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 825.11 - 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.