Part 590 of title 14 is amended as follows:

• Clarifies the background and intent of the rule to state the purpose of comprehensive psychiatric emergency programs (CPEP) for those individuals with a known or suspected mental illness is to provide emergency observation, evaluation, care, and treatment in a safe and comfortable environment. The rule also removes reference to the intent of CPEPs to establish a primary entry point into the mental health system for the catchment area it serves.

• Clarifies that in accordance with Mental Hygiene Law Sec. 9.13 voluntary patients may seek admission to a comprehensive psychiatric emergency program. Voluntary treatment means that a person has a mental illness for which care and treatment as a patient in a comprehensive psychiatric emergency program is essential to such person’s welfare and such person understands and consents to the need for such care and treatment.

• Removes outdated definitions for Brief Emergency visits, crisis residential services and interim crisis services.

• Defines Collaterals to mean an individual who is a member of the patient’s family or household, or other individual who interacts with the patient and is directly affected by or has the capability of affecting their condition and is identified in the comprehensive psychiatric emergency plan as having a role in treatment and/or is necessary for participation in the evaluation and assessment of the recipient prior to admission.

• Updates definition for Crisis outreach to mean face to face psychiatric emergency services provided outside an emergency room setting which includes evaluation, assessment and stabilization services. Such services include but are not limited to therapeutic communication, coordination with identified supports, psychiatric consultation, safety planning, referral, linkage, peer services and may be provided outside the emergency room of the hospital, in the community or in other clinical areas within the hospital, for purposes of face to face visits with individuals discharged from the comprehensive psychiatric emergency program. These services do not have to result in a visit or admission to the comprehensive psychiatric emergency program and for individuals discharged from the comprehensive psychiatric emergency program, crisis outreach includes face to face contact with a mental health professional for purposes of facilitating an individual’s community tenure prior to engagement or re-engagement with community-based providers.

• Medical examination is defined to mean an examination conducted as part of a comprehensive psychiatric emergency programs full emergency visit, conducted by an appropriately credentialed professional employed by the comprehensive psychiatric emergency program or emergency department and must include. Such medical examination must include: a history and physical including a past medical history, review of systems, review of medications and allergies, and assessment of vital signs and where clinically indicated, include a targeted physical exam, and orders for laboratory and other diagnostic studies.

• On duty is defined to mean that the professional is physically present in the building and accessible.

• Received is defined to mean the individual has completed all required registration materials upon entry to the comprehensive psychiatric emergency program, and a record has been created for such individual.

• Satellite facility is defined to mean a medical facility providing psychiatric emergency services that is managed and operated by a general hospital who holds a valid operating certificate for a comprehensive psychiatric emergency program and is located away from the central campus of the general hospital. A satellite facility at minimum must provide crisis intervention services including triage and referral and full emergency visits and/or extended observation bed services.

• Triage and referral is defined to mean a face to face interaction between a patient and a staff physician, preferably a psychiatrist, or Psychiatric Nurse Practitioner to determine the scope of emergency service required. This interaction should include a psychiatric diagnostic examination. It may result in further comprehensive psychiatric emergency program evaluation or treatment activities on the patient's behalf or discharge from the comprehensive psychiatric emergency program. For those persons who are discharged from the comprehensive psychiatric emergency program and who require additional mental health services triage and referral must include a discharge plan.

• Clarifies professions identified as professional staff and defines certified peer specialist to mean an individual who is credentialed as a peer in New York State.

• Clarifies CPEP organization and administration requirements to ensure cultural compentency and that governing bodies make 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 & hard of hearing, individuals who are Limited English Proficient, immigrants, and individuals re-entering communities from jails and prisons and to make efforts 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. Additionally, stated that CPEPs should review demographic data for the program’s catchment area to determine the cultural and linguistic needs of the population, that staff is trained to be aware and respond appropriately to the cultural and linguistic needs of the catchment area, that data should be reviewed to identify disparities of access to treatment and should implement policy and procedures to address such disparities, ensure the 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 and that language access services will be made available in such a way that assessment or treatment activities will not be delayed.

• Clarifies that CPEPs 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 and requires all new staff to 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, with annual refresher training.

• Requires the Hospital’s incident review committee to review incidents, make recommendations and ensure implementation of action plans with the comprehensive psychiatric emergency program’s administrator.

• Specifies the CPEP should access the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) or other available electronic health records or database(s) to identify the patient’s treatment providers and prior medication use and/or treatment engagement history, and the program shall document efforts to identify and contact with the individual’s consent, the individual’s treatment team and other relevant providers (e.g., housing providers, care coordination, managed care organizations), and collaterals.

