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Title: Section 488.9 - Personnel

Effective Date

02/10/2016

488.9 Personnel. (a) General requirements. (1) The operator must provide staff sufficient in number and qualified by training and experience to render, at a minimum, those services mandated by statute or regulation. 

(2) The operator must 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 served by the enriched housing program; 

(ii) discussion of the residents' rights and the program's rules and regulations for residents; 

(iii) discussion of the duties and responsibilities of all staff; 

(iv) discussion of the general and specific duties and responsibilities of the individual(s) being trained; 

(v) training in emergency procedures; 

(vi) 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 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; and

(vii) 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. 

(3) The operator must develop and maintain current written staffing schedules. Staffing schedules must be retained for 12 months. 

(4) The operator must maintain personnel records which include: 

(i) individual employee records containing verification of qualifications for any position for which qualifications are set by regulation, pre-employment and annual medical evaluations, 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 a 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. 

(5) 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 enriched housing program or which might interfere with the performance of the individual's duties; and 

(ii) the individual has had: 

(a) a ppd (Mantoux) skin test for tuberculosis within 30 days prior to employment and no less frequently than every two years after employment begins; positive findings require appropriate clinical follow-up but no repeat skin test; and 

(b) any test that may be required by the local board of health. 

(6) Notwithstanding paragraph (5) 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 must require documentation of the employee's standing as a member. 

(7) 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/herself or others or is unable to perform his/her assigned duties, may be employed or permitted to work as either an employee or volunteer. 

(8) No individual is permitted to work, either as an employee or volunteer, if infected with a communicable disease that might endanger the health of residents. 

(9) Each individual must: 

(i) be emotionally, mentally and physically able, as required by function, to provide services and supervision to the population served by the enriched housing program; and 

(ii) maintain personal hygiene and clothing which is clean and appropriate for the functions performed. 

(10) Employees who have direct contact with residents must be able to speak, read and write English, and speak the predominant language of residents. 

(11) No person under 18 years of age may be charged with direct responsibility for the supervision and personal care of residents; or be permitted to work without onsite supervision. 

(12) The operator must inform the appropriate regional office by telephone, or in writing within three business days of a vacancy in the position of coordinator, case manager or dietary consultant. 

(13) 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, to verify that such person is not on the Justice Center's registry of substantiated category one cases of abuse or neglect as established pursuant to section 495 of the Social Services Law (staff exclusion list).

(b) Resident employment. (1) Employment of residents may 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. 

(2) The operator must 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 must appoint an enriched housing program coordinator who will be directly accountable to the operator for operating the enriched housing program and maintaining the program in compliance with applicable requirements. 

(2) An enriched housing program coordinator must be employed on the basis of one and one-half hours per resident per week for the first 16 residents and one hour per resident per week for each additional resident until the equivalent of a full-time employee is attained. 

(3) The program coordinator must be capable of and responsible for: 

(i) supervision of the enriched housing program; 

(ii) operation of the enriched housing program 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 the residents' 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. 

(4) The operator may be required to discharge a program coordinator who is unable or unwilling to carry out the responsibilities set forth in paragraph (3) of this subdivision. 

(5) A program coordinator must: 

(i) be at least 21 years of age; and 

(ii) possess the following education and work experience: 

(a) a master's degree in social work from an accredited college or university plus one year of related work experience; or 

(b) a bachelor's degree from an accredited college or university in an approved course of study, plus three years of related experience acceptable to the department of which one must have been in a supervisory capacity. Approved courses of study may include, but need not be limited to, human services for dependent adults, health care management programs, social work programs, gerontological studies and home economics. Related work experience may include, but need not be limited to, work in residential care, rehabilitation, health care management and social work. 

(d) Case management. (1) Each operator must designate sufficient staff to perform case management functions. This function may be carried out by the program coordinator. In the event that the case management function is being carried out by the program coordinator, the operator must designate an employee in addition to the program coordinator to be a designated investigator and reporter of occurrences which would constitute a reportable incident. However, nothing in this paragraph shall relieve any mandated reporter from his or her obligations under law. A qualified case manager must be on staff and on duty for one-half hour per week per program resident. 

(2) A case manager must be capable of, and responsible for, executing, through direct performance and coordination of:

(a) the services and functions described in section 488.7(e) of this Part; and 

(b) investigation of and reporting to the department allegations of occurrences which would constitute a reportable incident. 

(3) A case manager must have the following education and work experience: 

(i) a master's degree in social work from an accredited college or university; or 

(ii) a bachelor's degree from an accredited college or university with 
major work in human services or service delivery and one year of fulltime experience in the provision of services to a frail adult population; or 

(iii) 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 frail adult population. 

(e) Personal care, housekeeping, food service. (1) An operator must provide sufficient staff to perform personal care, housekeeping and food service activities. 

(2) The operator must provide housekeeping, personal care, and food service staff at a rate of six hours per resident per week. The hourly breakdown of service provided will depend on the aggregate service needs of residents. 

(3) Operators desiring to train their own personal care staff must develop and submit to the department for approval an in-service training plan for personal care staff. 

(4) Aides performing personal care tasks must have completed an approved certified personal care training program prior to employment or must: 

(i) within six months of hiring complete a department-approved certified personal care training program; or 

(ii) within three months of hiring complete an approved operator in-service training plan for personal care staff. 

(5) Aides performing food service functions must: 

(i) have demonstrated ability in meal preparation for groups of people; 

(ii) be knowledgeable of nutritional needs of older persons; 

(iii) be able to follow and prepare modified diets; and 

(iv) have knowledge of food protection principles. 

(f) The operator must arrange for the service of a qualified dietitian or dietetic technician as a dietary consultant to provide supervision and consultation sufficient to maintain compliance with food service requirements. A person utilized by an operator to provide food service and nutrition consultation and support is considered qualified if the person is: 

(1) 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 

(2) 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 years full-time work experience in dietetics. 

(g) Volunteers. (1) Resident volunteers. Residents choosing to volunteer may be permitted to do so only to the extent that such voluntary services are: 

(i) entered into without use of coercion or threats to the resident; 

(ii) not inconsistent with the physical or emotional needs or limitations of the resident. 

(2) If an operator uses community volunteers, each volunteer must be: 

(i) supervised by the program coordinator or his/her designee; 

(ii) given orientation to the characteristics and needs of the resident population, the rights of residents, the physical layout of the enriched housing program, emergency procedures and an explanation of their specific responsibilities; and 

(iii) given a copy of the residents' rights. 

(3) The operator must maintain a record for each volunteer, which will include the individual's name, current address and telephone number. 

(4) If a community volunteer organization is providing services within the enriched housing program, the operator may have an agreement with the organization to retain the information required in paragraph (3) of this subdivision. Such agreement must 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 

(3) of this subdivision. 

(5) Volunteer services must not be substituted for the program coordinator and case manager as required elsewhere in this Part. 

Volume

VOLUME B-1 (Title 18)

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