N.Y. Comp. Codes R. & Regs. Tit. 18 § 487.9 - Personnel
(a)
General
requirements.
(1) The operator shall
provide staff sufficient in number and qualified by training and experience to
render, at a minimum, those services mandated by statute or
regulation.
(2) In a facility with
a resident census in excess of 200 persons, a significant number of mentally
disabled persons or a population with special needs, the department may require
additional staff or specially qualified staff. Such requirements shall be based
upon the number of residents, resident needs, physical layout and location of
the facility.
(3) The operator
shall conduct an initial program of orientation and in-service training for
employees and volunteers, which includes:
(i)
orientation to the characteristics and needs of the population;
(ii) discussion of the residents' rights and
the facility's rules and regulations for residents;
(iii) discussion of the duties and
responsibilities of all staff;
(iv)
discussion of the general duties and responsibilities of the individual(s)
being trained;
(v) discussion
relative to the specific duties and tasks to be performed;
(vi) training in emergency procedures;
and
(vii) with respect to
facilities subject to the Justice Center, training in the identification of
reportable incidents, facility reporting procedures and, if the employee is a
mandated reporter under section
488 of the
Social Services Law or otherwise required to report under section
424-a of
the Social Services Law, such person's responsibility to file reports under
those provisions;
(viii) with
respect to facilities subject to the Justice Center, provision of a copy of the
code of conduct established by the Justice Center pursuant to section
554 of the
Executive Law. Such code of conduct shall be provided at the time of initial
employment, and at least annually thereafter during the term of employment.
Receipt of the code of conduct must be acknowledged, and the recipient must
further acknowledge that he or she has read and understands such code of
conduct. Any other individuals, including contractors or other service
providers who will or could have resident contact, and falling within the
definition of custodian under section
488 of the
Social Services Law, must also be provided with, and acknowledge receipt and
understanding of, such code of conduct.
(4) The operator shall conduct ongoing
in-service training, and shall provide opportunities for employees and
volunteers to participate in work-related training provided by the operator or
others.
(5) The operator shall
maintain documentation of the orientation and training sessions, including
date, time, topic and names of persons conducting and attending.
(6) The operator shall develop and maintain
current written staffing schedules. Past staffing schedules shall be retained
for 12 months.
(7) The operator
shall maintain personnel records which include:
(i) individual employee records containing
verification of qualifications for any position for which qualifications are
set by regulation, medical evaluation, and any incident reports involving the
employee;
(ii) payment records
containing all wages, benefits, reimbursements, bonuses, gifts or payments
given each employee;
(iii) with
respect to facilities subject to the Justice Center, documentation that the
facility has verified, through consultation with the Justice Center, prior to
hiring the employee, volunteer, or contractor falling within the definition of
custodian in section
488 of the
Social Services Law, whether the individual is on the Justice Center's register
of substantiated category one cases of abuse or neglect as established pursuant
to section
495 of the
Social Services Law (staff exclusion list) and, where such individual is not on
such list, documentation that the facility has verified whether the individual
is on the Office of Children and Family Services' Statewide Central Registry of
Child Abuse and Maltreatment (State Central Registry); and
(iv) prior to hiring or otherwise engaging
anyone who will or may have direct contact with residents, or approving
credentials for any such person, the operator of a facility subject to the
Justice Center shall follow the procedures established by the Justice Center in
regulations or policy, to verify that such person is not on the Justice
Center's staff exclusion list. If such person is not on the Justice Center's
staff exclusion list, such operator shall also consult the State Central
Registry as required by section
424-a of
the Social Services Law. If such person is on the staff exclusion list, a
facility subject to the Justice Center shall not hire or otherwise engage such
person; if such person is not on the staff exclusion list but is on the State
Central Registry, a facility subject to the Justice Center shall consider the
inclusion of such person on the State Central Registry as a factor in its
decision, but shall not be prohibited from hiring or otherwise engaging such
person.
(8) At the time
of employment and at least every 12 months thereafter, or more frequently if
needed, an employee must provide the operator with a statement from a
physician, or, with physician oversight, a physician's assistant (PA) or a
registered professional nurse (RN) with special training in primary health care
who has physically examined the individual, that:
(i) the individual is free from any health
impairment which is of potential risk to residents of an adult home or which
might interfere with the performance of the individual's duties; and
(ii) that the individual has had:
(a) an initial individual tuberculosis (TB)
risk assessment, symptom evaluation, and TB test (either tuberculin skin test
or blood assay approved by the Food and Drug Administration for the detection
of latent tuberculosis infection) prior to employment and subsequent annual
assessments after employment begins; positive findings shall require
appropriate clinical follow-up. The operator shall develop and implement
policies regarding positive findings, including procedures for facilitating and
documenting treatment for latent TB infection where indicated. The annual TB
assessments shall include education, individual risk assessment, and follow-up
tests as indicated; and
(b) any
test that may be required by the local board of health.