• Requires all presenting individuals shall be screened for risk of harm to self and others, staff shall collaborate with collaterals as appropriate and available, and all individuals should be screened for alcohol and substance abuse, use and dependence. Where individuals are determined to be of moderate to high risk, efforts shall be made to obtain or develop a safety plan. Requires any screening tools to be evidence based and validated where possible, and assessments should be strength-based and person-centered.

• Where it is determined to be necessary to divert new CPEP admissions to affiliates according to a contingency plan, the CPEP must notify the appropriate OMH Field Office.

• Discharges are clarified to require the completion of referrals to community services providers, in collaboration with the individual receiving services and CPEP staff, address the person's identified needs. Further, the CPEP is required to verify that after-care appointment(s) occurred and follow up with individuals to ensure satisfactory linkage to care. Until linkage to care is completed, or for other clinically-indicated reasons, comprehensive psychiatric emergency program staff should provide crisis outreach services to ensure individuals are safe and stable in the community and continue to provide support, care and assistance with linkage to follow up care. Such services shall be reimbursed pursuant to section 591.4(f).

• Crisis outreach is clarified to mean face to face psychiatric emergency services provided outside an emergency room setting which includes evaluation, assessment and stabilization services. Crisis outreach services may be provided outside the emergency room of the hospital, in the community or in other clinical areas within the hospital, for purposes of face to face visits with individuals discharged from the comprehensive psychiatric emergency program. Crisis outreach does not have to result in an admission to the comprehensive psychiatric emergency program. For individuals discharged from comprehensive psychiatric emergency programs, crisis outreach includes face to face contact with a mental health professional for purposes of facilitating an individual’s community tenure prior to engagement or re-engagement with a community-based provider. Such services can include but are not limited to assessment, therapeutic communication, coordination with identified supports, psychiatric consultation, safety planning, referral, linkage, peer services, and referrals can be made through internal referrals, external referrals or through CPEP discharge referrals.

• Removes outdated references to crisis residential services.

• Clarifies that appropriate professional staff shall be available to assist in emergencies on at least an on-call basis at all times.

• Clarifies that case records should document CPEP’s attempts to contact collaterals and documentation of the patient’s legal status.

• Clarifies that the following information is required for each case record for individuals who receive a full emergency visit and/or is admitted to an extended observation bed and may be included in the case record for individuals who receive a triage and referral visit and/or crisis outreach: reports of all mental and physical diagnostic exams, assessments, tests, and consultations, notes which relate to special circumstances and untoward incident, dated and signed orders for all medications, discharge summary, including referrals to other programs and services, which must be completed within five days of discharge, and documentation of attempts to contact collaterals.

• Clarifies that satelite facilities shall maintain premises adequate and appropriate for the safe and effective operation of the program.

Part 591 of title 14 is amended as follows:

• Removes outdated definitions of a brief emergency visit and interim crisis service, and adds definitions for Crisis outreach, medical examination, and triage and referral to conform with Part 590.

• Clarifies language relating to reimbursement to conform with Part 590.

• Clarifies services provided in a medical/surgical emergency setting for comorbid conditions should be separately reimbursed and removes reference limiting CPEPs to brief emergency visits where medical evaluations conducted outside the CPEP are utilized by the CPEP for purposes of treating the individual.

• Removes reference to specific CPEP fee schedules.

1. Statutory Authority: Sections 7.09 and 31.04 of the Mental Hygiene Law grant the Commissioner of Mental Health the power and responsibility to adopt regulations that are necessary and proper to implement matters under his or her jurisdiction, and to set standards of quality and adequacy of facilities, equipment, personnel, services, records and programs for the rendition of services for adults diagnosed with mental illness or children diagnosed with emotional disturbance, pursuant to an operating certificate.

2. Legislative Objectives: The proposed rule furthers the legislative policy of providing high quality mental health services to individuals with mental illness in a cost-effective manner. Makes regulatory changes to conform with Chapter 58 of the Laws of 2020.

3. Needs and Benefits: The proposed rule is necessary to provide high quality mental health services to individuals with mental illness in a cost-effective manner. The rule would clarify and provide uniformity relating to the establishment and operation of a comprehensive psychiatric emergency program (CPEP). The rule removes outdated or obsolete references and provides clarification relating to reimbursement, requirements for admission and discharge, and requirements for staffing, services, treatment planning, recordkeeping and appropriate community linkages. Additionally, the amendments seek regulatory changes to conform with Chapter 58 of the Laws of 2020.

