(d) The governing body shall approve a written plan or plans that, at a minimum, address the following aspects of the operation of each crisis residence program:

1. (1) the goals and objectives of the crisis residence program, including the admission and discharge criteria;
2. (2) the plan of organization that clearly indicates lines of responsibility;

3. (3) a written plan for services and staff composition which:

   1. (i) includes the qualifications and duties of each staff position by title, and addresses all essential aspects of the operation of the crisis residence program, including clinical, administrative, supervision, fiscal, clerical, housekeeping, maintenance, dietetic, and recordkeeping and reporting functions; and
   2. (ii) specifies all services available through the crisis residence program;
4. (4) the written quality assurance plan pursuant to section 589.10 of this Part; and
5. (5) the written utilization review plan pursuant to section 589.11 of this Part.

(e) The governing body shall approve written policies and procedures of the crisis residence program including but not limited to:

1. (1) admission and discharge policies and procedures;
2. (2) policies and procedures regarding the rules and regulations necessary for program participation;
3. (3) personnel policies and procedures. Such policies and procedures shall prohibit discrimination on the basis of race, color, creed, disability, national origin, sex, marital status, age, HIV status, military status, predisposing genetic characteristics, gender identification or sexual orientation and shall provide for a review of the qualifications of all clinical staff and verification of employment history, personal references and work record and determination of past convictions of a crime in New York State or any other jurisdiction;
4. (4) staff training and development policies and procedures. Such policies and procedures shall address orientation, ongoing training and staff development to ensure that the design and operation of the program is consistent with and appropriate to the ethnic and cultural background of the recipient population; and that staff are trained in how to provide appropriate Language Access for recipients and family members or guardians with limited English proficiency;
5. (5) medication policies and procedures. Such policies and procedures shall be consistent with applicable Federal and State laws and regulations;
6. (6) case record policies and procedures. Such policies and procedures shall ensure confidentiality of recipient records in accordance with section 33.13 of the Mental Hygiene Law, and shall ensure appropriate retention of case records;
7. (7) policies and procedures related to performing the services provided by the crisis residence program;
8. (8) policies and procedures describing a recipient grievance process which ensures the timely review and resolution of recipients’ complaints and which provides a process allowing recipients to request review by the appropriate Office of Mental Health field office when resolution is not satisfactory; and

9. (9) for children’s crisis residence programs, written policies and procedures shall also include:

   1. (i) a staff supervision plan that identifies the minimum skills and competencies necessary for staff to supervise recipients in the program independent of direct supervision; including general child supervision practices and individual precautions designed to ensure a safe environment for all recipients;
   2. (ii) visiting procedures for family members or guardians, including the ability to participate in planned clinical, supportive and/or recreational activities; and
   3. (iii) provisions addressing the identification and mandatory reporting of child abuse or neglect, including, 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.

(g) The governing body shall delegate responsibility for the day-to-day management of the crisis residence program in accordance with the written plan of organization provided for in paragraph (e)(2) of this section.

1. (1) Onsite direction shall be delegated to an individual who shall be known as the director and who shall meet the qualifications specified in section 589.8(d) of this Part.
2. (2) The director shall be employed by the agency as a full-time employee.
3. (3) Overall administrative direction may be the responsibility of the director or may be delegated by the governing body to an individual who shall meet qualifications that are acceptable to the Office of Mental Health.

(h) The crisis residence program shall provide for the following:

1. (1) an annual written evaluation of the crisis residence program's attainment of its stated goals and objectives including any required changes in policies and procedures;
2. (2) in programs which are not State or local government-operated, an annual audit of the financial condition and accounts of the crisis residence program must be performed by a certified public accountant who is not a member of the governing body or an employee of the crisis residence program or the provider of service. Government-operated programs shall comply with applicable laws concerning financial accounts and auditing requirements. The audit may be program specific or may be performed as part of an overall facility audit;
3. (3) emergency evacuation plans for the building in which the crisis residence program is located. Evacuation plans shall address emergencies resulting from fire as well as potential hazards in the geographic area in which the crisis residence program is located; and
4. (4) up-to-date copies of any regulations, guidelines, manuals or other information required by the Office of Mental Health.