New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Chapter XIII - Office of Mental Health › Part 598 - Integrated Outpatient Services › Section 598.15 - Inspection

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The State
				licensing agency witli autliority for tlie liost 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. 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, eloped 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:
(i) on-site inspection of clinic appearance,
				conditions and general safety;
(ii)
				evaluation of the sponsor, its management systems, and procedures;
(ill) patient case record review;
(iv) interviews of staff and
				patients;
(v) examination of
				staffing patterns and staff qualifications;
(vi) analysis of statistical information
				contained in reports required to be submitted by the clinic;
(vii) compliance with the reporting
				requirements;
(viii) verification of
				staff credentials, as applicable;
(ix) incident reporting requirements;
				and
(x) 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 integrated services clinic administrative staff to
				discuss all deficiencies identified during the inspection.