N.Y. Comp. Codes R. & Regs. tit. 14, § 690.6 – Standards of certification.

(a) OPWDD shall verify (see glossary) that each operator of a Part 690 certified day treatment facility has annually submitted the names and addresses of the current members of its governing body to the commissioner in accordance with the requirements of section 13.39 of the Mental Hygiene Law.
(b) OPWDD shall verify that the governing body has established, maintained, and implemented a plan of organization for the facility which accurately indicates lines of account ability, the nature of professional responsibility to be exercised, and the professional qualifications required.
(c) OPWDD shall verify that since the last survey:
1. (1) any new/revised policies have been provided to the governing body;
2. (2) any new/revised policies have been distributed to staff, and, when applicable, staff have been advised or trained regarding their responsibilities; and
3. (3) staff are knowledgeable regarding their responsibilities under any new/revised policies/procedures.
(d) Minutes of all official meetings of the governing body of other than State-operated Part 690 day treatment facilities are maintained as a permanent record in relation to the policy making decisions and any decisions made relative to the operation of the facility.
(e) OPWDD shall verify that the facility's staffing plan and actual day-to-day allocation of staff includes provisions for all services to be delivered by or under the direct supervision (see glossary) of qualified professionals.
(f) At least 25 percent of the full-time equivalent professional staff shall meet the QIDP requirement.
(g) OPWDD shall verify that each person admitted for service has a treatment coordinator.
(h) OPWDD shall verify that a person's individual program plan reflects coordination between the treatment coordinator and the person's case manager.
(i) OPWDD shall verify that each person's individual program plan has been approved by the facility's medical director/physician within 30 days of its implementation, and within 30 days of any subsequent substantial (i.e., involving input or recommendations of the interdisciplinary treatment team) change to the plan.
(j) OPWDD shall verify that individual program plans refiect:
1. (1) the adequacy of the record and the appropriateness of the services delivered relative to the person's comprehensive functional assessment;
2. (2) integration of all services provided at the day treatment facility;
3. (3) coordination of day treatment services with the person's services provided in a certified residence;
4. (4) reviews and assessments are present; and
5. (5) the appropriate notifications have been made.
(k) OPWDD shall verify that the activities and services engaged in by the person are consistent with, and generally reflect the values associated with individualization, inclusion, independence and productivity.
(l) OPWDD shall verify that the annual interdisciplinary treatment team review process includes:
1. (1) such reassessments of the person's capabilities, capacities, needs, and preferences as may be indicated;
2. (2) participation by the person, the person's correspondent (which includes invitation, if not actual attendance), and advocate (if appropriate), unless the person is an adult capable of objecting to such participation and has so objected;
3. (3) review of a person's comprehensive functional assessment for relevancy, updating it as necessary, and revising the individual program plan as appropriate;
4. (4) a review of the outcome of the services delivered;
5. (5) establishment of modified or new outcomes, if need or preference is indicated;
6. (6) a listing of all parties who attended the review, by name and title or role; and
7. (7) notification, at least semi-annually, of the person's status and progress sent to the person's correspondent and the certified residential facility, if applicable, unless the person is an adult with the capacity to object to such notification and does object.
(m) OPWDD shall verify that, at least annually, the interdisciplinary treatment team, with the medical director's input, reviewed the status of persons receiving services with regard to the following:
1. (1) the advisability of continued receipt of day treatment services; or
2. (2) the advisability and availability of alternative services; and
3. (3) how the person may exercise his or her civil and legal rights.
(n) OPWDD shall verify that the facility's quality assurance process defines methods for the identification and selection of clinical and administrative problems to be reviewed, and includes:
1. (1) the establishment of review criteria developed for monitoring and assessing the appropriateness of treatment and clinical performance;
2. (2) regularly scheduled reviews of clinical records, complaints, suggestions from persons served, their correspondents and/or advocates, reported incidents or allegations of abuse, and other documents pertinent to problem identification;
3. (3) documentation of all quality assurance activities, including but not limited to the findings, recommendations, and actions taken to resolve identified problems; and
4. (4) the timely implementation of corrective actions and periodic assessments of the results of such actions with adjustments, as appropriate.
