Section 553.3 of Title 14 NYCRR is amended to read as follows:
§ 553.3 Scope of reviews and inspections.
(a) For purposes of this Part, “facilities under the jurisdiction of the Office of Mental Health” shall mean facilities required to obtain an operating certificate from the Commissioner pursuant to Article 31 of the Mental Hygiene Law.
(b) Prior to visiting a facility, the reviewer will study reports of previous reviews and inspections and the following information submitted by the facility:
(1) clinical and statistical data, and
(2) the policies of the facility.
[(b)](c) The onsite review and inspection shall include, as appropriate:
(1) review of program operation in comparison to programs authorized;
(2) private conversation with any person receiving mental health services or employee who so desires;
(3) review of case records of persons currently or previously served;
(4) review of the legal admission documents of persons receiving services and the conformity of the facilities admission procedures with the law and regulations;
(5) review of the records of restraint and seclusion;
(6) review of the qualifications of the staff and the staffing pattern in comparison to those authorized;
(7) inspection of the records and storage of medications, and procedures for prescription and dispensing of medications;
(8) review of the minutes of meetings of the governing body;
(9) inspection of the physical plant and equipment, and review of protective procedures in relation to structural and fire hazards;
(10) identification of any construction or improvements to the premises completed since the last visit; and
(11) review of written reports by local inspectors and other authorized inspection, certifying, or accrediting agencies, and review of conditions about which any recommendations for improvement have been made.
Text of proposed rule and any required statements and analyses may be obtained from:
Sue Watson, NYS Office of Mental Health, 44 Holland Avenue, Albany, NY 12229, (518) 474-1331, email: regs@omh.ny.gov
Data, views or arguments may be submitted to:
Same as above.
Public comment will be received until:
45 days after publication of this notice.
Regulatory Impact Statement
1. Statutory Authority: Section 7.09 of the Mental Hygiene Law gives the Commissioner of the Office of Mental Health the power and responsibility to adopt regulations that are necessary and proper to implement matters under his or her jurisdiction.
Subdivisions (a) and (b) of Section 7.15 of the Mental Hygiene Law authorize the Commissioner to evaluate programs and services of prevention, diagnosis, examination, care, treatment, rehabilitation, training, and research for persons with mental illness, and permits such activities to be undertaken in cooperation and agreement with other departments or agencies of the State, local or Federal government, or with other organizations and individuals.
Section 7.17 of the Mental Hygiene Law establishes and identifies a distinct list of hospitals to be directly operated by the Office of Mental Health. This section directs the Commissioner to establish policies and procedures for the organization, administration and operation of these facilities under his or her jurisdiction.
Sections 31.02 and 31.04 of the Mental Hygiene Law authorize the Commissioner to set standards of quality and adequacy of facilities, equipment, personnel, services, records and programs for the rendition of services for persons diagnosed with mental illness, pursuant to an operating certificate.
Section 31.05 of the Mental Hygiene Law establishes criteria for the issuance of operating certificates.
Section 31.07 of the Mental Hygiene Law gives the Commissioner the power to conduct periodic investigations into the operations of providers of mental health services which are required by Article 31 to have an operating certificate, and to inspect and examine records, including, but not limited to, medical service and financial records, to determine whether such providers are complying with applicable provisions of the Mental Hygiene Law and applicable laws, rules and regulations.
Section 31.09 of the Mental Hygiene Law gives the Commissioner or his or her authorized representative the power to inspect facilities, examine records, conduct examinations and interviews, and obtain such other information as necessary to carry out his or her responsibilities under Article 31. All such investigations and inspections shall be made by persons competent to conduct them.
Section 31.11 of the Mental Hygiene Law requires every holder of an operating certificate to cooperate with the Commissioner in any inspection or investigation, and to permit the Commissioner to inspect its facility, books and records, including records of persons receiving services.
Sections 31.13 and 31.19 of the Mental Hygiene Law further authorize the Commissioner or his or her representatives to examine and inspect such programs to determine their suitability and proper operation.
2. Legislative Objectives: Articles 7 and 31 of the Mental Hygiene Law reflect the Commissioner’s authority to establish regulations regarding mental health programs and charges OMH with the responsibility for ensuring that persons with mental illness receive high quality care and treatment.
