N.Y. Comp. Codes R. & Regs. tit. 14 § 512.9

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

Section 512.9 - Organization and administration

(a) The provider of service shall identify a governing body, which shall have overall responsibility for the operation of the program. The governing body may delegate responsibility for the day-to-day management of the program to appropriate staff pursuant to an organizational plan approved by the office.

(b) In programs operated by not-for-profit corporations other than hospitals licensed pursuant to article 28 of the Public Health Law, no person shall serve as a member of the governing body and of the paid staff of the program without prior approval of the office.

(c) The governing body shall be responsible for the following duties:

(1) to meet at least four times a year;

(2) to review, approve and maintain minutes of all official meetings;

(3) 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 designated professional who is qualified by training and experience to supervise program staff;

(4) to review the program's compliance with the terms and conditions of its operating certificate, applicable laws and regulations;

(5) to design and operate the program consistent with and appropriate to the ethnic and cultural background of the population to be served by the PROS program;

(6) to develop a mechanism for PROS program participants, and any individuals they identify, to participate in the development and ongoing review of the IRP;

(7) to develop, approve, and 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:

(i) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, marital status, age, national origin or sexual orientation, and the applicable obligations imposed by: title VII of the Civil Rights Act; Federal Executive Order 11246; the Rehabilitation Act of 1973, section 504; the Vietnam Era Veteran's Readjustment Act; the Federal Age Discrimination in Employment Act of 1967; the Federal Equal Pay Act of 1963; the Americans with Disabilities Act of 1990; and the State Human Rights Law (Executive Law, article 15);

(ii) written policies, applicable to job applicants and volunteers, which shall provide for verification of employment history, personal references, work record and qualifications, as well as documentation of compliance with Part 550 of this Title-- criminal history records check;

(iii) written policies and procedures, when applicable, concerning the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations;

(iv) written policies and procedures regarding the confidentiality of individuals' records consistent with applicable Federal and State laws and regulations, and the appropriate retention of such records;

(v) written criteria for admission and discharge from the program;

(vi) written policies and procedures regarding the mandatory reporting of child abuse or neglect;

(vii) written policies and procedures describing an incremental grievance process that addresses the timely review and resolution of individuals' complaints, including documentation thereof, and which provides a process enabling individuals to request review by the provider's governing body, and ultimately the Office of Mental Health, when resolution is not satisfactory;

(viii) written policies and procedures regarding the use of recipient employees that address, at a minimum, the requirements pursuant to section 512.7(d)(9) of this Part; and

(ix) standards of conduct which shall be delineated for all staff in regard to relationships with PROS participants consistent with OMH guidance.

(d) Restraint and seclusion shall not be utilized in programs governed by this Part. Each PROS program must have ongoing education and training and must demonstrate competence in techniques and alternative methods of safely handling crisis situations. In situations in which alternative procedures and methods not involving the use of physical force cannot reasonably be employed, nothing in this section shall be construed to prohibit the use of reasonable physical force when necessary to protect the life and limb of any person.

(e) Individuals' participation in research shall only occur in accordance with applicable Federal and State requirements.

(f) A provider of service shall report, investigate, review, monitor and document incidents in accordance with section 29.29 of the Mental Hygiene Law and Part 524 of this Title.

(g) There shall be an emergency evacuation plan and staff shall be trained about its procedures.

(h) There shall be a written utilization review procedure to monitor the appropriateness of service provision.

(i) The provider of service shall participate as required with the local governmental unit in local planning processes pursuant to sections 41.05 and 41.16 of the Mental Hygiene Law. At a minimum, such participation shall include:

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

(2) identification of the population being served by the program;

(3) identification of the geographic area being served by the program;

(4) description of the program's relationship to other providers of service including, but not limited to, a description of all written agreements entered into pursuant to this Part; and

(5) provision of copies to the local governmental unit of any plans or documents submitted to the office for approval pursuant to this Part at the time of such submission to the office. The provider of service shall consult with the local governmental unit prior to the submission of any such plans or documents and, to the extent practicable, prior to any changes or alterations to the PROS program not otherwise addressed in such plans or documents.

(j) In programs that are not operated by a unit of New York State government, there shall be an annual audit, pursuant to a format prescribed by the office, of the financial condition and accounts of the program performed by a certified public accountant who is not a member of the governing body or an employee of the program. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements.

(k) The provider of service shall establish mechanisms for the meaningful participation of current or former recipients of service either through direct participation on the governing body, or through the creation of an advisory board. If an advisory board is used, the provider of service shall establish a mechanism for the advisory board to make recommendations to the governing body.

(l) The provider of service shall establish mechanisms for priority access by individuals, referred to the provider, who are enrolled in an assisted outpatient treatment program established pursuant to section 9.60 of the Mental Hygiene Law. Prior to the discharge by a provider of service of an individual who is also enrolled in an assisted outpatient treatment program, the provider of service shall notify the individual's case manager and the director of the assisted outpatient treatment program.

(m) The provider of service shall establish mechanisms that promote the competency of its workforce.

(n) The provider of service shall maintain adequate information in personnel files concerning the scope of activities for workforce development, additional certificate or academic programs which staff have engaged in while employed, and special credentialing that staff have achieved to obtain necessary competencies.

(o) Comprehensive PROS programs with clinical treatment shall have a mechanism to provide, or arrange for, face-to-face contact with individuals enrolled in the program who need assistance when the program is not in operation.

(p) Comprehensive PROS programs without clinical treatment shall develop a plan for appropriately responding to individuals enrolled in the program who need assistance when the program is not in operation. Such plan shall be subject to approval by the office.

(q) The PROS program shall develop a plan that addresses continuity of care within the mental health system and other service systems (e.g., social services, health care, alcoholism and substance abuse services, local correctional systems). The plan shall be included in the case record and must include a protocol for the development and monitoring of coordination and integration between the PROS provider and outside service providers. Such plan shall be subject to approval by the office.

(r) Upon the request of the office, or upon the request of the local governmental unit with which the provider has an agreement in accordance with section 512.14(b) of this Part, each provider of service shall furnish any and all information and records concerning the operation and administration of the program including, but not limited to, information regarding the program or services, person-specific services, performance indicators, contracts or other agreements and statistical, administrative and fiscal operations.

(s) Providers shall comply with applicable data submission requirements identified by the office.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 512.9