N.Y. Comp. Codes R. & Regs. tit. 14, § 582.7 – Staffing.

(a) The governing body shall continuously employ an adequate number of appropriately qualified staff to carry out the program of examination, diagnosis, care, treatment and rehabilitation effectively. A written rationale for the staffing pattern utilized shall be developed for approval by the Office of Mental Health. The written rationale shall include a plan for appropriate supervision of staff and volunteers. The plan shall include procedures for periodic supervisory conferences for staff and volunteers and procedures for written performance evaluations consistent with collective bargaining requirements.
(b) The director and all staff physicians shall be currently registered and licensed to practice medicine in the State of New York; their qualifications shall be reported to the office at the time of their employment.
1. (1) The hospital shall not permit physicians in training to perform a service for which a license is required by the State of New York except as a part of an approved training program and unless authorized by a temporary certificate to practice medicine at the hospital and they are at the time under the direct control and supervision of a currently registered and licensed physician.
  1. (i) A training program to be approved must be accredited by the Council on Medical Education of the American Medical Association, the appropriate specialty boards or any other recognized approval body based on standards acceptable to the office.
  2. (ii) With respect to the care of persons eligible for health insurance and medical assistance only, training programs must comply with the requirements of applicable rules and regulations of the Secretary of Health and Human Services pertaining to resident, intern and medical student training programs enacted pursuant to the Health Insurance for the Aged Act.
2. (2) All direct service, other than in an emergency, provided by interns, house officers, residents or physicians with equivalent titles must be provided as specified in paragraph (1) of this subdivision or must be provided by a physician currently registered and licensed to practice in New York State.
(c) The nursing service shall be under the direction of a nurse practitioner or registered nurse experienced in the care of patients with mental illness and in the administration of psychiatric nursing services.
(d) The medical recordkeeping shall be under the direction of a registered records librarian or in accordance with consultation by a person eligible for registration by the American Medical Records Association.
(e) All staff members providing services as members of professions, the practice of which is by law required to be licensed, certified or registered, shall file documentation of compliance with the governing body; this documentation shall be retained on file and made available to the office upon request.
(f) All staff members providing services as members of professions, the practice of which does not by law require licensure, certification or registration, shall file documentation of their training and experience with the governing body.
(g) All other program staff shall have qualifications appropriate to their assigned responsibilities as set forth in written policies of the governing body, and shall be subject to appropriate professional staff supervision.
(h) There shall be properly trained personnel adequate for continuous maintenance and housekeeping of buildings, grounds, equipment, and for all other duties necessary for the administration of the hospital.
(i) The certificate holder shall submit reports to the office, as required, of the staff employed by and available in the hospital.