3. Needs and Benefits: Part 553 of Title 14 NYCRR requires that all facilities under the jurisdiction of the Office of Mental Health (OMH) be visited and inspected by reviewers designated by the Commissioner. Existing regulations further state that unless otherwise specifically stated in the Part, reviewers shall be personnel of OMH who are competent and qualified to conduct such inspections. This proposal will amend Part 553 by clarifying that the term, “facilities under the jurisdiction of the Office of Mental Health,” pertains to facilities that are required to obtain an operating certificate from the Commissioner pursuant to Article 31 of the Mental Hygiene Law. This specifically excludes OMH-operated psychiatric centers, which are psychiatric facilities that are run by OMH, not licensed by OMH, and which are subject to OMH policies by operation of law. This amendment will enable an external entity to review and inspect OMH-operated facilities, rather than having the reviews be completed by personnel of the Office. It is believed that this external review will enhance the health, safety and quality of care in OMH-operated psychiatric centers. There will be no impact on OMH-licensed facilities or programs.
4. Costs:
(a) Costs to Local Government: These regulatory amendments will not result in any additional costs to local government.
(b) Costs to State: It is difficult to quantify the cost to State government as a result of this regulatory amendment, but the expense of paying an outside entity to perform reviews may be partially offset by the savings in costs associated with OMH personnel completing the reviews.
(c) Costs to Regulated Parties: These regulatory amendments will not result in any additional costs to regulated parties.
5. Local Government Mandates: These regulatory amendments will not result in any additional imposition of duties or responsibilities upon county, city, town, village, school or fire districts.
6. Paperwork: These amendments will not result in any increase in paperwork requirements of facilities covered by the regulations.
7. Duplication: These regulatory amendments do not duplicate existing State or federal requirements.
8. Alternatives: The only potential alternative would be inaction. As the amendments are intended to enhance health, safety and quality of care in OMH-operated facilities, this alternative was not considered.
9. Federal Standards: The regulatory amendments do not exceed any minimum standards of the federal government for the same or similar subject areas.
10. Compliance Schedule: These regulatory amendments will be effective immediately upon adoption.
Regulatory Flexibility Analysis
A Regulatory Flexibility Analysis has not been submitted with this notice. The proposed regulatory amendments serve to clarify that, for purposes of Part 553, the term, “facilities under the jurisdiction of the Office of Mental Health,” pertains to facilities that are required to obtain an operating certificate from the Commissioner pursuant to Article 31 of the Mental Hygiene Law. This specifically excludes OMH-operated psychiatric centers, which are psychiatric facilities that are run by OMH, and which are subject to policies and procedures established by the Office pursuant to Mental Hygiene Law Section 7.17. This amendment will enable an external entity to review and inspect OMH-operated facilities, rather than having the reviews be completed by personnel of the Office. It is believed that this external review will enhance the health, safety and quality of care in OMH-operated psychiatric centers. There will be no impact on OMH-licensed facilities or programs, nor will there be any adverse economic impact on small businesses or local governments as a result of these amendments; therefore a regulatory flexibility analysis for small businesses and local governments is not required.
Rural Area Flexibility Analysis
A Rural Area Flexibility Analysis has not been submitted with this notice. The proposed regulatory amendments serve to clarify that, for purposes of Part 553, the term, “facilities under the jurisdiction of the Office of Mental Health,” pertains to facilities that are required to obtain an operating certificate from the Commissioner pursuant to Article 31 of the Mental Hygiene Law. This specifically excludes OMH-operated psychiatric centers, which are psychiatric facilities that are run by OMH, and which are subject to policies and procedures established by the Office pursuant to Mental Hygiene Law Section 7.17. This amendment will enable an external entity to review and inspect OMH-operated facilities, rather than having the reviews be completed by personnel of the Office. It is believed that this external review will enhance the health, safety and quality of care in OMH-operated psychiatric centers. There will be no impact on OMH-licensed facilities or programs, nor will the rule impose any adverse economic impact on rural areas; therefore, a Rural Area Flexibility Analysis is not submitted with this notice.
Job Impact Statement
A Job Impact Statement is not submitted with this notice because it is evident from the subject matter that there will be no adverse impact on jobs and employment opportunities as a result of these amendments. The proposed regulatory amendments serve to clarify that, for purposes of Part 553, the term, “facilities under the jurisdiction of the Office of Mental Health,” pertains to facilities that are required to obtain an operating certificate from the Commissioner pursuant to Article 31 of the Mental Hygiene Law. This specifically excludes OMH-operated psychiatric centers, which are psychiatric facilities that are run by OMH, and which are subject to policies and procedures established by the Office pursuant to Mental Hygiene Law Section 7.17. This amendment will enable an external entity to review and inspect OMH-operated facilities, rather than having the reviews be completed by personnel of the Office. It is believed that this external review will enhance the health, safety and quality of care in OMH-operated psychiatric centers.
