Header:
NEW YORK CODES, RULES AND REGULATIONS
TITLE 14. DEPARTMENT OF MENTAL HYGIENE
CHAPTER XIII. OFFICE OF MENTAL HEALTH
PART 589. OPERATION OF CRISIS RESIDENCE
Date:
08/31/2009
Document:
ยง 589.6 Organization and administration
(a) The provider of services shall identify the individual or individuals who have overall responsibility for the operation of the crisis residence program. This individual or individuals shall be known as the governing body. The governing body may delegate responsibility for the day-to-day management of the program to appropriate staff in accordance with a plan of organization approved by the Office of Mental Health. No individual shall serve as both member of the governing body and of the paid staff of the crisis residence program without prior approval of the Office of Mental Health.
(b) The provider of services shall assure that the crisis residence has space, program, staff, policies and procedures that are programmatically and physically separate from any other programs which may be operated by the provider of services.
(c) Situational and acute psychiatric crisis residences may be located in the same building and share staff provided that they are programmatically and physically separate and distinct. The Office of Mental Health will review such requests and consider waivers of individual program staffing and administrative staffing if the applicant documents:
(1) the programmatic and physical separateness of the two programs;
(2) appropriateness of available space;
(3) appropriate number and mix of staff; and
(4) appropriate administrative staffing.
(d) 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 permanent record of the decisions made in relation to the operation of the crisis residence program. The minutes shall be reviewed and approved by the governing body.
(e) The governing body shall approve a written plan or plans that, at a minimum, address the following aspects of the operation of each crisis residence program:
(1) the goals and objectives of the crisis residence program, including the admission and discharge criteria;
(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 crisis residence program, including clinical, administrative, fiscal, clerical, housekeeping, maintenance, dietetic, and recordkeeping and reporting functions;
(ii) specifies all services available through the crisis residence program; and
(iii) for an acute psychiatric crisis residence, specifies all services provided by the affiliated intensive day treatment program;
(4) the written quality assurance plan pursuant to section 589.10 of this Part; and
(5) the written utilization review plan pursuant to section 589.11 of this Part.
(f) The governing body shall approve written policies and procedures of the crisis residence program including but not limited to:
(1) admission and discharge policies and procedures;
(2) policies and procedures regarding the rules and regulations necessary for resident compliance for program participation;
(3) personnel policies and procedures. Such policies and procedures shall prohibit discrimination on the basis of race, color, creed, disability, national origin, sex, marital status or age and shall provide for a review of the qualifications of all clinical staff and verification of employment history, personal references and work record and determination of past convictions of a crime in New York State or any other jurisdiction;
(4) staff training and development policies and procedures. Such policies and procedures shall address orientation, ongoing training and staff development;
(5) 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 resident records in accordance with section 33.13 of the Mental Hygiene Law, and shall ensure appropriate retention of case records; and
(7) policies and procedures related to performing the services provided by the crisis residence program.
(g) The governing body shall review the written plan or plans and policies and procedures required pursuant to subdivisions (e) and (f) of this section at least annually, and shall make appropriate amendments or revisions.
(h) The governing body shall delegate responsibility for the day-to-day management of the crisis residence program in accordance with the written plan of organization provided for in paragraph (e)(2) of this section.
(1) On-site direction shall be delegated to an individual who shall be known as the director and who shall meet the qualifications specified in section 589.8(d) of this Part.
(2) The director shall be employed by the crisis residence program as a full-time employee.
(3) Overall 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.
(i) There shall be a special review committee that includes at least two members of the clinical staff, one of which must be a professional staff member. The committee shall:
(1) develop a written special review plan, pursuant to section 589.10(c) of this Part which shall provide for review of all untoward incidents;
(2) review and evaluate untoward incidents in accordance with the plan, excluding from the committee's final deliberation those committee members who were present when the untoward incident occurred;
(3) determine the facts in any untoward incident reported, review ongoing practices and procedures in relation to such incidents, and recommend to the director changes in policies, practices, and procedures or recommend such other action as may be indicated; and
(4) meet as often as necessary to properly execute its functions and in no event less often than quarterly, keeping written minutes of its deliberations and submitting reports to the director as necessary.
(j) The crisis residence program 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 crisis residence program;
(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 patients being served; and
(5) attendance at planning meetings as may reasonably be required by the local governmental unit.
(k) The crisis residence program shall provide for the following:
(1) an annual written evaluation of the crisis residence program's attainment of its stated goals and objectives including any required changes in policies and procedures;
(2) in programs which are not State-or local government-operated, an annual audit of the financial condition and accounts of the crisis residence program must be performed by a certified public accountant who is not a member of the governing body or an employee of the crisis residence program or the provider of service. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements. The audit may be program specific or may be performed as part of an overall facility audit;
(3) emergency evacuation plans for the building in which the crisis residence program is located. Evacuation plans shall address emergencies resulting from fire as well as potential hazards in the geographic area in which the crisis residence program is located; and
(4) up-to-date copies of any regulations, guidelines, manuals or other information required by the Office of Mental Health.
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