(o) OPWDD shall verify that the findings, conclusions, recommendations, and actions taken as a part of the facility's quality assurance program have been reported to the governing body.
(p) OPWDD shall verify that persons admitted and their correspondents and/or advocates were notified as to hours of operation, availability and source of emergency services, phone number(s) of answering services for messages at times when the facility is not in operation, and rights associated with the receipt of services. Further, this information has been provided in a person's primary language and/or in a manner that facilitates communication and understanding.
(q) OPWDD shall verify that assessment and treatment information was provided in a person's primary language and/or in a manner that facilities communication and understanding.
(r) OPWDD shall verify that individual program plans are maintained in a confidential manner and that the plans contain at least:
1. (1) identification information about the person and his or her family, and services received outside of the day treatment facility (including identification of practitioner or responsible entity);
2. (2) source of referral, date service commenced, and the name of the party responsible for treatment coordination;
3. (3) initial, interim, and/or final diagnosis(es), as applicable, set forth in appropriate official terminology, including those related to the person's developmental disability, other mental disability(ies) if present, and medical condition/diagnoses;
4. (4) reports of all known, recent (i.e., within the last year) diagnostic examinations and assessments, including findings and conclusions, regardless of source, including reports of any special studies and/or laboratory procedures performed at the day treatment facility's recommendation;
5. (5) the individual written plan of services for all services being recommended and delivered by the facility; and
6. (6) treatment notes signed by the professional staff member or treatment coordinator making the note.
(s) OPWDD shall verify that individual program plans of persons admitted to the day facility include:
1. (1) progress notes describing the person's response in terms of the established objectives;
2. (2) written notations regarding significant changes in the person's performance, attitudes, feelings and physical condition;
3. (3) summaries specific to the person's goals and objectives prepared or reviewed and approved by qualified professionals providing or supervising services and reviewed by the treatment coordinator of the person's program plan; or a summarization, by the treatment coordinator, of all services being provided to the person;
4. (4) an activity and attendance schedule for each person;
5. (5) identification of the staff members responsible for providing each service; and
6. (6) at the time of discharge, a plan by which the person will be discharged to a facility or services more consistent with the person's needs and/or preferences. The plan shall include specific identification of any services needed and/or desired by the person.
(t) OPWDD shall verify that allowable services (see section 690.3[a] of this Part) have been provided by or under the supervision of a qualified professional(s) in accordance with the provisions of the persons' individual program plans.
(u) OPWDD shall verify that the facility has maintained written records which document the names of staff participating in the orientation and in-service training programs, the content and frequency of these training programs, and the qualifications of the parties conducting the training programs.
(v) OPWDD shall verify that before releasing information to parties who are otherwise not authorized to receive it, the facility had obtained written consent from the person, except that the written consent may have been obtained from the parent or guardian when the following applies:
1. (1) the person has been adjudicated incompetent under State law; and
2. (2) there is a demonstrable need for the information and it may be reasonably expected to not be detrimental to the person; or
3. (3) the person is under the age of 18.
(w) OPWDD shall verify there is documentation that:
1. (1) a preliminary screening, based on task oriented observations or a review by qualified professionals of the person's clinical records obtained from another appropriate source, was completed to the extent necessary to support admission to the facility, and included a preliminary appraisal or determination of the person's capabilities, capacities, and needs in the areas of communication, mobility, learning, independent living, self-care, health care and self-direction; and
2. (2) within 90 days of admission, this preliminary screening information has been fully verified by assessments (see glossary), and documented in the person's individual program plan.
(x) OPWDD shall verify that facility staff have, with due diligence, sought to make available or arrange for appropriate alternative services for those persons for whom the interdisciplinary treatment team has determined that day treatment services are no longer suitable. Such efforts shall be documented in the person's individual program plan or a formal discharge plan.