Executive Order 11246, the Rehabilitation Act of 1973, section 504, as amended, and the Vietnam Era Veteran's Readjustment Act.

(ii) Personnel policies and procedures shall provide for verification of employment history, personal references, work record and qualifications. Such policies shall also provide for securing a signed sworn statement whether, to the best of their knowledge, the applicant has ever been convicted of a crime in this State or any other jurisdiction.

(iii) Written policies and procedures governing patient records that ensure confidentiality consistent with the Mental Hygiene Law, sections 33.13, 33.14 and 33.16, 45 C.F.R. parts 160 and 164 and which provide for appropriate retention of such records pursuant to this Part.

(iv) Written policies that ensure the protection of patients' rights. At a minimum these policies shall establish and describe a patient grievance procedure. The provider shall post a statement of patients' rights in a conspicuous location easily accessible to the public. The statement shall be provided in the individual's preferred language, and be accessible to the blind and visually impaired.

(4) The governing body shall establish written staff development and training policies which address orientation and ongoing staff development and training which shall include but not be limited to, behavioral management interventions, techniques and alternative methods of safely handling crisis situations, and safety and security procedures. In addition, in those hospitals serving children, staff training shall include the principles of child development and developmentally-appropriate interventions, family engagement, the laws and regulations governing child abuse reporting and the protection of children from child abuse and maltreatment. Such training in those hospitals serving children shall include preemployment orientation and continuing education.

(5) The governing body shall establish written volunteer policies and procedures. Such policies and procedures shall provide for screening of volunteers and verification of employment history, personal references, and work history; supervision of volunteers; training in accordance with paragraph (4) of this subdivision. Such policies shall also provide for securing a signed sworn statement whether, to the best of their knowledge, the volunteer has been convicted of a crime in this State or any other jurisdiction and shall include provisions implementing criminal history record checks in accordance with Part 550 of this Title.

(6) The governing body shall establish procedures to assure the health and safety of the individuals in the program and shall develop, implement, and regularly monitor clinical risk management programs including but not limited to reviews of the use of restraint and seclusion and treatment over objection, in order to protect the health and safety of individuals and enhance their quality of care.

(7) The governing body shall meet as often as necessary to properly execute is functions, and in no event less often than quarterly. Minutes of all official meetings of the governing body shall be maintained as permanent record of the decisions made in relation to the operation of the hospital.

(8) Ongoing direction and control of the program of the hospital shall be delegated by the governing body to a physician whose qualifications in psychiatry are appropriate to the program. For purposes of this Part, this person shall be known as the director.

(9) Administrative management of the hospital may be delegated by the governing body to an appropriately qualified administrator.

(b) Administration.

(1) The governing body shall cause to be made an annual written evaluation of the total program to assess effectiveness and efficiency and to indicate any required changes in policies or services of the hospital.

(2) The governing body shall cause to be made an annual audit of the financial condition and accounts of the hospital by a certified public accountant who is not a member of the governing body or an employee of the hospital.

(3) The governing body shall establish admission policies, including those pertaining to eligibility for service, and a description of available services which shall be written and made available to staff members, persons served and their families, cooperating agencies and the general public.

(i) All admission policies shall prohibit discrimination on the basis of race or ethnicity, religion, creed, sex, age, national origin, sexual orientation, gender identity, physical disability, previous hospitalization in a licensed or State-operated psychiatric facility or ability to pay fees, provided, however, nothing in this subparagraph shall be interpreted to prevent a facility from making admission or discharge decisions based upon the functional, clinical and behavioral needs of a n individual which are relevant to its program.

(ii) No facility shall deny care and treatment to, or otherwise discriminate against, persons who are Limited English Proficient, deaf or hard-of hearing, in accordance with section 527.4 of this Title.

(iii) A facility shall not deny access to a person who otherwise meets requisite admission criteria solely on the basis of multiple diagnoses or a diagnosis of HIV infection, other chronic medical comorbidity, history of suicide attempt, history of violence, criminal and juvenile justice system involvement, personality disorder, substance use disorder, or intellectual or developmental disability.

(4) The governing body shall cause to be procured and maintained for reference by the governing body and staff members an up-to-date copy of this Part and copies of any guideline instruction or information manuals or other communications as may be prescribed by the office.

(5) The governing body shall appoint a special review committee, including members of the professional clinical staff, which shall:

(i) develop a written special review plan subject to approval by the governing body and the office. This plan shall provide for review of all incidents in accordance with Part 524 of this Title and extra-risk procedures administered. Extra-risk procedures may include, but not be limited to, interventional therapies, experimental treatment modalities, and restraint or seclusion;

(ii) review and evaluate incidents and extra-risk procedures in accordance with Part 524 of this Title and the plan;

(iii) determine the facts in any incident reviewed, review ongoing practices and procedures in relation to such incidents and extra-risk procedures, and recommend changes in policies, practices or procedures which may be indicated;

(iv) include, either on a regular membership basis or by special arrangement as indicated, the participation of appropriately qualified and experienced physicians; and

(v) meet as often as necessary to properly execute its functions, and in no event less often than quarterly, keeping written minutes of its deliberations and submitting reports to the governing body as necessary.

(6) The governing body shall provide for the following in those hospitals which provide services to children:

(i) procedures for notification of the child's parent or guardian of alleged child abuse or maltreatment involving the child or other incidents as required by law, including but not limited to Mental Hygiene Law section 33.23 and 33.25; and

(ii) procedures for the proper reporting of all incidents of alleged child abuse or maltreatment as follows, in accordance with the Mental Hygiene Law and Part 524 of this Title:

(a) to the Statewide Central Register of Child Abuse and Maltreatment immediately;

(b) to the appropriate Office of Mental Health field office, within two weeks, using forms designated by the Office of Mental Health;

(c) to the Justice Center; and

(d) to the Mental Hygiene Legal Service within the next working day.

(7) The governing body shall cause to be written, made known to all employees and maintain current a plan for safeguarding all individuals in the event of a major natural disaster or civil disturbance.

(8) The governing body shall require staff of the facility to participate with the local governmental unit in local planning processes as required by sections 41.05(e) and 41.16 of the Mental Hygiene Law. Such participation shall be documented in the approved local services or unified services plan of each local governmental unit served by the facility. At a minimum, facility participation shall include:

(i) provision of budgeting and planning data as requested by the local governmental unit;

(ii) identification of the population being served by the facility;

(iii) identification of the geographic area being served by the facility;

(iv) description of the facility's relationship to other providers of services who serve the same geographic area, including, but not limited to, written agreements to ensure expeditious access to programs by persons who need them. At a minimum, these agreements shall provide a process for prompt referral, evaluation, and, as necessary, admission to cooperating programs; specify mechanisms for coordinated development of service plans for individuals being served by more than one program; and provide a mechanism for sharing information about individuals being served; and

(v) attendance at planning meetings as may reasonably be required by the local governmental unit.

(c) Education program.

(1) If any children of legal school age are served, an appropriate instructional program approved by the New York State Education Department shall be made available to them by the hospital.

(2) The treatment program in those hospitals which provide services to children shall include the means for providing instruction to individuals under the age of 18, and, when required pursuant to an Individualized Education Plan, to certain individuals over the age of 18, consistent with their age, needs and clinical condition, as well as the needs and circumstances within the facility or program, in techniques and procedures which will enable such individuals to protect themselves from abuse and maltreatment.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 582.5

Amended New York State Register December 18, 2024/Volume XLVI, Issue 51, eff. 12/18/2024