N.Y. Comp. Codes R. & Regs. tit. 14 § 690.5

Current through Register Vol. 46, No. 51, December 18, 2024

Section 690.5 - Governance, administration, and operations - Principles of compliance

(a)Governing body responsibilities.

(1) There shall be a governing body (see glossary) with the policy making authority for the day treatment facility and legal responsibility for its operation and management. Each member of the governing body shall be identified by name and address in the agency/facility (see glossary) records. No one shall serve as both a member of the governing body and of the paid staff of the day treatment facility.

(2) The governing body shall be responsible for the operation of the day treatment facility according to the principles and standards established in this Part and other applicable rules, regulations, and statutes. This includes, but is not limited to, Parts 620, 624, 633 and 635 of this Title. Further, it shall:

(i) Ensure that the facility has a plan for a management and fiscal audit, and that such audit is conducted at least annually. This audit is to ensure that the facility complies with State and Federal laws and regulations and the facility's policies and procedures; and that it is operating in a fiscally responsible manner. Results of the evaluation are to be in writing, including recommendations, plans of correction and timeframes, and the names(s) of the party(ies) responsible for those corrections. The results of the audit shall be available on request for review by OPWDD.

(ii) Delegate the continuous day-to-day direction and control of the facility to a specific staff member who is referred to in this Part as the administrator (see glossary).

(iii) Ensure that the facility, and its associated satellite(s), have sufficient qualified professionals (see glossary) and direct care staff to deliver the services offered in accordance with the intensity, duration and frequency recommended by the treating clinician(s) for persons admitted to the facility. This includes setting forth procedures (available to and periodically reviewed with staff) to address and ensure adequate and appropriate coverage in the event of absenteeism (for any reason) by administrative, clinical, and/or direct care personnel.

(3) The governing body shall ensure the development, implementation, revision when necessary, and use of written policies/procedures (see glossary). The policies/procedures shall specify the facility's operational procedures and the staff titles operationally responsible for various facility activities in at least the following areas:

(i) services available, treatment planning, service delivery;

(ii) treatment coordination;

(iii) staffing, qualifications, and personnel policies;

(iv) administration;

(v) admission (see glossary) and discharge criteria;

(vi) quality assurance and quality improvement, including program and individual service evaluation;

(vii) standing committees;

(viii) program goals;

(ix) recordkeeping and reporting; and

(x) budgeting and expenditure controls.

(4) In addition, there shall be policies/procedures specifying:

(i) Steps to follow in the event of any unusual occurrence, including serious illness, accident, impending death or death. Such steps would include, as appropriate, notification of the correspondent, the residence, the medical examiner. (If an autopsy is performed on a person receiving day treatment services, it shall be performed by an impartial qualified physician who is not employed by the facility).

(ii) Practices to be followed in the event of emergencies. The administrator shall develop a written staff organization plan with detailed written procedures for meeting all potential emergencies and disasters, such as missing persons, severe weather, power outages, fires, floods, bomb threats, strikes and medical emergencies (e.g., epidemics, food poisoning, chemical poisoning, etc.). This plan shall be posted at suitable locations throughout the facility and clearly communicated to and periodically reviewed with staff.

(5) The governing body shall ensure the development and implementation of a written quality assurance program that includes a planned and systematic process for monitoring and assessing, on an ongoing basis, the quality and appropriateness of treatment and clinical performance of staff, as well as the continuing adequacy of the facility's physical plant, equipment and supplies.

(i) The plan shall include a means to resolve identified problems, pursue opportunities to improve the care and treatment provided and incorporate the regular, ongoing input of individuals, parents and/or advocates, and other relevant service providers.

(ii) The plan shall be subject to OPWDD review and approval as part of the process for issuing a new operating certificate or the facility's first certification subsequent to the effective date of this Part.

