N.Y. Comp. Codes R. & Regs. tit. 14, § 85.5 – Organization and administration.

(1) The certificate holder shall identify individually by name a group of persons responsible for the overall operation and management of the outpatient service. For purposes of this Part, this group shall be known as the governing body.
(2) The governing body shall establish and maintain current a plan of organization for the outpatient facility which clearly indicates lines of accountability, the nature of professional responsibility to be exercised according thereto, and the professional qualifications required.
(3) The governing body shall develop and revise as necessary written policies for the quantity, quality, and scope, goals, objectives, and evaluation of all programs, policies for the accomplishment of stated purposes, and personnel policies. Personnel policies shall prohibit discrimination on the basis of race, creed, sex, age or national origin.
(4) Minutes of all official meetings of the governing body shall be maintained as permanent record of the decisions made in relation to the operation of the outpatient facility.
(5) Ongoing direction and control of the program of the facility shall be delegated by the governing body to an appropriately qualified professional. For the purposes of this Part this person shall be known as the director.
(6) Administrative management of the facility may be delegated by the governing body to an appropriately qualified administrator.
(7) No person shall serve as both a member of the governing body and of the paid staff of the facility without the prior approval of the commissioner.
(b) Administration.
(1) The governing body shall cause to be made an annual written evaluation of the total program to assess effectiveness and efficiency and to indicate any required changes in policy or service of the facility.
(2) The governing body shall cause to be made an annual audit of the financial condition and accounts of the facility by a certified public accountant who is not a member of the governing body or an employee of the facility.
(3) Admission policies, including those pertaining to eligibility for service, and a description of available services which shall be written and made available to staff members, persons served and their families, cooperating agencies and the general public. All admission policies shall prohibit discrimination on the basis of race, creed, sex, age, or national origin.
1. (i) Criteria of suitability for admission to any program shall be based upon clearly defined factors appropriate to the purposes of the program.
2. (ii) Admission policies shall provide for appropriate referral of those persons applying for admission who do not meet the pre-established criteria for admission to any program.
(4) The governing body shall cause to be procured and maintained for reference by the governing body and staff members an up-to-date copy of this Part and copies of any guideline instruction or information manuals or other communications as may be prescribed by the department.
(5) The governing body shall appoint a special review committee, including members of the professional clinical staff which shall:
1. (i) Develop a written special review plan subject to approval by the governing body and the department. This plan shall provide for review of all untoward incidents which may occur and extra risk procedures administered. (Untoward incidents may include, but not be limited to, serious drug reactions, suicides and sudden deaths, assaults, accidents, and terminations of service against professional advice. Extra risk procedures may include, but not be limited to, behavior modification, somatic therapies, and experimental treatment modalities),
2. (ii) Review and evaluate untoward incidents and extra risk procedures in accordance with the plan,
3. (iii) Determine the facts in any incident reviewed, review ongoing practices and procedures in relation to such incidents and extra risk procedures and recommend changes in policies, practices or procedures which may be indicated.
4. (iv) Include either on a regular membership basis or by special arrangement as indicated the participation of appropriately qualified and experienced physicians, and
5. (v) 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 governing body as necessary.
  (6)
6. (i) The governing body of a facility providing services to the mentally ill pursuant to an operating certificate issued by the Office of Mental Health shall require staff of the facility to participate with the local governmental unit in local planning processes as required by sections 41.05(e) and 41.16 of the Mental Hygiene Law. Such participation must be documented in the approved local services or unified services plan of each local governmental unit served by the facility. At a minimum, facility participation shall include:
  1. (a) provision of budgeting and planning data as requested by the local governmental unit;
  2. (b) identification of the population being served by the facility;
  3. (c) identification of the geographic area being served by the facility;
  4. (d) description of the facility's relationship to other providers of services who 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 a process for prompt referral, evaluation, and, as necessary, admission to cooperating programs; specify mechanisms for coordinated development of service plans for patients being served by more than one program; and provide a mechanism for sharing information about patients being served; and
  5. (e) attendance at planning meetings as may reasonably be required by local governmental unit.
7. (ii) For facilities issued operating certificates by the Office of Mental Health, the Regional Director shall determine, after hearing if necessary, whether the facility has participated in the planning process in good faith and reasonable conformity with the goals and objectives of the statewide comprehensive plan for services.

(a) Organization.