(9) Notwithstanding paragraph (8)
of this subdivision, physical examinations need not be required for an
applicant or an employee who relies upon or is being furnished treatment by
spiritual means through prayer in lieu of medical treatment, in accordance with
the tenets and practices of a recognized church or religious denomination of
which the employee is a member or bona fide adherent. In such cases the
operator shall require documentation of the employee's standing as a
member.
(10) No individual who is
suffering from a degree of mental illness or habituation or addiction to
alcohol or other drugs such that the individual causes, or is likely to cause,
danger to himself or others or is unable to perform his/her assigned duties,
shall be employed or permitted to work as either an employee or
volunteer.
(11) No individual shall
be permitted to work, either as an employee or volunteer, if infected with a
communicable disease that might endanger the health of residents.
(12) Each individual shall:
(i) be emotionally, mentally and physically
able, as required by function, to provide services and supervision to the
population served by the facility; and
(ii) maintain personal hygiene and clothing
which is clean and appropriate for the functions performed.
(13) Employees who have direct
contact with residents shall be able to speak, read and write English, and
speak the predominant language of residents.
(14) No person under 18 years of age shall:
(i) be charged with direct responsibility for
the supervision and personal care of residents; or
(ii) be permitted to work without onsite
supervision.
(15) At
least one individual currently qualified by a recognized organization to
administer basic first aid shall be on duty and onsite at all times.
(16) The operator must inform the appropriate
regional office by telephone or in writing within three business days of a
vacancy in the position of administrator, case manager, activities director,
dietary consultant or health consultant.
(17) Prior to hiring or otherwise engaging
any employee, volunteer or others falling within the definition of
custodian under section
488 of the
Social Services Law which will or may have direct contact with residents, the
operator of a facility subject to the Justice Center shall consult with the
Justice Center for the Protection of People with Special Needs, to verify that
such person is not on the Justice Center's register of substantiated category
one cases of abuse or neglect as established pursuant to section
495 of the
Social Services Law (staff exclusion list).
(18) Repealed
(b)
Resident employment and volunteer
work.
(1) Use of residents as
volunteers shall be permitted only to the extent that such voluntary services
are:
(i) entered into without use of coercion
or threats to the resident;
(ii)
not substituted for services of paid employees as required elsewhere in this
Part; and
(iii) not inconsistent
with the physical or emotional needs or limitations of the resident.
(2) Employment of residents shall
be permitted only to the extent that such employment:
(i) is entered into without use of coercion
or threats to the resident;
(ii) is
performed in return for fair compensation; and
(iii) meets all applicable requirements of
Federal and State Labor Law.
(3) The operator shall maintain written
records which document each instance in which a resident elects to perform
routine paid or volunteer services, including:
(i) the name of each resident performing paid
or volunteer services;
(ii) the
tasks performed;
(iii) the rate,
type and amount of compensation, if any; and
(iv) the hours and days worked.
(c)
Administration.
(1) The operator
shall employ an administrator, or act in his own stead if qualified. The
administrator shall be directly accountable to the operator for operating and
maintaining the facility in compliance with applicable requirements.
(2) A person shall not be designated as
administrator without prior written approval of the department. Such approval
shall be based upon a review of the qualifications set forth in paragraph (9)
of this subdivision and demonstrated knowledge of regulation of adult homes as
evidenced by previous satisfactory experience or examination by the
department.
(3) Approval of an
administrator may be withdrawn and civil penalties may be imposed if the
department finds, upon inspection and enforcement, that the administrator is
unable or unwilling to carry out any of the responsibilities set forth in
paragraph (8) of this subdivision.
(4) In facilities with a certified capacity
of 25 or more beds, a qualified administrator shall be employed and on duty
during the day at least 40 hours per week.
(5) In facilities with a certified capacity
of 24 beds or less, a qualified administrator shall be employed and on duty
during the day for a minimum of 20 hours per week.