• Clarifies the background and intent of the rule to state the purpose of comprehensive psychiatric emergency programs (CPEP) for those individuals with a known or suspected mental illness is to provide emergency observation, evaluation, care, and treatment in a safe and comfortable environment. The rule also removes reference to the intent of CPEPs to establish a primary entry point into the mental health system for the catchment area it serves.

• Clarifies that in accordance with Mental Hygiene Law Sec. 9.13 voluntary patients may seek admission to a comprehensive psychiatric emergency program. Voluntary treatment means that a person has a mental illness for which care and treatment as a patient in a comprehensive psychiatric emergency program is essential to such person’s welfare and such person understands and consents to the need for such care and treatment.

• Removes outdated definitions for Brief Emergency visits, crisis residential services and interim crisis services.

• Defines Collaterals to mean an individual who is a member of the patient’s family or household, or other individual who interacts with the patient and is directly affected by or has the capability of affecting their condition and is identified in the comprehensive psychiatric emergency plan as having a role in treatment and/or is necessary for participation in the evaluation and assessment of the recipient prior to admission.

• Updates definition for Crisis outreach to mean face to face psychiatric emergency services provided outside an emergency room setting which includes evaluation, assessment and stabilization services. Such services include but are not limited to therapeutic communication, coordination with identified supports, psychiatric consultation, safety planning, referral, linkage, peer services and may be provided outside the emergency room of the hospital, in the community or in other clinical areas within the hospital, for purposes of face to face visits with individuals discharged from the comprehensive psychiatric emergency program. These services do not have to result in a visit or admission to the comprehensive psychiatric emergency program and for individuals discharged from the comprehensive psychiatric emergency program, crisis outreach includes face to face contact with a mental health professional for purposes of facilitating an individual’s community tenure prior to engagement or re-engagement with community-based providers.

• Medical examination is defined to mean an examination conducted as part of a comprehensive psychiatric emergency programs full emergency visit, conducted by an appropriately credentialed professional employed by the comprehensive psychiatric emergency program or emergency department and must include. Such medical examination must include: a history and physical including a past medical history, review of systems, review of medications and allergies, and assessment of vital signs and where clinically indicated, include a targeted physical exam, and orders for laboratory and other diagnostic studies.

• On duty is defined to mean that the professional is physically present in the building and accessible.

• Received is defined to mean the individual has completed all required registration materials upon entry to the comprehensive psychiatric emergency program, and a record has been created for such individual.

• Satellite facility is defined to mean a medical facility providing psychiatric emergency services that is managed and operated by a general hospital who holds a valid operating certificate for a comprehensive psychiatric emergency program and is located away from the central campus of the general hospital. A satellite facility at minimum must provide crisis intervention services including triage and referral and full emergency visits and/or extended observation bed services.

• Triage and referral is defined to mean a face to face interaction between a patient and a staff physician, preferably a psychiatrist, or Psychiatric Nurse Practitioner to determine the scope of emergency service required. This interaction should include a psychiatric diagnostic examination. It may result in further comprehensive psychiatric emergency program evaluation or treatment activities on the patient's behalf or discharge from the comprehensive psychiatric emergency program. For those persons who are discharged from the comprehensive psychiatric emergency program and who require additional mental health services triage and referral must include a discharge plan.

• Clarifies professions identified as professional staff and defines certified peer specialist to mean an individual who is credentialed as a peer in New York State.

• Clarifies CPEP organization and administration requirements to ensure cultural compentency and that governing bodies make 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 & hard of hearing, individuals who are Limited English Proficient, immigrants, and individuals re-entering communities from jails and prisons and to make efforts 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. Additionally, stated that CPEPs should review demographic data for the program’s catchment area to determine the cultural and linguistic needs of the population, that staff is trained to be aware and respond appropriately to the cultural and linguistic needs of the catchment area, that data should be reviewed to identify disparities of access to treatment and should implement policy and procedures to address such disparities, ensure the 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 and that language access services will be made available in such a way that assessment or treatment activities will not be delayed.

• Clarifies that CPEPs 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 and requires all new staff to 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, with annual refresher training.

• Requires the Hospital’s incident review committee to review incidents, make recommendations and ensure implementation of action plans with the comprehensive psychiatric emergency program’s administrator.