(6) To ensure that services are focused on developing those skills/capacities that enable each person to exercise alternative, less restrictive service choices, and as an integral part of a day treatment facility's internal quality assurance plan, a means shall be implemented whereby the facility's management can assess:

(i) the appropriateness of the admissions to the facility;

(ii) the appropriateness of the services provided relative to the presenting and/or current needs of persons admitted; and

(iii) the appropriateness of continuing a person's current level of participation at the day treatment facility.

(7) The governing body shall ensure that admission and discharge policies, including those pertaining to eligibility for service/treatment and a description of available services, are written and made available to staff members, persons served and their families, cooperating/referring agencies, and, as requested, to the general public.

(b)Administration responsibilities.

(1) There shall be a designated administrator of the day treatment facility who shall be a qualified intellectual disability professional (QIDP), as defined in the glossary under "professional staff" with at least one year of administrative experience in a developmental disability program. The executive director of the agency cannot serve as the administrator of the program without written approval of the commissioner. Credentials of the administrator shall be available for review.

(i) If the facility serves 50 or more full-time persons on a daily basis, there shall be a full-time administrator. If, however, the administrator is also the physician responsible for the program's medical services, there shall be a full-time assistant administrator (see glossary) on the staff of the facility.

(ii) If the facility serves fewer than 50 full-time persons on a daily basis, there may be an administrator who works on a part-time basis. However, employment may not be less than half-time. In the instances where the administrator is part-time and/or is not assigned on-site, a QIDP shall be designated to be responsible for the day-to-day- administrative direction of the facility when the administrator is absent. If the administrator devotes less than half-time as administrator because he or she is also the physician responsible for the facility's medical services, there shall be a full-time assistant administrator assigned to the facility.

(2) The administrator of the facility shall be responsible for:

(i) the continuous direction and day-to-day control of the facility;

(ii) designating a QIDP staff member to be responsible for the administrative direction of the facility at all times when the administrator and/or assistant administrator are absent;

(iii) maintaining a current table of organization which shows the services of the facility, the administrative personnel in charge of the services and their lines of authority, responsibility and communication. This table of organization shall identify the party(ies) and/or agencies providing services to admitted persons on a contractual or agreement basis, including staff shared with another provider of service, if any;

(iv) developing working relationships with other providers of service with the object of ensuring, to the greatest extent possible, that opportunities exist in the community for movement to more appropriate program/service settings;

(v) ensuring that the services meet the physical, social and developmental needs of all persons attending the facility, that there is adequate protection of each person's health, safety, comfort, well-being, and civil, human and legal rights and that selection takes account of the person's preferences;

(vi) ensuring that there is a standing committee, or comparable mechanism, to address the issue of infection control. The committee shall maintain minutes of its deliberations including recommendations made and documentation of follow-up actions;

(vii) establishing policies concerning the day-to-day operation of the facility and the well-being of the person's served, in conformance with the philosophy and goals established by the agency's governing body. In accordance with agency administrative practices, the administrator shall ensure the governing body is aware of these policies;

(viii) ensuring that policies and procedures required by this Part are kept up-to-date and that the facility is in compliance with the requirements therein;

(ix) ensuring that the governing body is informed of the regulations governing the operation of the day treatment facility and receives all audit reports of the facility's compliance with this Part;

(x) ensuring that each person to be admitted and his/her correspondent is informed orally and in writing prior to his or her admission, of all services available, personal items provided by the facility, and the financial charges which may be incurred by him or her for these services:

(a) This information must be provided on a continuing basis as changes in services or charges occur during the person's participation.

(b) The facility must clearly state the financial responsibility each person must bear for items not reimbursable under Medicaid.

