N.Y. Comp. Codes R. & Regs. tit. 14 § 600.7

Current through Register Vol. 46, No. 22, May 29, 2024
Section 600.7 - Organization and administration
(a) Governing Body or Sponsor: The Crisis Stabilization Center shall identify a Governing Body or Sponsor (Governing Body) which shall have overall responsibility for the operation of the Center. The Governing Body may delegate responsibility for the day-to-day management of the Center to appropriate staff in accordance with the organizational plan approved by the Office. No individual shall serve as both a member of the Governing Body and as paid staff of the Crisis Stabilization Center without prior approval of the Office.
(b) For hospital-based Crisis Stabilization Centers, the Governing Body of the hospital shall be responsible for the overall operation and management of the Crisis Stabilization Center. The Governing Body may delegate responsibility for the day-to-day management of the Center to appropriate staff pursuant to an organizational plan approved by the Office. No individual shall serve as both member of the Governing Body and of the paid staff of the Crisis Stabilization Center without prior approval of the Office.
(c) For Crisis Stabilization Centers, the Governing Body shall delegate responsibility for the day-to-day management of the Crisis Stabilization Center in accordance with the written plan of organization provided for in paragraph (e)(2) of this section.
(1) Onsite direction shall be delegated to an individual who shall be known as the Program Director and who shall meet the qualifications specified in section 600.11(f) of this Part.
(2) The Program Director shall be employed by the Crisis Stabilization Center as a full-time employee.
(3) Overall administrative direction may be the responsibility of the Program Director or may be delegated by the Governing Body to an individual who shall meet qualifications that are acceptable to the Office.
(d) The Governing Body shall comply with all requirements set forth in 10 NYCRR Part 405 .2 as well as requirements established by appropriate local, State and Federal standard-setting bodies.
(e) The Governing Body shall be responsible for the following duties:
(1) to develop an organizational plan which indicates lines of accountability and the qualifications required for staff positions. Such plan may include the delegation of the responsibility for the day- to-day management of the program to a Program Director who shall be a member of the professional staff employed by the Crisis Stabilization Center. Where such Crisis Stabilization Center is hospital-based, the Program Director shall report to the Director of Psychiatry or Medical Director of the host hospital.
(2) to develop written personnel policies which shall prohibit discrimination on the basis of race or ethnicity, religion, disability, gender identity or sexual orientation, marital status, age, documentation status, or national origin, as well as, written policies on affirmative action which 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;
(f) The Governing Body shall develop, approve, periodically review and revise as appropriate all programmatic and administrative policies and procedures. Such policies and procedures shall include, but are not limited to the following:
(1) policies that guide efforts to reduce disparities in access, quality of care and treatment outcomes for underserved/unserved and/or marginalized populations, including but not limited to: people of color, members of the LBGTQ+ community, older adults, pregnant persons, Veterans, individuals who are hearing impaired, individuals with limited English proficiency, immigrants, individuals with intellectual/developmental disabilities and all justice system-involved populations;
(2) policies that ensure that efforts are made to employ staff that are proficient in the most prevalent languages spoken by service Recipient;
(3) policies and procedures governing Recipient records which 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 section 590.12 of this Title;
(4) policies regarding the confidentiality of substance use disorder treatment records in accordance with state and federal law including 42 CFR Part 2 and HIPAA;
(5) policies that ensure the protection of Recipients' rights;
(i) At a minimum these policies shall establish and describe a Recipient's grievance procedure.
(ii) The Crisis Stabilization Center shall post a statement of Recipients' rights in a conspicuous location easily accessible to the public and provide a copy to service Recipients.
(6) policies for training staff to recognize the signs and symptoms of severe reactions to or overdose on substances including but not limited to alcohol, sedative-hypnotics, opioids, stimulants, cannabis and synthetic cannabinoids, and the appropriate interventions when overdose occurs in accordance with guidance from the Office
(i) Training on these interventions shall include but not be limited to education about the use of naloxone overdose prevention kits.
(ii) Centers must develop and implement a plan to have staff trained in the use of a naloxone overdose prevention kit and must ensure that such kit and appropriately trained staff are available during all program hours of operation.
(iii) Staff should be trained that overdose risk can exist with any illicit substance use, not limited to known opioid use or intended substance of choice.
(7) policies for the provision of overdose prevention education and training and availability of overdose prevention kits or prescriptions for service Recipients and their collaterals.
(g) Cultural and linguistic competency.
