N.Y. Comp. Codes R. & Regs. tit. 18 § 488.10

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

Section 488.10 - Records and reports

(a) The operator must collect and maintain such information, records or reports as determined by the department to be necessary.

(b) The department may examine the books and records of any enriched housing program to determine the accuracy of the annual financial statement, or for any other reason deemed appropriate by the department to effectuate the purposes of this Title. The Justice Center shall have access to any enriched housing program in which a resident who received mental health services as described in section 488.7(b)(8)(iv), (9)(ii), and (10) of this Part, and information, reports or records in such enriched housing program's possession as needed to carry out the functions, powers and duties of the Justice Center, and shall have such access related to the investigation of deaths concerning patients of mental hygiene facilities who resided at such enriched housing program at the time of their death or were former residents of such enriched housing programs, and for which the Justice Center determines that such information, report or record is necessary for the completion of its investigation. The department and the Justice Center shall, when required by law, or when so directed by the department or the Justice Center and except as otherwise prohibited by law, be permitted to share information obtained in their respective investigations of incidents.

(c)Resident records.

(1) The operator must maintain complete, accurate and current records for each resident which must be available for review and inspection by department staff or designees.

(2) Records must be maintained in a manner which assures resident privacy and accessibility to staff to use in the provision of routine and emergency services.

(3) The operator must maintain:

(i) financial records for each resident which contain at a minimum a copy of the current admission agreement, documentation of the status of the resident's payment account and personal fund account and a current inventory of any personal property held in custody for the resident by the operator;

(ii) personal records for each resident which contain at a minimum personal data, including identification of the resident's next of kin, family or resident's representative, the name and address of the person or persons to be contacted in the event of an emergency; copies of the resident's medical evaluations and other medical information; summaries of the social evaluations; copies of the initial and annual functional assessments; and details of referral and such other correspondence and papers as are available to document the physical, mental and social status of the resident; and

(iii) records which are readily available to food services staff and enable staff to plan for and accommodate prescribed dietary regimens, allergies and individual food preferences.

(4) In situations where residents of an enriched housing program have individual leases for their respective apartments, the operator must review these leases at least annually to ensure that all such leases are adhered to and renewed.

(d)Program records.

(1) The operator must maintain complete, accurate and current records which document operation and maintenance of the enriched housing program in accordance with applicable law and regulation.

(2) Records must be maintained at the enriched housing program site unless written authorization is given by the department for record retention at another location. All records must be available for review and inspection by department staff and designees.

(3) Records must be maintained in a manner which assures the individual resident's right to confidentiality and privacy.

(4) At a minimum, the operator must maintain:

(i) individual resident records as required in subdivision (c) of this section;

(ii) resident records required elsewhere in these regulations including incident reports;

(iii) a chronological admission and discharge register consisting of a listing of residents registered in and discharged from such enriched housing program by name, age, sex, and place from or to which the resident is registered or discharged;

(iv) program records, including a policies and procedures manual, activities schedules, agreements with external service providers, emergency plans and records of evacuation drills;

(v) food service records, including menus and food purchase records;

(vi) records of maintenance or documentation of efforts to ensure maintenance of the physical plant and environmental standards;

(vii) staff records, including personnel procedures, job descriptions, staffing schedules and payment records;

(viii) certificates or reports issued by local and other state jurisdictions related to the enriched housing program operations, on file and readily accessible for department review, or posted, if required; and

(ix) a valid current agreement with a building manager, if the enriched housing operator does not own or control the building in which the enriched housing program is located, which is in accordance with section 485.6(d)(13) of this Title.

(e)Program reports.

(1) Annual financial statement.

(i) The operator of an enriched housing program must file an annual financial statement on an approved form with the department on or before the 15th day of the sixth calendar month after the close of its fiscal year. Such statement must clearly set forth all financial information pertaining to the operation of such enriched housing program in accordance with generally accepted accounting principles, including but not limited to revenues and expenses by categories during such fiscal year, together with such other information as may be required by the department.

(ii) The operator of an enriched housing program which submits a charitable organization annual report to the Secretary of State or a residential health care facilities annual report to the Department of Health may submit copies of those reports, together with such other data as may be necessary to satisfy the requirement in subparagraph (i) of this paragraph.

(iii) An operator must maintain and make available all such books and records as may be required by the department to determine the accuracy of any and all information contained in the financial statement filed by the operator.

(2) Financial statements must be filed by the operator as requested by the department.

(3) Apartment records.

The operator of an enriched housing program must notify the department, using Form DSS-934, of any change in apartments occupied by program residents in a multiple apartment building at least 15 days before such change is expected.

(4) Quarterly reports.

The operator must submit a quarterly statistical information report to the department which must:

(i) identify the quarter being reported on;

(ii) contain a census report; and

(iii) contain the number of resident deaths which occurred during the quarter being reported on.

(f)Mandated forms.

(1) The department mandates utilization of the following forms for enriched housing programs:

(i) a Personal Data Sheet (DSS-2949);

(ii) an Incident Report (DSS-3123);

(iii) a Medical Evaluation (DSS-3122);

(iv) an Inventory of Resident Property (DSS-3027);

(v) a Notice of Change (DSS-934); and

(vi) a Chronological Admission and Discharge Register (DSS-3026).

(2) The following personal allowance account forms must be used unless prior written authorization for substitutions has been given by the department:

(i) a Statement of Offering (DSS-2853);

(ii) a Personal Allowance Summary (DSS-2855); and

(iii) a Personal Allowance Ledger (DSS-2854).

(g) The operator must post the following documents:

(1) the operating certificate;

(2) the inspection report for the most recent or summary inspection, with any related follow-up inspections;

(3) the statement of rights of residents;

(4) the current week's menus;

(5) the current month's activity schedule;

(6) the program's evacuation procedures; and

(7) the access schedule for personal needs accounts.

(h)Records retention.

(1) Records required by the department, except financial records of the previous operator, must be retained by the enriched housing program upon change of operator.

(2) Records relating to an individual must be retained for three years after the death or discharge of a resident.

(3) Program records, business records and records relating to application or renewal for an operating certificate must be retained for seven years.

(i) Except as otherwise prohibited by law, the operator of a facility, as defined in section 488(4) of the Social Services Law and not otherwise subject to article six of the Public Officers Law shall make records available for public inspection and copying to the extent required by subdivision six of section 490 of the Social Services Law and regulations of the Justice Center.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 488.10

Amended New York State Register February 10, 2016/Volume XXXVIII, Issue 06, eff.2/10/2016