(c) The information must be provided in the person's and/or his/her correspondent's primary language or means of communication;

(xi) making arrangements or preparations for persons to obtain additional services needed through other agencies at locations that are accessible to the person, regardless of handicap;

(xii) ensuring that arrangements are made for the provision of appropriate follow-up services pursuant to a discharge plan to persons who leave the program;

(xiii) keeping records as follows:

(a) maintaining individual program plans, as required in this Part;

(b) maintaining, where appropriate, a written financial record for each participant that is available to the person served and to his/her correspondent (unless the person is an adult capable of objecting to the disclosure of such information, and does object), which may include receipts for monies deposited with the facility for personal use, and a record of disbursement of that money;

(c) documenting receipt of those personal possessions that may have been left with the facility for the person's use while attending the facility; and

(d) maintaining the confidentiality of, and appropriate access to clinical records;

(xiv) ensuring the means whereby staff, persons and their correspondents may communicate ideas and concerns to the facility's administration without fear of penalty; and

(xv) the administrator shall maintain or cause to be maintained the following records of facility operations:

(a) a chronological admission and discharge register, which is a daily listing of persons admitted to and discharged from the facility, listed by name and including referral and/or placement information;

(b) a daily census record, including daily census and cumulative census for each month and year, accompanied by records which document and fully detail the extent of services provided and the length of each service;

(c) incident/abuse reports;

(d) fire drill records;

(e) dietary service record (for facilities providing routine food services);

(f) records that document compliance with applicable sanitation, health and environmental safety codes,

(g) copies of all placement and affiliation agreements;

(h) a copy of each emergency plan;

(i) a personnel record for each staff member, including all available preemployment information and, for professional staff, a copy of the current registration, license, or certificate. The record shall also contain documentation that each employee has been informed of and is aware of his/her job description; and

(j) an accounting of inventory which indicates purchase, assignment, disposal and/or replacement requirements.

(3) Each day treatment facility shall have a licensed physician designated medical director appointed by the governing body, who reports to the facility administrator. The medical director/physician shall be responsible for:

(i) ensuring that services provided by the facility to appropriately admitted persons are necessary to diagnose, treat, correct or habilitate conditions associated with the person's developmental disability;

(ii) reviewing each person's treatment plan or any substantial revisions within 30 days of its implementation, and indicating by signature that said treatment plan (or its substantial revision) is appropriate and not medically contraindicated;

(iii) facilitating, where appropriate, contact with the person's primary physician or health care provider;

(iv) ensuring that staff of the day treatment facility responsible for planning and/or delivering services are aware of any medical conditions or needs of the person and which are then accounted for, as appropriate, in the person's treatment plan;

(v) providing input at least annually to the interdisciplinary team as to the person's continuing need to receive day treatment services; and

(vi) maintaining the general health conditions of the facility and encouraging appropriate health promotion activities.

(c)Enrollment and admission.

(1) Day treatment facilities shall admit only persons who have a diagnosis of developmental disability.

(i) If a person manifests a diagnosed medical condition necessitating individual attention by health care staff (see glossary), he or she may be admitted to a day treatment facility if that required period of individualized medical attention is less than three hours, and the facility can meet that person's medical needs.

(ii) Only those persons able to participate in activities at a site other than where they reside, shall be admitted.

(iii) Admission to and participation in a day treatment facility shall be based on a finding of significant deficiency in adaptive behavior (see glossary) or a self-care deficit(s) with or without related physical handicaps. This shall be determined by the interdisciplinary treatment team comprehensive assessment, and documented in a format acceptable to the commissioner. This form shall include specific criteria of impaired functioning.

(2) Ability to pay shall not be considered as a criterion for admission. However, a facility is not obligated to accept (and may discharge) a person who will not pay for services rendered when he/she is financially capable of payment.

(3) Persons referred for or seeking admission may be enrolled (see section 690.99[p] of this Part, - Enrollment) for a maximum of 10 full or 20 half-day preliminary screening (see glossary) visits for the purposes of gathering assessment information and determining the appropriateness of admission to the day treatment facility.

(4) Facilities governed by this Part shall admit only persons who have had either a preliminary screening (see glossary), or a current comprehensive functional assessment (see glossary) which was developed by an interdisciplinary treatment team and is acceptable to the day treatment facility. Only persons whose functional and developmental needs can be met by the facility shall be admitted.

