(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 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 recipients and, where appropriate, their family members;

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 criteria for admission, and discharge from the program. Admission policies should include a mechanism for screening individuals at the time of referral and assuring that those referred from inpatient, forensic, or emergency settings, those determined to be at high risk, and those determined to be in urgent need by the Director of Community Services receive initial assessment services within five business days, and if indicated, are admitted to the clinic or referred to an appropriate provider of services. The county may establish, subject to the approval of the office, categories of individuals to be considered in urgent need of services;
   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 by the clinic or that an appropriate referral to a treatment provider and subsequent follow up is made;
   3. (iii) policies and procedures addressing recipient engagement and retention in treatment, including, at minimum, plans for outreach and re-engagement efforts commensurate with an individual’s assessed risk;
   4. (iv) policies and procedures for age appropriate health monitoring, which describe whether such monitoring will be performed by the provider or, if not, how the provider will seek to ascertain relevant health information. Such policies and procedures must include a requirement that an individual’s refusal to provide access to such information be documented in the case record;
   5. (v) policies and procedures for screening for abuse or dependence on alcohol or other substances;
   6. (vi) policies and procedures ensuring that a reasonable effort shall be made to obtain records from prior recent episodes of treatment;
   7. (vii) policies and procedures ensuring that a reasonable effort shall be made to communicate with family members, current service providers, and other collaterals, as appropriate;
   8. (viii) written policies and procedures to ascertain whether individuals are currently receiving or are eligible to receive Medicare or Medicaid or other form of reimbursement for services provided. If it is determined that an individual is eligible for any such program but not currently enrolled, the policies and procedures shall include means of facilitating the enrollment of such individual in such program;
   9. (ix) written policies and procedures concerning the prescription and administration of medication which shall be consistent with applicable Federal and State laws and regulations and which includes procedures for ensuring that individuals are receiving prescribed medications and using them appropriately;
   10. (x) written policies and procedures governing recipients' records which ensure confidentiality consistent with sections 33.13 and 33.16 of the Mental Hygiene Law and 45 CFR parts 160 and 164, and which provide for appropriate retention of such records pursuant to section 599.11 of this Part;
   11. (xi) written policies and procedures describing a recipient grievance process which ensures the timely review and resolution of recipient complaints and which provides a process enabling recipients to request review by the office when resolution is not satisfactory;
   12. (xii) written personnel policies which shall prohibit discrimination on the basis of race, color, creed, disability, sex, marital status, age, HIV status, national origin, military status, predisposing genetic characteristics, or sexual orientation;
   13. (xiii) written policies which are consistent with the obligations imposed by titles VI and VII of the Civil Rights Act, Federal Executive Order 11246, article 15 of the Executive Law (Human Rights Law), article 15-a of the Executive Law (Minority and Women Business Enterprises Program), section 504 of the Rehabilitation Act of 1973, the Vietnam Era Veteran's Readjustment Act, the Federal Age Discrimination in Employment Act of 1967, and the Federal Americans with Disabilities Act;
   14. (xiv) for clinics 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 in accordance with Part 550 of this Title;
   15. (xv) for clinics that will provide services exclusively to adults, written policies which shall provide for verification of employment history, personal references, work record, and qualifications, as well as requesting the office to perform criminal history record checks in accordance with Part 550 of this Title;
   16. (xvi) written volunteer policies which shall provide for screening of volunteers, through the New York Statewide Central Register of Child Abuse and Maltreatment (for clinics that will provide services to minors), 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;
   17. (xvii) written policies regarding the selection, supervision, and conduct of students accepted for training in fulfillment of a written agreement between the clinic 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;
   18. (xviii) written policies regarding the employment, supervision and privileging of nurse practitioners and physician assistants. Such policies shall ensure that physician assistants have responsibilities related to physical health only. Such policies shall ensure compliance with Part 550 of this Title concerning the requirement for criminal history record checks, for obtaining clearance from the New York State Central Register of Child Abuse and Maltreatment for persons who have the potential for regular and unsupervised or unrestricted contact with children, and for appropriate consideration and confidentiality of such information;
   19. (xix) 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 patients of the clinic do not have a criminal history that could represent a threat to the health, safety, or welfare of the patients of the clinic, 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; and
   20. (xx) 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
8. (8) to ensure the establishment and implementation of an ongoing training program for current and new employees and volunteers that addresses the policies and procedures regarding child abuse and neglect described in paragraph (7) of this subdivision.

(e) The provider of service shall establish mechanisms to ensure that priority access is given to individuals referred to the provider, who are enrolled in an assisted outpatient treatment program established pursuant to section 9.60 of the Mental Hygiene Law, in accordance with the following:

1. (1) The provider of service shall cooperate with the local governmental unit or the commissioner, or their authorized representatives, in ensuring priority access by such individuals, and in the development, review and implementation of treatment plans for such individuals.
2. (2) Prior to discharge by a provider of service of an individual who is also enrolled in an assisted outpatient treatment program, the provider of service shall notify the individual's case manager and the director of the assisted outpatient treatment program for the county.
3. (3) Any and all related information, reports and data that may be requested by the commissioner or the local governmental unit shall be furnished by the provider of service. Any requests for clinical records from persons or entities authorized pursuant to section 33.13 or 33.16 of the Mental Hygiene Law, regarding individuals who are the subject of, or under consideration for, a petition for an order authorizing assisted outpatient treatment shall be given priority attention and responded to without delay.

(h) A provider of service shall ensure that any clinic subject to this Part does not:

1. (1) 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. (2) perform electroconvulsive therapy or aversive conditioning therapy for any purpose, including, but not limited to, as a treatment intervention.

(l) There shall be a written utilization review procedure to ensure that all recipients are 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, at a minimum, on a random 25 percent sample of open cases, 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 recipient under review. Such utilization review procedure shall provide for:

1. (1) a review of the appropriateness of admission to a clinic treatment program; and

2. (2) a review of the need for continued treatment in a clinic treatment program within seven months after admission and every six months thereafter unless the recipient is:

   1. (i) discharged out of the program and subsequently readmitted, wherein the cycle begins again; or
   2. (ii) receiving medication therapy and medication education services only, wherein the need for continued treatment shall be reviewed every 12 months thereafter.