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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo
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Licensing

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Background

Pursuant to Article 31 of the NYS Mental Hygiene Law, the Commissioner of the Office of Mental Health has the authority and responsibility to set standards for the quality and adequacy of facilities and programs that provide services for the treatment and recovery of persons who suffer from mental illness.

The standards governing the operation of facilities and programs are contained in various sections of Title 14 of the Codes, Rules, and Regulations of the State of New York (14 NYCRR).

A provider of services is required to obtain an operating certificate (license) issued by the Office of Mental Health (OMH) prior to the operation of such facilities and programs that are subject to the regulatory jurisdiction of the Commissioner of Mental Health.

What programs must be licensed?

Under section 31.02 of the Mental Hygiene Law and various sections of 14 NYCRR, a provider of services must be issued an operating certificate in order to operate the following mental health programs:

  • Comprehensive psychiatric emergency program (CPEP)
  • Outpatient (non-residential) program, including clinic, continuing day treatment, day treatment, partial hospitalization, intensive psychiatric rehabilitation treatment, and personalized recovery oriented services (PROS)
  • Assertive community treatment (ACT) program
  • Psychiatric inpatient unit in a general hospital
  • Hospital for mentally ill persons (freestanding psychiatric hospital other than a state-operated psychiatric center)
  • Residential treatment facility for children and youth
  • Residential (housing) facility such as a community residence or apartment program.

Please see Definitions for more detailed information on which types of programs require licensure. OMH authorizes some residential and non-residential programs which do not require licensure.

Statutory responsibilities

Section 31.11 of the Mental Hygiene Law requires every holder of an operating certificate to assist the Office of Mental Health in carrying out its regulatory functions by cooperating with the Commissioner in any inspection or investigation, permitting the Commissioner to inspect its facility, all books and records, including recipientsí records, and making such reports, uniform and otherwise, as are required by the Commissioner.

Section 31.07, 31.09, 31.13 and 31.19, further authorize the Commissioner or his or her representative to examine and inspect such programs to determine their suitability and proper operation. Section 31.16 authorizes the Commissioner to suspend, revoke or limit any operating certificate, or to impose a fine on the holder of an operating certificate.

Issuance of an operating certificate (license)

The Commissioner has assigned responsibility for the issuance and renewal of operating certificates to the Bureau of Inspection and Certification within the Office of Quality Management. Licensing surveys (inspections) are conducted under the direction of the Bureau of Inspection and Certification by staff in the OMH field offices.

An unannounced inspection of the program occurs prior to renewal of the operating certificate. A program that is found in substantial compliance with the licensing standards for the program will be issued an operating certificate at the conclusion of the license renewal process. The operating certificate will identify the provider of services, the type of program, the location of the program, and the effective dates of the license.

If applicable, the operating certificate will be accompanied by a report of the findings (monitoring outcome report) from the inspection. The monitoring outcome report (MOR) identifies any areas of the program that are not in full compliance with regulatory requirements. In most cases, the provider of services is required to submit a plan of corrective action to OMH to address the issues identified in the MOR.

Comments or questions about the information on this page can be directed to the Division of Quality Management.