(5) The agency/facility shall cause to be completed or obtained for every person referred for intake, a developmental/demographic inventory of information on the person's characteristics and needs. Said inventory shall be completed and submitted to OPWDD in a manner and on a schedule acceptable to the commissioner.

(d)Treatment planning and review.

(1) The staff of the facility shall keep confidential, and make available only to authorized parties, all medical, social, programmatic, personal and financial information about all persons who are admitted to the facility. Authorized parties shall include staff of OPWDD who are assigned responsibility for monitoring the delivery of services to persons at the facility.

(2) The individual program plans of the persons admitted are the property of the facility, which shall protect same from loss, damage, tampering, or use by unauthorized individuals.

(3) Each person in a day treatment facility shall have an individual program plan.

(i) The person shall participate (unless the person is a capable adult and chooses not to participate), and the person's correspondent shall be invited to actively participate in the development of the individual program plan, unless the person is a capable adult who objects to such correspondents' participation.

(ii) The person shall be given the opportunity to invite additional parties of his/her choice to participate in the program planning process. The facility shall make reasonable efforts for said invitees to actually participate.

(iii) If no correspondent is available, and if the person does not have the capacity himself/herself to knowledgeably select an outside party to participate in the program planning process, an advocate (see glossary) shall be appointed who shall be invited to actively participate.

(iv) The coordinator at the person's residential facility, if applicable, or case manager shall also be invited to attend and participate in all interdisciplinary treatment team meetings.

(4) The initial individual program plan shall be developed by an interdisciplinary treatment team which shall:

(i) review current assessments and/or an existing individual program plan, if available. Assessments or plans developed within twelve months by another agency or certified facility prior to enrollment shall be considered acceptable, based on review and approval by the interdisciplinary treatment team; and

(ii) in the absence of current and acceptable assessments and/or an individual program plan, conduct a preliminary screening of the person.

(5) A QIDP (see glossary) shall prepare and submit to the administrator a single written summary interpreting the assessments and/or preliminary screenings, including a health needs assessment, which shall contain recommendations for admission and service delivery.

(i) The administrator shall review the material submitted and make the final decision to admit a person, in accordance with the facility's admission policies and procedures.

(ii) Upon making the decision to admit a person, the administrator shall:

(a) designate a treatment coordinator (see glossary) for the person; and

(b) ensure that a temporary program plan is established which will provide for the completion of assessments and a schedule of activities that will address the person's immediate habilitative need.

(iii) Within the 21 working days after the date of admission, the following shall have completed:

(a) all necessary assessments which were not complete, current, updated, or acceptable to the interdisciplinary treatment team at the time of admission (assessments shall be considered current if developed within the twelve months prior to admission; updates are valid up to one year from the date of the original assessment); and/or

(b) a comprehensive functional assessment;

(c) a summary clinical statement(s) by the Interdisciplinary Team that can be used for comprehensive programming; and

(d) at least a preliminary individual program plan, which shall then be finalized within the next 30 days.

(6) Each person's individual program plan shall include, but not be limited to, the following:

(i) A comprehensive functional assessment which addresses the persons capacities and capabilities in the areas of communication, mobility, learning, independent living, self-care, health care and self-direction. The comprehensive functional assessment shall:

(a) identify the person's problems and disabilities and where possible, their causes;

(b) identify the person's specific developmental strengths;

(c) identify the person's specific developmental and behavioral management needs;

(d) identify the person's need for services within the day treatment facility without regard for availability of the services needed;

(e) include physical development, health and nutritional status, sensorimotor development, affective development, speech and language development and auditory functioning, cognitive development, social development, adaptive behaviors or independent living skills necessary for the person to be able to function in the community, and vocational skills if applicable; and

(f) identify the person's preferences (see section 690.99[ab] of this Part) with respect to the activities, interventions, and outcomes which will become components of or be taken into account in the design of his/her individual program plan.

