New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XXI - OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES › Part 825 - Integrated Outpatient Services › Section 825.15 - Inspection

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The state
				licensing agency with authority for certifying, licensing and monitoring the
				host clinic shall have ongoing inspection responsibility for the integrated
				services clinic, pursuant to this Part. The purpose of the inspection is to
				ensure compliance with all applicable laws, rules, and regulations, as well as
				to determine the renewal term of the operating certificate or license, as
				applicable. The inspection activities shall not be duplicated.
(b) The host state licensing agency shall
				consult with the adjunct state licensing agency on matters specific to the
				provision of such add-on services, as may be necessary to assure patient health
				and safety. Any significant deficiencies will immediately be referred for
				enforcement to the responsible state licensing agency. If at any point during
				the inspection, findings are identified that suggest imminent risk of serious
				harm or injury to patients, the inspector(s) will immediately contact their
				supervisor, who will consult with the adjunct state licensing agency, as
				applicable.
(c) Inspections shall
				be conducted utilizing a joint-licensing instrument, developed collaboratively
				by the three state licensing agencies. This standardized procedure will ensure
				consistency of the inspection process throughout the State and provide
				standardized reviews of the operations and services at each integrated services
				clinic. All deficiencies and/or corrective action will be overseen by the
				monitoring state licensing agency with notice to the adjunct state licensing
				agency or agencies, as applicable.
(d) Each integrated services provider shall
				undergo an unannounced inspection which will occur prior to renewal of the
				Operating Certificate or License.
(1) At the
				start of the inspection, the inspector(s) will meet with integrated services
				clinic administrative staff to explain the purpose and scope of the inspection
				and request any documentation (e.g., policies; staffing information; etc.) that
				may be needed to facilitate the review.
(2) The inspection will include, but not be
				limited to, the following areas of review:
(a) on-site inspection of clinic appearance,
				conditions and general safety;
(b)
				evaluation of the sponsor, its management systems, and procedures;
(c) patient case record review;
(d) interviews of staff and
				patients;
(e) examination of
				staffing patterns and staff qualifications;
(f) analysis of statistical information
				contained in reports required to be submitted by the clinic;
(g) compliance with the reporting
				requirements;
(h) verification of
				staff credentials, as applicable;
(i) incident reporting requirements;
				and
(j) such other operating areas
				of activities as may be necessary or appropriate to determine compliance with
				applicable laws and regulations.
(3) At the conclusion of the inspection, the
				inspector(s) will meet with the integrated services clinic administrative staff
				to discuss all deficiencies identified during the
				inspection.