(1) Crisis Stabilization Centers shall review demographic data for the Crisis Stabilization Center's Catchment Area to determine the cultural and linguistic needs of the population as well as disparities in access to treatment. Staff shall be trained to be aware and respond appropriately to the cultural and linguistic needs of the Catchment Area and develop a plan to address disparities in treatment access.
(2) Crisis Stabilization Centers shall ensure provision of language assistance services at no cost to the Recipient and/or their family/collaterals and shall make all necessary documents available in the Recipient's preferred language. Language access services will be made available in such a way that assessment or treatment activities will not be delayed. Crisis Stabilization Centers are responsible for ensuring the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
(3) Crisis Stabilization Centers shall provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area, with a focus on the varied literacy levels among the service user population.
(h) County planning.
(1) Crisis Stabilization Centers shall participate in county and community planning activities annually, and as additionally needed, to ensure, maintain, improve or develop community services that demonstrate recovery outcomes. These outcomes include, but are not limited to, quality of life, socio-economic status, entitlement status, social networking, coping skills and reduction in use of crisis services.
(i) Incidents.
(1) The Crisis Stabilization Center shall ensure the timely reporting, investigation, review, monitoring and documentation of incidents pursuant to the Mental Hygiene Law and 14 NYCRR Part 524.
(i) The Crisis Stabilization Center shall utilize New York Incident Management Reporting System reports or other available incident/data analysis reports to assist in risk management activities and compile and analyze incident data for the purpose of identifying and addressing possible patterns and trends to improve service delivery.
(2) Incident Training.
(i) All new staff shall receive training which must include at a minimum, the definition of incidents, reporting procedures, an overview of the review process, and the role of risk management.
(ii) Refresher incident reporting training shall be conducted at least annually for all staff and evidence of such training must be recorded in the staff personnel file.
(3) For hospital-based Centers , the hospital's incident review committee shall review incidents, make recommendations and ensure implementation of action plans with the Crisis Stabilization Center's Program Director.
(j) Non-discrimination. No Recipient that meets the criteria for treatment may be denied a based solely on the Recipient's:
(1) prior treatment history;
(2) referral source;
(3) pregnancy;
(4) history of contact with the criminal justice system;
(5) HIV and AIDS status;
(6) physical or mental disability;
(7) lack of cooperation by collaterals in the treatment process;
(8) toxicology test results;
(9) use of any illicit or prescribed substances, including but not limited to, benzodiazepines;
(10) use of medications for substance use disorder prescribed and monitored by a physician, physician's assistant or nurse practitioner;
(11) age;
(12) actual or perceived gender;
(13) national origin;
(14) race/color;
(15) actual or perceived sexual orientation;
(16) marital status;
(17) military status;
(18) familial status; or
(19) religion.
(k) Posting notices. The Crisis Stabilization Center shall ensure the posting of notices displaying the availability of on-site peer counseling/mutual-aid services and the address and telephone number of local off-site peer counseling/mutual aid services.
(l) The Crisis Stabilization Center will have memorandums of understanding (MOUs) with any available crisis residential services or comparable services for Recipients determined to need crisis stabilization beyond 23 hours and 59 minutes.
(m) Crisis Stabilization Centers shall develop policies and procedures describing Recipient drop off from law enforcement, emergency medical services, mobile crisis and other outreach and treatment teams.
(n) Supportive Crisis Stabilization Centers shall develop policies and procedures describing how Recipients will access services identified in screening and assessment that are not provided by the Crisis Stabilization Center and follow-up to ensure such services are accessed.
(o) The Commissioners or their designee may prevent new presentations to the Crisis Stabilization Center emanating from emergency medical services, ambulance services and law enforcement if a conclusion is reached that the ability of the Crisis Stabilization Center to deliver quality service would be jeopardized.
(1) The Commissioners or their designee shall review the continued necessity for such prevention at least once every twenty-four hours according to a mutually developed plan.
(2) The Crisis Stabilization Center shall develop a contingency plan with other local affiliated hospitals, emergency medical services and law enforcement for the prevention of new presentations during periods of high demand and overcrowding.
(3) Where a Crisis Stabilization Center prevents new presentations pursuant to this paragraph, the Crisis Stabilization Center must notify the appropriate OMH Field Office and OASAS Regional Office according to a mutually developed plan.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 600.7

Adopted New York State Register June 29, 2022/Volume XLIV, Issue 26, eff. 6/13/2022