(ii) Treatment plans for a coordinated program of individually designed activities, experiences and services necessary to achieve individual program objectives written in the form of outcomes (see glossary). These plans shall contain, as appropriate, specific medical prescriptions or written direction (i.e., interventions, (see glossary). These plans shall contain, as appropriate, specific medical prescriptions or written direction (i.e., interventions, methodologies or strategies) from the interdisciplinary treatment team for all specified services. Such services, interventions, and methodologies shall be described in terms sufficiently clear to be understood by all parties participating in the implementation of the individual program plan.

(7) The day treatment facility shall provide to each person a range of allowable services to meet that person's needs, as identified by the comprehensive functional assessment, and which are directed toward the acquisition of the behaviors and skills necessary for the person to function with as much self determination and independence as possible, including, as appropriate, the prevention or deceleration of regression or loss of current optimal functional status. The outcomes (see glossary) to be achieved shall ensure promoting achievement of the following overall values, to the greatest extent possible:

(i) independence - the person has opportunities to develop capacities that lessen his/her dependence;

(ii) inclusion - the person has opportunities to engage in experiences and activities with those who are not disabled;

(iii) individualization - the person's self-esteem is developed by ensuring respect, by giving him/her meaningful choices, and by providing services in terms of his/her unique and valued individuality; and

(iv) productivity - the person is provided opportunities to make an increasingly meaningful contribution to his/her living and community environment.

(8) The individual program plan and processes for its development and monitoring shall document conformity with the definition of active treatment and ensure its provision.

(9) Review of each individual program plan shall take place at intervals determined by the agency/facility, but with sufficient responsiveness to ensure review whenever a person has completed an objective/goal, is regressing or losing skills already gained, is failing to progress toward identified objectives after reasonable efforts have been made, when a person is being considered for training towards new objectives or when the person or their correspondent requests.

(i) The interdisciplinary treatment team is responsible for reviewing and evaluating each person's individual program plan and developmental progress.

(ii) At least annually, the interdisciplinary treatment team shall meet to review and evaluate each person's individual program plan and developmental progress.

(iii) If the physician is not present, a registered nurse must attend at least the annual review (and any other interdisciplinary treatment team meetings) where it is necessary to interpret the medical assessment and integrate the person's identified health care needs into the individual program plan.

(iv) The physician shall review and sign all reviews for those persons who are self-injurious, require daily individual attention from health care staff, or for whom a physician has determined that there is the need for a physician's review and sign-off due to medication regimen, physical condition, etc.

(e)Day treatment services to persons residing in ICF/DDs.

The following provisions, applicable to persons who reside in OPWDD certified or operated intermediate care facilities for persons with developmental disabilities (ICF/DDs) and who are receiving services from a day treatment facility, shall be met:

(1) The day treatment facility is responsible for providing during the day, a program of services, activities, and interventions, which are integrated and consistent with the person's overall individual program plan, developed pursuant to applicable ICF/DD regulations as referenced in Part 681 of this Title.

(2) The person's treatment coordinator at the day treatment facility shall be responsible for maintaining periodic contact with the assigned QIDP at the ICF/DD. Said contact shall be for the purposes of providing information on the person's day treatment experience, to receive information about the person's situation at the residence and to facilitate the integration of services and their consistency with the person's overall individual program plan. Contacts should be made as needed, and always if/when any of the following should occur:

(i) a change in the person's status;

(ii) the achievement of an identified objective for which the day treatment facility has responsibility;

(iii) a need for a change in the person's overall individual program plan;

(iv) differences in professional judgment concerning the services, activities or interventions to be provided by the respective facilities need to be resolved; or

(v) new assessment or other information becomes available.

(3) The day treatment facility shall participate in the development and/or updating of a person's comprehensive functional assessment and shall provide for cooperation, integration, and consistency of resultant service plans and service delivery through any means deemed appropriate including, but not limited to, meetings, correspondence, and/or telephone contact. The means chosen and the frequency of contact shall be determined jointly by both the ICF/DD and day treatment provider.

(f)Staffing.