• Specifies the CPEP should access the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES) or other available electronic health records or database(s) to identify the patient’s treatment providers and prior medication use and/or treatment engagement history, and the program shall document efforts to identify and contact with the individual’s consent, the individual’s treatment team and other relevant providers (e.g., housing providers, care coordination, managed care organizations), and collaterals.

• Requires all presenting individuals shall be screened for risk of harm to self and others, staff shall collaborate with collaterals as appropriate and available, and all individuals should be screened for alcohol and substance abuse, use and dependence. Where individuals are determined to be of moderate to high risk, efforts shall be made to obtain or develop a safety plan. Requires any screening tools to be evidence based and validated where possible, and assessments should be strength-based and person-centered.

• Where it is determined to be necessary to divert new CPEP admissions to affiliates according to a contingency plan, the CPEP must notify the appropriate OMH Field Office.

• Discharges are clarified to require the completion of referrals to community services providers, in collaboration with the individual receiving services and CPEP staff, address the person's identified needs. Further, the CPEP is required to verify that after-care appointment(s) occurred and follow up with individuals to ensure satisfactory linkage to care. Until linkage to care is completed, or for other clinically-indicated reasons, comprehensive psychiatric emergency program staff should provide crisis outreach services to ensure individuals are safe and stable in the community and continue to provide support, care and assistance with linkage to follow up care. Such services shall be reimbursed pursuant to section 591.4(f).

• Crisis outreach is clarified to mean face to face psychiatric emergency services provided outside an emergency room setting which includes evaluation, assessment and stabilization services. Crisis outreach services may be provided outside the emergency room of the hospital, in the community or in other clinical areas within the hospital, for purposes of face to face visits with individuals discharged from the comprehensive psychiatric emergency program. Crisis outreach does not have to result in an admission to the comprehensive psychiatric emergency program. For individuals discharged from comprehensive psychiatric emergency programs, crisis outreach includes face to face contact with a mental health professional for purposes of facilitating an individual’s community tenure prior to engagement or re-engagement with a community-based provider. Such services can include but are not limited to assessment, therapeutic communication, coordination with identified supports, psychiatric consultation, safety planning, referral, linkage, peer services, and referrals can be made through internal referrals, external referrals or through CPEP discharge referrals.

• Removes outdated references to crisis residential services.

• Clarifies that appropriate professional staff shall be available to assist in emergencies on at least an on-call basis at all times.

• Clarifies that case records should document CPEP’s attempts to contact collaterals and documentation of the patient’s legal status.

• Clarifies that the following information is required for each case record for individuals who receive a full emergency visit and/or is admitted to an extended observation bed and may be included in the case record for individuals who receive a triage and referral visit and/or crisis outreach: reports of all mental and physical diagnostic exams, assessments, tests, and consultations, notes which relate to special circumstances and untoward incident, dated and signed orders for all medications, discharge summary, including referrals to other programs and services, which must be completed within five days of discharge, and documentation of attempts to contact collaterals.

• Clarifies that satelite facilities shall maintain premises adequate and appropriate for the safe and effective operation of the program.

• Part 591 of title 14 is amended to remove outdated definitions of a brief emergency visit and interim crisis service, and adds definitions for Crisis outreach, medical examination, and triage and referral to conform with Part 590, to clarify language relating to reimbursement to conform with Part 590, to clarify services provided in a medical/surgical emergency setting for comorbid conditions should be separately reimbursed and removes reference limiting CPEPs to brief emergency visits where medical evaluations conducted outside the CPEP are utilized by the CPEP for purposes of treating the individual and to remove reference to specific CPEP fee schedules.

4. Costs:

(a) Cost to State government: There is no anticipated cost, as the proposed rule seeks to maximize efficiency in the operation of CPEPs.

(b) Cost to local government: These regulatory amendments will not result in any additional costs to local government.

(c) Cost to regulated parties: These regulatory amendments will not result in any additional costs to those regulated parties.

5. Local Government Mandates: These regulatory amendments will not result in any additional imposition of duties or responsibilities upon county, city, town, village, school or fire districts.

6. Paperwork: No substantial increase in paperwork is anticipated as a result of the amendments.

7. Duplication: These regulatory amendments do not duplicate existing State or federal requirements.

8. Alternatives: The Office was required to consider regulations to conform with Chapter 58 of the laws of 2020. Additional amendments to the rule provide clarity to the operations of CPEPs, to provide uniformity statewide.

9. Federal Standards: The regulatory amendments do not exceed any minimum standards of the federal government for the same or similar subject areas.