(6) In a facility with 24 or less beds, the
administrator, in addition to being designated as case manager and activities
director, may perform personal care, food service, housekeeping or other
required functions for up to 10 hours of the required 20-hour
minimum.
(7) In a multilevel health
care facility, the administrator of the residential health care facility may be
approved as the administrator of the adult home. Such approval will be granted
if the following conditions are met:
(i) The
administrator must be a licensed nursing home administrator, and must be in the
adult home and accessible to residents at least eight hours each
week.
(ii) The operator must
provide a satisfactory written plan for supervision of the adult care facility,
which includes:
(a) a description of the
system by which supervision of the facility will be exercised;
(b) designation of an assistant
administrator; and
(c) a profile of
the education and experience qualifications of the proposed assistant
administrator.
(iii) The
minimum hourly requirements for the combined on-duty presence of the
administrator and assistant administrator shall be equal to those required in
paragraphs (4) and (5) of this subdivision.
(8) The administrator shall be capable of and
responsible for:
(i) supervision of the
facility;
(ii) operation of the
facility in compliance with law and regulations;
(iii) recruitment and general supervision of
staff and volunteers;
(iv)
supervision of resident services;
(v) admission, transfer and discharge of
residents;
(vi) coordination with
and development of community activities and services for residents;
(vii) maintenance of community
relations;
(viii) protection of
residents' rights and development of appropriate mechanisms for their
protection;
(ix) maintenance of a
system to enable residents to present grievances or recommendations regarding
facility operations and programs; and
(x) investigation of and reporting to the
department allegations of occurrences which would constitute a reportable
incident.
(9) An
administrator shall:
(i) be at least 21 years
of age;
(ii) be of good moral
character, as evidenced by at least three recent letters of recommendation from
individuals knowledgeable of the proposed administrator's background,
qualifications and interest in the field of adult care;
(iii) in a facility with a capacity of 24
beds or less, have the following education and work experience:
(a) a high school diploma or equivalency
certificate, plus three years of related work experience acceptable to the
department, one year of which includes related supervisory experience;
or
(b) an associate degree from an
accredited college or university in an approved course of study, plus two years
of related work experience acceptable to the department, one year of which
includes related supervisory experience; or
(c) a bachelor's degree from an accredited
college or university in an approved course of study, plus one year of related
supervisory experience acceptable to the department.
(iv) in a facility with a capacity of 25 to
90 beds, have the following education and other experience:
(a) a high school diploma or equivalency
certificate, plus four years of related work experience acceptable to the
department, two years of which include related supervisory experience;
or
(b) an associate degree from an
accredited college or university in an approved course of study, plus three
years of related work experience acceptable to the department, one year of
which includes related supervisory experience; or
(c) a bachelor's degree from an accredited
college or university in an approved course of study, plus two years of related
work experience acceptable to the department, one year of which includes
related supervisory experience.
(v) in a facility with a capacity of 90 beds
or more, have the following education and other experience:
(a) a high school diploma or equivalency
certificate, plus five years of related work experience acceptable to the
department, two years of which include related supervisory experience;
or
(b) an associate degree from an
accredited college or university in an approved course of study, plus three
years of related work experience acceptable to the department, two years of
which include related supervisory experience; or
(c) a bachelor's degree from an accredited
college or university in an approved course of study, plus two years of related
supervisory experience acceptable to the department.
(10) One year in full-time
attendance in an approved course of study at an accredited college may be
substituted for each year of work experience, other than required supervisory
experience.
(11) Approved courses
of study may include, but need not be limited to, human services for dependent
adults, health care management programs, social work programs, hotel
management, home economics, business management.
(12) Related work experience may include, but
need not be limited to, work in residential care, rehabilitation, health care
management, social work and hotel management.
(13) Related supervisory experience may
include, but need not be limited to, work in a setting described in paragraph
(12) of this subdivision where the individual had responsibility for the
recruitment and supervision of staff and the coordination and management of
related program activities.
(14) An
administrator appointed prior to October 1, 1978 is exempt from the minimum
employment and education requirements specified in subparagraphs (iii), (iv)
and (v) of paragraph (9) of this subdivision while employed at the same
facility or another facility within the same or a smaller size group.
