(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 ensure that the design and operation of the program is consistent with and appropriate to the ethnic and cultural background of the patient population;
6. (6) to ensure that recipients and their families have a mechanism for participating in treatment or psychiatric rehabilitation service planning decisions;

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

   1. (i) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, marital status, age, national origin or sexual orientation;
   2. (ii) written policies which shall provide for verification of employment history, personal references, work record and qualifications, as well as securing a signed, sworn statement whether, to the best of his or her knowledge, the applicant has ever been convicted of a crime in this State or any other jurisdiction and for appropriate consideration and confidentiality of such information;
   3. (iii) written volunteer policies which shall provide for screening of volunteers, verification of employment history, personal references and work history, and supervision of volunteers. Such policies shall also provide for securing a signed, sworn statement whether, to the best of his or her knowledge, the volunteer has ever been convicted of a crime in this State or any other jurisdiction, for appropriate consideration and confidentiality of such information;
   4. (iv) written policies which are consistent with the 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, and the American Disabilities Act of 1990;
   5. (v) written policies and procedures concerning the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations;
   6. (vi) written policies and procedures governing recipients' records which ensure confidentiality consistent with the Mental Hygiene Law, and which provide for appropriate retention of such records pursuant to section 587.18 of this Part;
   7. (vii) written criteria for admission, and discharge from the program;
   8. (viii) written policies and procedures regarding the mandatory reporting of child abuse or neglect, reporting procedures and obligations of persons required to report, provisions for taking a child into protective custody, 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 recipients who are children, or who are the parents or guardians of children; and
   9. (ix) written policies and procedures describing a recipient grievance process which ensure the timely review and resolution of recipients' complaints and which provides a process enabling recipients to request review by the Office of Mental Health when resolution is not satisfactory; and
8. (8) to ensure the establishment and implementation of an ongoing training program for current and new employees and volunteers which address the policies and procedures regarding child abuse and neglect described in subparagraph (7)(viii) of this subdivision.

(m) The provider of service shall participate as required with the local governmental unit in local planning processes pursuant to sections 41.05 and 41.16 of the Mental Hygiene Law. At a minimum, such participation shall include:

1. (1) provision of budgeting and planning data as requested by the local governmental unit;
2. (2) identification of the population being served by the program;
3. (3) identification of the geographic area being served by the program; and
4. (4) description of the program's relationship to other providers of service including, but not limited to, a description of all written agreements entered into pursuant to this Part.