(c) The governing body shall be responsible for the following duties:

1. (1) to meet at least four times a year;
2. (2) to review, approve and maintain minutes of all official meetings;
3. (3) to develop an organizational plan which indicates lines of accountability and the qualifications required for staff positions. Such plan may include the delegation of the responsibility for the day-to-day management of the program to a designated professional who is qualified by training and experience to supervise program staff;
4. (4) to review the program's compliance with the terms and conditions of its operating certificate, applicable laws, and regulations;
5. (5) to design and operate services consistent with and appropriate to the ethnic and cultural background of the population served. This can include ethnic representation on the staff and board and inclusion of culturally and ethnically relevant content in service programs;
6. (6) to ensure that planning decisions are based upon input from the child and, where appropriate, their family members;

7. (7) to develop, approve, and periodically review and revise, as appropriate, all program and service policies and procedures. Such policies and procedures shall include, but are not limited to, the following:

   1. (i) written criteria for admission, and discharge from the program;
   2. (ii) policies and procedures for conducting initial and ongoing risk assessments and for development of plans to address identified areas of elevated risk, including procedures to ensure that any health or mental health issues identified are treated appropriately or that an appropriate referral to a treatment provider and subsequent follow up is made;
   3. (iii) policies and procedures addressing child engagement and retention in treatment, including, at minimum, plans for outreach and re-engagement efforts commensurate with a child’s assessed risk;
   4. (iv) policies and procedures for screening for abuse or dependence on alcohol or other substances;
   5. (v) policies and procedures ensuring that a reasonable effort shall be made to obtain records from prior recent episodes of treatment;
   6. (vi) policies and procedures ensuring that a reasonable effort shall be made to communicate with family members, current service providers, and other collaterals, as appropriate;
   7. (vii) written policies and procedures describing an individual grievance process which ensures the timely review and resolution of child complaints and which provides a process enabling the child to request review by the office when resolution is not satisfactory;
   8. (viii) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, gender identity, marital status, age, national origin or sexual orientation, HIV status, military status, predisposing genetic characteristics and the applicable obligations imposed by: title VII of the Civil Rights Act; Federal Executive Order 11246; the Rehabilitation Act of 1973, section 504; the Vietnam Era Veteran's Readjustment Act; the Federal Age Discrimination in Employment Act of 1967; the Federal Equal Pay Act of 1963; the Americans with Disabilities Act of 1990; and the State Human Rights Law (Executive Law, article 15);
   9. (ix) for programs that will provide services to minors, written policies which shall provide for screening of employees, through the New York Statewide Central Register of Child Abuse and Maltreatment, verification of employment history, personal references, work record and qualifications as well as requesting the office to perform criminal history record checks;
   10. (x) written volunteer policies which shall provide for screening of volunteers, through the New York Statewide Central Register of Child Abuse and Maltreatment, verification of employment history, personal references, work history, and supervision of volunteers, as well as requesting the office to perform criminal history checks, in accordance with Part 550 of this Title;
   11. (xi) written policies regarding the selection, supervision, and conduct of students accepted for training in fulfillment of a written agreement between the agency and a State Education Department accredited higher education institution, as well as requesting the office to perform criminal history record checks, in accordance with Part 550 of this Title;
   12. (xii) written policies which shall establish that contracts with third party contractors that are not subject to the criminal history background check requirements established in section 31.35 of the Mental Hygiene Law include reasonable due diligence requirements to ensure that any persons performing services under such contract that will have regular and substantial unsupervised or unrestricted contact with of the program do not have a criminal history that could represent a threat to the health, safety, or welfare of a child in the program, including, but not limited to, the provision of a signed, sworn statement whether, to the best of his or her knowledge, such person has ever been convicted of a crime in this State or any other jurisdiction;
   13. (xiii) written policies and procedures regarding the mandatory reporting of child abuse or neglect, reporting procedures and obligations of persons required to report, mandatory reporting of deaths, immunity from liability, penalties for failure to report, and obligations for the provision of services and procedures necessary to safeguard the life or health of the child. Such policies and procedures shall address the requirements for the identification and reporting of abuse or neglect regarding individuals who are children, or who are the parents or guardians of children; and
   14. (xiv) to ensure the establishment and implementation of training for current and new employees and volunteers that addresses the policies and procedures regarding child abuse and neglect.
8. (8) A provider of service shall ensure that no child who is otherwise appropriate for admission is denied access to services solely on the basis of having a co-occurring non-mental health diagnosis, or a diagnosis of HIV infection, AIDS, or AIDS-related complex.
9. (9) Written policies and procedures governing the child’s records which ensure confidentiality consistent with sections 33.13 and 33.16 of the Mental Hygiene Law and 45 CFR parts 160 and 164.
10. (10) The provider of service shall establish mechanisms for the meaningful participation of child and/or family representatives either through direct participation on the governing body, or through the creation of an individual advisory board. If an individual advisory board is used, the provider of service shall ensure a mechanism for the individual advisory board to make recommendations to the governing body.
11. (11) The provider of service shall develop and make available to individuals and collaterals, a plan which will assure an appropriate response to individuals admitted to the agency and their collaterals who need assistance when the program is not in operation.

12. (12) A provider of service shall ensure that any program subject to this Part does not:

    1. (i) utilize restraint or seclusion for any purpose, including, but not limited to, as a response to a crisis situation, provided, however, that in situations in which alternative procedures and methods not involving the use of physical force cannot reasonably be employed, nothing in this section shall be construed to prohibit the use of reasonable physical force when necessary to protect the life and limb of any person; and
    2. (ii) perform electroconvulsive therapy or aversive conditioning therapy for any purpose, including, but not limited to, as a treatment intervention.
13. (13) A provider of service shall ensure that individual participation in research only occurs in accordance with applicable Federal and State requirements.
14. (14) A provider of service shall ensure the development, implementation and ongoing monitoring of a risk management program that includes the requirements for identification, documentation, reporting, investigation, review, and monitoring of incidents pursuant to the Mental Hygiene Law and Part 524 of this Title.
15. (15) A provider of service has written emergency preparedness and response plan for all of its services and locations that includes responses to environmental and natural disasters and staff shall be trained about it procedures.
16. (16) A provider of service has written protocols to address personal safety of staff and provides appropriate training in de-escalation techniques.

17. (17) There shall be a written utilization review procedure to ensure that the child is receiving appropriate services and are being served at an appropriate level of care. Such policies and procedures shall include provisions ensuring that utilization review is performed and shall be performed only by professional staff trained to do such reviews, or by staff who are otherwise qualified by virtue of their civil service standing, and shall ensure to the maximum extent possible that the designated utilization review authority functions independently of the clinical staff that is treating the individual under review. Such utilization review procedure shall provide for:

    1. (i) a review of the appropriateness of admission to services; and
    2. (ii) a review of the need for continued treatment.