(15) An administrator shall participate in a
program of continuing education which shall:
(i) consist of a minimum of 60 clock hours
over a two-year period;
(ii)
require the prior approval of the department;
(iii) include courses, workshops, educational
seminars, conferences or college-level programs which are directly related to
the fields of administration, supervision, program planning and services, human
behavior, geriatrics, care of the mentally and physically disabled, social
work, health care, financial management or nutrition; and
(iv) include, for the administrator of a
facility with a significant number of mentally disabled residents, at least 15
hours of programming related to the care and treatment of the mentally
disabled.
(16)
Continuing education credits will not be required of an administrator holding a
valid, current New York State license as a nursing home
administrator.
(17) If an
administrator has a post-baccalaureate degree in an approved course of study, a
minimum of 30 clock hours for each two-year period shall be accepted for the
three two-year cycles following award of the degree.
(18) Continuing education courses approved by
the department and attended by the case manager or activities director shall be
accepted for a maximum of 20 of the 60 clock hours required.
(19) In the absence of the administrator, a
responsible person shall be designated to be in charge of the facility and
shall be so identified on the facility staffing schedule. The person designated
shall:
(i) be at least 18 years of
age;
(ii) be mentally and
physically capable of carrying out the duties of an administrator;
(iii) be knowledgeable of facility
operations;
(iv) have access to
records concerned with facility operations;
(v) be empowered to act on behalf of the
operator during the administrator's absence concerning the health, safety,
comfort and well-being of the residents; and
(vi) have had training to carry out
assignments and take care of emergencies and sudden illnesses of
residents.
(d)
Case management.
(1) Each operator shall designate sufficient
staff to perform case management functions.
(i) In facilities with less than 50 beds, the
administrator may be designated in lieu of a qualified case manager.
(ii) In facilities with 50 or more beds, a
qualified case manager shall be on staff and on duty on a pro rata basis for
0.5 hour per week per each additional bed, up to 40 hours per week.
(iii) In a facility where the administrator
is acting as case manager, the operator must designate an employee in addition
to the administrator to be a designated investigator and reporter of
occurrences which would constitute a reportable incident. Nothing in this
subparagraph shall relieve any mandated reporter of his or her legal
obligations to report reportable incidents.
(2) A person may not be designated as case
manager without the prior written approval of the department.
(3) A case manager shall be capable of, and
responsible for, executing, through direct performance and coordination:
(i) the services and functions set forth in
section 487.7(g) of this
Part; and
(ii) investigation of and
reporting to the department and, as applicable, to the Justice Center,
allegations of occurrences which would constitute a reportable
incident.
(4) A case
manager shall have the following education and work experience:
(i) a bachelor's or master's degree from an
accredited college or university with major work in human resources or service
delivery, and one year of full-time experience in the provision of services to
a dependent adult population; or
(ii) an associate degree from an accredited
college or university with major work in human resources or service delivery,
and three years of full-time experience in the provision of services to a
dependent adult population.
(5) A case manager employed in a facility
prior to September 1, 1984 may be exempt from the requirements of paragraph (4)
of this subdivision if he/she has a minimum of one year of experience in the
provision of services to a dependent adult population.
(e)
Activities.
(1) Each operator shall designate staff to
perform the activities services function.
(i)
In facilities with less than 50 beds, the administrator may be designated in
lieu of a qualified activities director;
(ii) In facilities with 50 or more beds, a
qualified activities director shall be on staff and on duty on a pro rata basis
for 0.5 hour per week per each additional bed, up to 40 hours per
week.
(2) An activities
director shall be capable of and responsible for executing, through direct
performance and coordination, the services and functions stipulated in section
487.7(h) of this
Part.
(3) An activities director
shall have, at a minimum, the following education or work experience:
(i) an associate degree from an accredited
college or university, or satisfactory completion of two years of college; in
either case with major work in recreation or a related field; or
(ii) two years of full-time experience in the
recreation field with a dependent, adult population.
(4) An activities director must have minimum
educational qualifications of an associate's degree from an accredited college
or university or satisfactory completion of two years of college with major
work in recreation unless the facility receives the prior written approval of
the department.
(f)
Supervision.
(1) Each operator
shall designate sufficient staff to perform supervision functions during all
hours of operation.
(2) Staff shall
be immediately accessible at all times while on duty.
(3) Provision shall be made for backup
staff.
(4) During the day and
evening, staff responsible for direct resident services, i.e.,
the administrator, case management, activities or personal care services staff,
may be designated to perform resident supervision services.
(5) Night staff may be assigned personal care
or other duties which do not interfere with their accessibility, provided that
such staff remain responsible and available for supervision services.
