CPEP Programming Standards

A CPEP is licensed emergency service in the State of New York regulated under NYCRR Part 590: https://omh.ny.gov/omhweb/policy_and_regulations/adoption/omh590591-redesign.pdf

A CPEP operates under a Hospital’s license and that Hospital’s Governing Body but we’ve seen them located in a variety of settings: in or adjacent to an ED, free-standing within the hospital, and freestanding on a hospital campus.

The environment of care/premises language is limited:

590.13 Premises.

(a) The comprehensive psychiatric emergency program and any satellite facility shall maintain

premises adequate and appropriate for the safe and effective operation of the program.

(b) The space provided shall be both adequate and appropriate for:

(1) the maintenance of privacy for interviews between staff members and persons

served;

(2) the comfort and convenience of those waiting for and receiving services. No

individual waiting for or receiving services may be placed in a hallway or other area

not approved by the Office of Mental Health as a waiting or treatment area;

(3) accommodation of routine activities and regularly used equipment;

(4) controlled access to, and maintenance of, case records; and

18(5) applicable Federal standards for space requirements which are necessary to assure

continued receipt of Federal reimbursement for care and services provided in the

comprehensive psychiatric emergency program or the host hospital.

(c) The emergency room of the comprehensive psychiatric emergency program shall be near or

adjacent to the medical emergency room of the host hospital but shall be allocated physically

discrete space acceptable to the Office of Mental Health.

(d) Extended observation beds shall be located in or adjacent to the comprehensive psychiatric

emergency program emergency room except that a waiver of this requirement may be made

when:

(1) an interim location is acceptable to Office of Mental Health; and

(2) the host hospital submits architectural plans for the establishment of the extended

observation beds in space in or adjacent to the emergency room within a period of

time acceptable to the Office of Mental Health.

(e) The premises shall be reasonably maintained to ensure access to services by all patients.

(f) Facilities shall comply with all local zoning and building laws, regulations and ordinances.

(1) Heating, lighting and ventilation shall be adequate for the comfort and well being of

the persons served and the employees.

(2) A written certificate of occupancy, or equivalent, by the local building inspection

authority shall be retained in the records of the program.

(3) Copies of all local inspection reports, and other relevant inspection reports, shall be

maintained and available upon request.