New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter A - Medical Facilities-minimum Standards › Article 1 - General › Part 404 - INTEGRATED OUTPATIENT SERVICES › Section 404.11 - Quality Assurance, Utilization Review and Incident Reporting

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Quality Assurance
(1) Physical Health Services.
(i) Integrated services providers of physical
					 health care shall ensure the development and implementation of a written
					 quality assurance program that includes a planned and systematic process for
					 monitoring and assessing the quality and appropriateness of patient care and
					 clinical performance on an ongoing basis. The integrated care services program
					 shall resolve identified problems and pursue opportunities to improve patient
					 care.
(ii) The integrated care
					 services program shall be supervised by the medical director. This
					 responsibility may not be delegated.
(iii) There shall be a written plan for the
					 quality assurance program which describes the program's objectives,
					 organization, responsibilities of all participants, scope of the program and
					 procedures for overseeing the effectiveness of monitoring, assessing and
					 problem-solving activities.
(iv)
					 The quality assurance plan shall define methods for the identification and
					 selection of clinical and administrative problems to be reviewed. The plan
					 shall include but not be limited to:
(a) the
					 establishment of review criteria developed in accordance with current standards
					 of professional practice for monitoring and assessing patient care and clinical
					 performance;
(b) regularly
					 scheduled reviews of medical charts, patient complaints and suggestions,
					 reported incidents and other documents pertinent to problem
					 identification;
(c) documentation
					 of all quality assurance activities, including but not limited to the findings,
					 recommendations and actions taken to resolve identified problems; and
(d) the timely implementation of
					 corrective actions and periodic assessments of the results of such
					 actions.
(v) The scope of
					 clinical and administrative problems selected to be reviewed for the purpose of
					 quality assurance shall reflect the scope of services provided and the
					 populations served at the center.
(vi) The outcomes of quality assurance
					 reviews shall be used for the revision or development of policies and in
					 granting or renewing staff privileges, as appropriate.
(vii) There shall be participation in the
					 quality assurance program by administrative staff and health-care professionals
					 representing each professional service provided.
(viii) There shall be joint participation in
					 the quality assurance program by representatives from the behavioral health
					 components of an integrated care services program; such participation shall
					 include, but is not limited to, specific identification of quality improvement
					 opportunities with respect to patient concerns and complaints, changes in
					 regulatory requirements, or other factors, no less frequently than once every
					 two years. Documentation shall be kept of all such reviews.
(ix) The findings, conclusions,
					 recommendations and actions taken as a part of the quality assurance program
					 shall be reported to the operator by the medical director. An annual report
					 shall be submitted to the governing authority, which documents the
					 effectiveness and efficacy of the integrated care services program in relation
					 to its goals and quality assurance plan and indicate any recommendations and
					 plans for improvement it its services to patients, as well as recommend changes
					 in its policies and procedures.