(6) The minimum number of staff required for
resident supervision shall be determined by resident census. The following
number of staff shall be on duty and on site 24 hours a day.
| Resident census | Staff required |
| 1-40 | 1 |
| 41-80 | 2 |
| 81-150 | 3 |
| 151-200 | 4 |
(7) An additional staff person shall be
required for each additional 60 residents or part thereof.
(8) The department may require additional
staff based on resident needs, physical layout and the location of the
facility.
(9) If local codes
require a night watchman, that position shall not be counted as part of the
minimum number of staff required for resident supervision.
(g)
Personal care.
(1) An operator shall assign sufficient staff
to perform personal care functions on a 24-hour basis.
(2) The operator shall assign a minimum of
3.75 hours of personal services staff time per week per resident, such hours to
be distributed throughout the day and evening shifts.
(3) With prior written approval from the
department, an operator may allocate a percentage of the required personal care
hours to the night shift. Such approval shall be based on a demonstration that
personal care tasks are performed during the night shift and the personal care
needs of residents are met during the remainder of the day.
(4)
(i) The
operator shall develop and submit to the department, for approval, an inservice
training plan for personal care staff which includes a plan for training new
employees and an ongoing, in-service program for all personal care
staff.
(ii) The ongoing, in-service
program for all personal care staff shall be developed on a 12-month schedule,
amended as necessary, and retained on file for department inspection.
(iii) Records documenting training shall be
maintained for each personal care employee.
(5) All new employees or current employees
being newly assigned to perform personal care tasks shall complete training
within three months of the date of employment or assignment.
(h)
Housekeeping.
The operator shall assign a minimum of 1.0 staff hour per week per resident for the purpose of housekeeping.
(i) The operator shall provide staff
sufficient in number and skill to comply with the maintenance requirements set
forth in section
487.11(k) of this
Part.
(j)
Food
service.
(1) The operator shall assign
a minimum of 2.0 hours of food service staff per week per resident. In no case
shall weekly staff hours assigned to food service be less than 35. The staff
requirements apply to a central kitchen and no more than two separate dining
areas; other systems of food preparation and service may necessitate a
requirement by the department for different staffing.
(2) A food service manager shall be
designated and identified on the staffing schedule.
(3) A qualified dietitian or dietetic
technician shall be retained by the operator as a dietary consultant to provide
supervision and consultation sufficient to maintain compliance with food
service requirements.
(4) There
shall be a written agreement between the dietary consultant and operator which
includes the qualifications, duties, time commitment of the consultant and the
duration of the agreement.
(5)
Persons utilized by an operator to provide food service and nutrition
consultation and support shall be qualified as:
(i) a dietitian who has received a
baccalaureate degree with major studies in food and nutrition or institutional
management from an accredited college or university, is a member or eligible
for membership in the American Dietetic Association, participates annually in
continuing dietetic education, and has at least two years' full-time work
experience in dietetics; or
(ii) a
dietetic technician who has successfully completed an associate degree program
which meets the educational standards established by the American Dietetic
Association, and has at least three year's full-time work experience in
dietetics.
(k)
Health consultant.
(1) An operator not in compliance with the
admission and retention standards set forth in section
487.4 of this Part or with the
provisions of subdivision (e), (f) or (g) of section
487.7 of this Part which relate to
the maintenance of resident health or mental health, may be required to retain
a health consultant or consultants.
(2) Persons utilized by an operator to
provide health consultations shall be a physician, physician's assistant or
registered nurse. A certified pharmacist may provide consultation in
medications management.
(l)
Volunteers.
If an operator uses community volunteers:
(1) Volunteers must be supervised by the
administrator or his designee.
(2)
All volunteers shall be given orientation to the characteristics and needs of
the resident population, the rights of residents, the physical layout of the
facility, emergency procedures and an explanation of their specific
responsibilities.
(3) All
volunteers shall be given a copy of the residents' rights.
(4) The operator shall maintain a record for
each volunteer, which includes the individual's name, current address and
telephone number.
(5) If a
community volunteer organization is providing service within the facility, the
operator may have an agreement with the organization to retain the information
required in paragraph (4) of this subdivision. Such agreement shall include:
(i) the name and address of the
organization;
(ii) a designated
contact person; and
(iii) a
statement that the volunteer organization is able and willing to provide the
specific volunteer information as required in paragraph (4) of this
subdivision.
(6)
Volunteer services may not be substituted for services of paid employees
required elsewhere in this Part.
Notes
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