(1) All professional staff shall spend a majority of their working hours in observation of, or direct interaction with, persons served and other staff in areas where activities and programs are taking place. Emphasis shall also be placed on training and supervision through direct interaction. Interdisciplinary treatment team meetings with admitted persons and/or the person's family present may be considered as a portion of time spent in direct interaction. Whenever possible, meetings, reporting, record keeping and other administrative tasks shall take place during the hours when people are not at the facility.

(2) Upon the decision to admit, there shall be a QIDP designated as treatment coordinator for each person. The treatment coordinator shall be responsible for supervising the implementation of the person's individual program plan; for ensuring the integration of the various treatment plan services received by the person; and for recording the person's progress and initiating periodic review of each individual program plan as stipulated by this regulation. All professionals assigned this responsibility shall have it clearly identified in their job descriptions.

(3) All staff members who are qualified professionals, as defined in section 690.99 of this Part, and who provide services as professionals, shall file appropriate documentation of their training, experience, licensure, certification and/or registration with the sponsoring agency. This documentation shall be retained on file by the agency and made available to OPWDD upon request.

(4) The agency/facility shall employ sufficient qualified staff and support personnel to accurately process, check, index, file and retrieve records and to record data promptly.

(5) The agency/facility shall employ or contract for an adequate maintenance and engineering staff to provide for a preventive and emergency program.

(6) The agency/facility shall employ or contract for an adequate housekeeping staff to meet the housekeeping needs of the facility.

(7) The agency/facility shall employ a sufficient number of trained and experienced personnel to perform purchase, supply and property control functions.

(8) There shall be a staff training program provided, or made available through outside resources, to all employees. The training shall include, but is not limited to:

(i) orientation for all new employees and all volunteers, including interns and students assigned for formal work experience, to acquaint them with the philosophy, organization, program practices and goals of the agency/facility as well as emergency and first aid procedures. Orientation shall also include familiarization of staff with appropriate laws, regulations, policies and procedures;

(ii) periodic in-service training to update and improve the skills of all employees;

(iii) intensive and ongoing in-service training for employees who have not achieved the desired level of competence;

(iv) supervisory and management training for all employees in, or candidates for, supervisory positions; and

(v) routine and ongoing direct care staff training in the skills and knowledge (including first aid and CPR in accordance with agency policies and procedures) necessary to provide appropriate services to admitted persons.

(9) There shall be, at a minimum, representation by qualified professional staff, as defined in section 690.99 of this Part, in nursing, psychology, social work and at least one or more of the following professional discipline areas: rehabilitation counseling, occupational therapy, therapeutic recreation, physical therapy, speech pathology, and human services specialties. Staff may also include paraprofessional (see glossary) and direct care staff and consultants. The staffing plan shall reflect a balance of all personnel required for the appropriate delivery of needed services to persons admitted to the facility.

(i) There shall be a sufficient number of qualified professionals on duty at all times that people are receiving services at the facility. The ratio between persons served at the facility and qualified professional staff, and direct care staff, shall be adequate to meet the individualized needs of each person, as identified by his/her comprehensive functional assessment.

(ii) At least 25 percent of all full-time equivalent qualified professional staff shall meet the standards of QIDP, as defined in section 690.99 of this Part, under "professional staff". The administrator may be counted for that portion of his or her time directly related to program issues (e.g., program development, supervision of service delivery, advocacy for persons in the program, policy and procedure development relating to service delivery). Time spent by the facility administrator in dealing with administrative and support matters is not to be counted in meeting the QIDP percentage requirement.

(iii) All allowable services shall be directly supervised by a QIDP or a qualified professional as defined in section 690.99 of this Part under "professional staff".

(10) All other facility staff shall have qualifications appropriate to their assigned responsibilities as set forth in the facility's written policies and, in the direct service delivery area, shall be subject to appropriate supervision by qualified professionals.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 690.5

Amended New York State Register September 21, 2016/Volume XXXVIII, Issue 38, eff. 9/21/2016