10. Compliance Schedule: This rulemaking will be effective immediately upon filing with the Department of State.

No regulatory flexibility analysis is required pursuant to section 202-(b)(3)(a) of the State Administrative Procedure Act. The proposed amendment does not impose an adverse economic impact on small businesses or local governments, and it does not impose reporting, record keeping or other compliance requirements on small businesses or local governments. The amendment to the regulation seeks to provide uniformity among Comprehensive Psychiatric Emergency Programs (CPEPs) to improve the timeliness, uniformity and efficiency of the program.

No rural area flexibility analysis is required pursuant to section 202-bb(4)(a) of the State Administrative Procedure Act. The proposed rule will not impose any adverse economic impact on rural areas; therefore, a Rural Area Flexibility Analysis is not necessary with this notice.

The amendments to 14 NYCRR Part 590 and 591 are intended to provide regulatory relief, provide uniformity and streamline the operations of Comprehensive Psychiatric Emergency Program (CPEP).

It is evident from the subject matter of this rule that it could only have a positive impact or no impact on jobs or employment, therefore a Job Impact Statement is not necessary with this notice.

As a rule that requires a RFA, RAFA or JIS, this rule will be initially reviewed in the calendar year 2024, which is no later than the 3rd year after the year in which this rule is being adopted.

Comment 1: A local government agency provided comments in support of the Emergency Rule. Commenter recommended that any guidance issued include the following clarifications for children and youth: (1) The youth and the caregiver(s) should be engaged in discharge planning. (2) Family Peer Advocates should be included in the definition of certified peer specialist and (3) Screening tools should be appropriate and valid for the age being served (e.g. adolescents).

Response 1: The comment was reviewed by the agency. Additional information will be provided through guidance.

Comment 2: A commenter recommended “with a known or suspected mental illness” be replaced by “displaying symptoms of mental illness” in the Background provision of the regulation.

Response 2: Amendment considered and rejected. OMH does not support the recommended suggestion, the broader term utilized in the regulation would cover substance use, and would encourage the consideration of possible mental illness as part of assessment.

Comment 3: Commenter recommended under Triage and Referral, that licensed clinical social workers and psychologists be permitted to provide the Triage and Referral service under the supervision of a psychiatrist.

Response 3: No change required as the proposed rule is consistent with scope of practice and such professionals are not prohibited from participating in activities.

Comment 4: Commenter recommended under staffing definitions that the regulation use the updated name of the Agency/Division, namely Office of Addiction Services and Supports.

Response 4: Comment is adopted into revised rule.

Comment 5: Commenter recommended using the term “individuals with sight, hearing, and/or speech impairments” when referring to these populations. Similarly, the use of the term “individuals with limited English proficiency” is recommended when referring to these populations throughout the document. Recommended that the term “sex” be replaced with “gender, sexuality” and recommended that materials be written in plain language at a sixth-grade reading level as general guidance for promoting inclusivity among communities with various levels of literacy and education. Recommended including substance use disorder in included diagnosis in section 590.6(h).

Response 5: Comment is partially adopted into revised rule. To the extent the comment relates to the recommended addition of substance use disorder in 590.6(h) is already included under “multiple diagnoses.” Additional clarification would be provided in guidance.

Comment 6: Commenter recommended under Admission and discharge procedures using the term “high risk use” and "substance use disorder," instead of the outdated terms, “abuse,” and "dependence." Commenter also recommends that assessment for physical dependence is included in the assessment of substance use disorder and include screening for existing and new withdrawal management needs.

Response 6: Comment is adopted to update language to reflect current practice. To the extent the comment relates to assessment for physical dependence included in the assessment of substance use disorder, such will be addressed in guidance.

Comment 7: Commenter recommended that guidance should specify what type of “legal status” the regulations are referring to. We recommend that case records do not include legal status as it pertains to immigration status and it could be a deterrent to seeking services.

Response 7: Comment will be considered in development of guidance, and the regulation has been clarified that “legal status” pertains to the individual’s status pursuant to mental hygiene law.

Comment 8: Commenter recommended under Reimbursement Definitions that “withdrawal management” be included as a reimbursable service and a definition for “withdrawal management” also be included. The definition for withdrawal management may be “assessment and treatment of withdrawal needs due to physical dependence on a drug or alcohol requiring medication management to address withdrawal symptoms, including medications to manage alcohol (i.e., a benzodiazepine) and opioids (i.e., Buprenorphine and methadone)including induction.”

Response 8: Comment has been considered, and additional amendments are not necessary as current definitions incorporate such services. Additional information will be addressed further in guidance.