N.Y. Comp. Codes R. & Regs. tit. 14 § 595.13

Current through Register Vol. 46, No. 45, November 2, 2024

Section 595.13 - Quality assurance

(a) Each provider of service shall develop a quality assurance plan. The plan shall include, but is not limited to:

(1) Utilization review. Each residential program must have a written utilization review procedure which includes but is not limited to, review of:

(i) appropriateness for admission to and continued stay in the residential program;

(ii) appropriateness of the services provided by the residential program; and

(iii) readiness for referral and transfer of clients who no longer meet criteria for the residential program. Utilization review must be carried out, to the maximum extent possible, by staff who function independently from the staff with primary clinical responsibility for the resident.

(2) Incident management and reporting. Residential programs shall have an internal incident reporting, investigation and management process. Residential programs shall comply with Mental Hygiene Law and Part 524 of this Title which governs incident reporting by licensed mental health programs. The quality assurance plan shall contain written procedures for carrying out incident management and reporting.

(3) Monitoring. Residential programs shall have procedures for internal monitoring of program performance. Performance should be monitored against the criteria stated in the program's functional program. The results of this internal monitoring shall be used to identify problems in client care and opportunities to improve care and shall be regularly reviewed and acted on by the governing body.

(b) The Office of Mental Health shall have responsibility for monitoring the quality of residential programs.

(1) Program monitoring. External program monitoring shall be carried out by the Office of Mental Health and/or its authorized agents. The Office of Mental Health will review program operations, quality assurance activities and the individual records of residents during periodic certification visits.

(2) Utilization review. External utilization review shall be carried out as necessary by the Office of Mental Health, its regional offices, or other agents against the criteria contained in the residential program's functional program.

(3) Incident reporting. The Office of Mental Health will conduct an external review of residential programs as necessary based on patterns or trends in reported incidents or on the occurrence of an individual incident of extreme gravity.

(c) If, based on a review of the program and practice of a provider of service, the Office of Mental Health determines that a provider of service is not exercising due diligence in complying with the requirements of this Part, the Office of Mental Health shall give notice of the deficiency to the provider of service and may also initiate the following:

(1) request that the provider of service prepare a plan of correction; and

(2) provide such technical assistance as the Office of Mental Health deems necessary to assist the provider of service in developing and implementing an appropriate plan of correction.

(d) If the provider of service fails to prepare an acceptable plan of correction within a reasonable time or refuses to permit the Office of Mental Health to provide technical assistance or fails to promptly or effectively implement a plan of correction, it shall be determined that the provider of service is in violation of this Part.

(e) Each residential program shall have a consumer evaluation process, in which residents as well as other relevant individuals involved with the resident shall have an opportunity to give feedback about the program in a confidential manner. The information from this process shall be summarized annually and submitted to the Office of Mental Health, the resident and all staff in the program. The confidentiality of residents, families and other impacted parties shall be protected.

(f) Upon a determination that a provider of service is in violation of this Part or upon a determination that a provider of service has failed to otherwise comply with the terms of its operating certificate or with the provisions of any applicable statute, rule or regulation, the commissioner may revoke, suspend or limit the provider's operating certificate or impose fine in accordance with the Mental Hygiene Law, section 31.16 and Parts 573 and 503 of this Title.

(g) Nothing in this section shall limit or preclude the commissioner from taking whatever immediate measures may be necessary, including the exercise of his authority under Mental Hygiene Law, sections 31.16(b) and 31.28, in the event that a resident's health or safety is in imminent danger or there exists any condition or practice which poses imminent danger to the health or safety or any resident or the public.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 595.13