N.Y. Comp. Codes R. & Regs. tit. 14 § 584.6

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

Section 584.6 - Organization and administration

(a) The provider of services shall identify the individuals who have overall responsibility for the operation of the residential treatment facility. These individuals shall be known as the governing body. No individual shall serve as both a member of the governing body and of the paid staff of the residential treatment facility without the prior approval of the Office of Mental Health.

(b) The provider of services shall assure that the residential treatment facility has space, programs, staff and policies and procedures that are separately identifiable from any other programs which may be operated by the provider of services.

(c) The governing body shall meet on a regular basis, in no event less often than quarterly, and shall maintain written minutes of all meetings as a permanent record of the decisions made in relation to the operation of the residential treatment facility. The minutes shall be reviewed and approved by the governing body.

(d) The governing body shall approve a written plan or plans that, at a minimum, address the following aspects of the operation of the residential treatment facility:

(1) the goals and objectives of the residential treatment facility, including the admission and discharge criteria and a statement of the involvement of the family;

(2) the plan of organization that clearly indicates lines of responsibility;

(3) a written plan for services and staff composition which:

(i) includes the qualifications and duties of each staff position by title, and addresses all essential aspects of the operation of the residential treatment facility including clinical, administration, fiscal, clerical, housekeeping, maintenance, dietetic, and recordkeeping and reporting functions; and

(ii) specifies all services available through the residential treatment facility including the treatment program and environment;

(4) the written quality assurance plan; and

(5) the written utilization review plan.

(e) The governing body shall approve written policies and procedures of the residential treatment facility, including but not limited to:

(1) Admission, transfer, continued stay and discharge policies and procedures.

(2) 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, color, creed, disability, sex, gender identity, marital status, age, national origin, sexual orientation, military status, domestic violence victim status, disability, pregnancy-related condition, predisposing genetic characteristics, prior arrest or conviction record or familial status. Personnel policies and procedures shall provide for verification of employment history, personal references, work record and qualifications, as well as requesting the Justice Center for the Protection of Persons with Special Needs to perform criminal history record checks in accordance with Part 550 of this Title.

(3) Staff training and development policies and procedures. Such policies and procedures shall address preemployment orientation, ongoing staff development and training which shall include child or youth abuse prevention and identification, safety and security procedures, the principles of child or youth development, use of physical intervention, techniques of group and child or youth management, the laws and regulations governing the protection of children from child abuse and maltreatment.

(4) 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 (3) of this subdivision. Such policies shall also provide for requesting the Justice Center for the Protection of Persons with Special Needs to perform criminal history record checks in accordance with Part 550 of this Title.

(5) Prescription and administration of medication policies and procedures. Such policies and procedures shall be consistent with applicable Federal and State laws and regulations.

(6) Case record policies and procedures. Such policies and procedures shall ensure confidentiality of patient records in accordance with the Mental Hygiene Law and shall ensure appropriate retention of case records.

(f) The governing body shall review the written plan or plans and policies and procedures required pursuant to subdivisions (d) and (e) of this section at least annually and shall make appropriate amendments or revisions.

(g) The governing body may delegate responsibility for the day-to-day management of the residential treatment facility in accordance with the written plan of organization provided for in paragraph (d)(2) of this section.

(1) Ongoing direction may be delegated to an individual who shall be known as the director and who shall meet the qualifications specified in section 584.10(d) of this Part.

(2) The director shall be employed by the residential treatment facility at least one half of the hours of a fulltime employee.

(3) Administrative direction may be the responsibility of the director or may be delegated by the governing body to an individual who shall meet qualifications that are acceptable to the Office of Mental Health.

(h) The residential treatment facility shall participate with the local governmental unit in local planning processes. At a minimum, participation shall include:

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

(2) identification of the population being served by the residential treatment facility;

(3) identification of the geographic area being served;

(4) description of the relationship to other providers of services which 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 for prompt referral, evaluation and, as necessary, admission to cooperating programs, and for sharing information about residents being served; and

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

(i) The residential treatment facility shall provide for the following:

(1) an annual written evaluation of the residential treatment facility's attainment of its stated goals and objectives which indicates any required changes in policies and procedures;

(2) an annual audit of the financial condition and accounts of the residential treatment facility performed by a certified public accountant who is not a member of the governing body or an employee of the residential treatment facility;

(3) emergency evacuation plans for the building in which the residential treatment facility is located. Evacuation plans shall address emergencies resulting from fire as well as potential hazards in the geographic area in which the residential treatment facility is located; and

(4) up-to-date copies of any regulations, guidelines, manuals, or other information required by the Office of Mental Health.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 584.6

Amended New York State Register August 17, 2016/Volume XXXVIII, Issue 33, eff. 8/17/2016

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