N.Y. Comp. Codes R. & Regs. tit. 14 § 584.19

Current through Register Vol. 46, No. 45, November 2, 2024

Section 584.19 - Premises

The following standards shall apply to the physical plant or physical facilities of a residential treatment facility:

(a)Construction standards.

(1) Facilities shall be and remain in compliance with applicable sections of the 2010 edition of the Guidelines for Design and Construction of Health Care Facilities published by the Facility Guidelines Institute with assistance from the United States Department of Health and Human Services, provided, however, that this provision shall apply only to facilities which undertake construction or major renovations on or after the effective date of this paragraph. Facilities which have been constructed or have completed major renovations prior to that date in accordance with Part 77 of this Title shall be deemed to be in compliance with this paragraph.

(2) The design of the facility shall meet the requirements of the applicable sections of the Americans with Disabilities Act and the ADA Standards for Accessible Design and implementing regulations found at 28 CFR Parts 35 and 36.

(3) Waivers of up to 10 percent of the square footage for bedroom space will be considered by the Office of Mental Health upon application from the agency.

(b)Fire safety.

(1) All buildings containing sleeping quarters for children or youth shall be protected by a fire detection system or a sprinkler system installed throughout. All buildings used by children or youth, but not containing sleeping quarters for them shall be protected throughout by a sprinkler system, fire detection system, or manually operated fire alarm system. All areas of high fire hazard in all buildings used by children or youth, whether or not they contain sleeping quarters for them, shall be protected by a sprinkler system and be separated from other areas by substantial, fire-resistant construction.

(2) All fire protection systems and equipment shall be installed according to recommendations of the National Fire Protection Association, and shall be inspected at least quarterly by a person who is expert in the installation, operation and inspection of such systems and equipment. A record of these inspections shall be kept by the facility. Facilities shall immediately correct any deficiency noted during inspection and testing.

(3) Each residential treatment facility shall request an annual inspection of each building used by children or youth and its fire protection equipment by local fire authorities and/or the residential treatment facility's fire and casualty insurance carrier, who shall be requested to give the facility a written report of their findings. This report shall be kept on file on the premises until replaced by the next annual report of inspection. The residential treatment facility shall be responsible for correcting any fire hazards called to its attention throughout such inspection, and for keeping a written record on file of the action taken and when.

(4) Fire safety training. Facilities shall provide fire safety training to all staff. Newly hired staff shall be trained upon hiring and existing staff trained at least annually. Fire safety training shall include, but not be limited to:

(i) fire prevention;

(ii) discovering a fire;

(iii) operating the fire alarm system;

(iv) use of firefighting equipment; and

(v) building evacuation including fire drill protocols which identify staff roles.

(5) Fire drills. On a quarterly basis, facilities shall conduct fire drills in each building that houses patients. At least 50 percent of such drills must be unannounced.

(i) For each quarter, each such building must have a minimum of one practice fire drill per shift.

(ii) Facilities must direct all staff members on all shifts to participate in fire drills.

(iii) Drills shall be scheduled at varying times during a shift.

(iv) Use of alternative exits shall be practiced during fire drills.

(v) Whenever practicable, drills shall involve the actual evacuation of patients to an assembly point as specified in the evacuation plan. Consistent with the Life Safety Code standards, in larger facilities that are subdivided into separate smoke compartments to limit the spread of fire and smoke and move patients without leaving the building or changing floors, evacuation may include the relocation of patients to such compartments.

(vi) Properly documented actual or false alarms may be used for up to 50 percent of required drills for each shift, if all elements of the facility's fire plan were implemented.

(vii) Facilities must document and maintain records regarding fire drill performance which include an evaluation of the results of each fire drill, any corrective action that may be required, and completion of steps taken to achieve such corrective action.

(c)Prohibited items.

(1) The following items are prohibited from use within the structure:

(i) devices for heating, cooking, or lighting which use kerosene, gasoline, wood, or alcohol;

(ii) portable electric hot plates; and

(iii) barbeque grills. The use of barbeque grills is permissible when used outside of buildings but not within 30 feet of any structure including overhangs, canopies or awnings.

(2) The use of portable space heating devices is prohibited in patient sleeping and treatment areas of the facility, as well as in the facility administration offices. Use of a portable space heating device in any other building on the grounds of a facility shall be in accordance with guidelines of the office, provided that:

(i) the unit has an Underwriters Laboratories (UL) certification mark;

(ii) the unit is thermostat-controlled and has a tip-over cutoff device;

(iii) the unit is plugged directly into a wall receptacle (no extension cords);

(iv) combustible materials are not stored around or near the unit;

(v) at least a three-foot clearance around the unit is maintained; and

(vi) the unit is not placed underneath a desk, furniture or other combustible items.

(d)Smoking. Facilities must not permit smoking within any buildings on the grounds of the facility. If smoking is permitted on the grounds of the facility, it shall be contained to a specific location(s) equipped with an approved non-combustible ash receptacle. Smoking shall not be permitted within 30 feet of any building structure, including overhangs, canopies or awnings.

(e)Medication storage. If medications are stored on the premises of the residential treatment facility, the residential treatment facility shall provide for controlled access maintenance of supplies in accordance with all applicable Federal and State laws and regulations.

(1) There shall be a single medication storage area within a single unit of the residential treatment facility.

(2) Medication shall be stored in a sturdy metal or sturdy wooden cabinet without glazing which shall be locked except when medication is needed. Controlled substances shall be stored in double-locked cabinets as follows:

(i) Schedule I, II, III and IV controlled substances shall be kept in stationary, double-locked cabinets. Both inner and outer cabinets shall have key-locked doors with separate keys. Spring locks or combination dial locks are not acceptable.

(ii) Schedule V controlled substances shall be stored in a stationary, secure, locked cabinet of substantial construction.

(3) Refrigerators used for storage of medication shall not be used for the storage of food or beverages unless the medication is stored in separate locked compartment within the refrigerator.

(f) Each living unit shall provide for the comfort and privacy of the residents and shall be limited in size to 14 residents. The premises shall be reasonably maintained to ensure access to services by all residents.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 584.19

Amended New York State Register July 3, 2024/Volume XLVI, Issue 27, eff. 7/3/2024