(c) The governing body shall comply with all requirements set forth in 10 NYCRR Part 405 as well as requirements established by appropriate local, State and Federal standard-setting bodies. In addition, the governing body shall be responsible for the following duties:

1. (1) 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 program director who shall be a member of the professional staff employed by the comprehensive psychiatric emergency program. The program director shall report to the director of the host hospital or to the Director of Psychiatry;

2. (2) ensure efforts to reduce disparities in access, quality of care and treatment outcomes for underserved/unserved marginalized populations, including but not limited to: people of color, members of the LBGTQ community, older adults, Veterans, individuals who are deaf and hard of hearing, individuals who are Limited English Proficient, immigrants, and individuals re-entering communities from jails and prisons. 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 or national origin, as well as, written policies on affirmative action which are consistent with the affirmative action and equal employment opportunity obligations imposed by title VII of the Civil Rights Act, Federal Executive Order 11246, the Rehabilitation Act of 1973, section 504, as amended, and the Vietnam Era Veteran's Readjustment Act;

3. (3) to develop, approve, 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 policies and procedures governing patient records which ensure confidentiality consistent with the Mental Hygiene Law, sections 33.13, 33.14 and 33.16, 45 C.F.R. parts 160 and 164 and which provide for appropriate retention of such records pursuant to section 590.12 of this Part; and
   2. (ii) written policies that ensure the protection of patients' rights. At a minimum these policies shall establish and describe a patient grievance procedure. The provider shall post a statement of patients' rights in a conspicuous location easily accessible to the public pursuant to section 590.15 of this Part.
4. (4) To make an effort that the comprehensive psychiatric emergency program’s staffing matches the demographic profile of the persons served, the program regularly uses data to set workforce recruitment targets. Efforts to recruit a diverse workforce should include all levels of the organization’s workforce, including management.

(f) Comprehensive psychiatric emergency programs shall ensure provision of language assistance services to individuals who are Limited English Proficient and/or have other communication needs (e.g., deaf or hard of hearing) at no cost to them to facilitate timely access to all health care and services. Language access services will be made available in such a way that assessment or treatment activities will not be delayed.

1. (1) The comprehensive psychiatric emergency program shall make all necessary documents available in the individual’s preferred language (e.g. releases). The program shall inform all individuals of their right to receive language assistance services clearly and in their preferred language, verbally and in writing.
2. (2) The comprehensive psychiatric emergency program provides easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area, with a focus on the varied reading levels among the service user population.
3. (3) Efforts are made to provide the individuals identified as collaterals with language assistance services translated into their preferred language, verbally and in writing.
4. (4) Efforts are made to employ staff that are proficient in the most prevalent languages spoken by services users.

5. (5) Ensures the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.

   (g) Incidents.

6. (1) The hospital shall ensure the timely reporting, investigation, review, monitoring and documentation of incidents pursuant to the Mental Hygiene Law and Part 524 of this Title. Additionally, such records and any related information shall be made available to the Department of Health, at their request.

   1. (i) The comprehensive psychiatric emergency program shall utilize New York Incident Management Reporting System reports or other available incident/data analysis program reports to assist in risk management activities and compile and analyze incident data for the purpose of identifying and addressing possible patterns and trends to improve service delivery.

7. (2) Incident training.

   1. (i) All new staff shall receive training which must include at a minimum, the definition of incidents, reporting procedures, an overview of the review process, and the role of risk management.
   2. (ii) Refresher incident reporting training shall be conducted at least annually for all staff and evidence of such training must be recorded in the staff personnel file.
8. (3) The hospital’s incident review committee shall review incidents, make recommendations and ensure implementation of action plans with the comprehensive psychiatric emergency program’s administrator.

(i) The hospital shall participate 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.