New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter C - State Hospital Code › Article 7 - Certified Home Health Agencies and Licensed Home Care Services Agencies › Part 763 - Certified Home Health Agencies, Long Term Home Health Care Programs And Aids Home Care Programs Minimum Standards › Section 763.11 - Governing authority

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 governing authority of the agency shall be responsible for the management,
					 operation and evaluation of the agency and shall:
(1) ensure compliance of the agency with the
					 applicable Federal, State and local statutes, rules and regulations;
(2) ensure adequate personnel resources to:
(i) effectively conduct administrative
					 functions of the agency; and
(ii)
					 provide care in the home, based on the needs of the persons served as specified
					 in the plan of care;
(3)
					 adopt the agency's budget, control assets and funds, and provide for annual
					 fiscal audits;
(4) prohibit
					 personnel paid directly by the agency from being reimbursed by any party other
					 than the agency for services provided by the agency;
(5) prohibit the splitting or sharing of fees
					 between a referral agency, facility, individual or other home care services
					 agency and the agency;
(6) adopt
					 and amend policies regarding management and operation of the agency and the
					 provision of patient care services;
(7) enter into agreements and contracts,
					 where applicable, to provide agency services or to assure services needed by
					 the agency;
(8) ensure the
					 development and implementation of a patient complaint procedure to include:
(i) documentation of receipt, investigation
					 and resolution of any complaint, including maintenance of a complaint log
					 indicating the dates of receipt and resolution of all complaints received by
					 the agency;
(ii) review of each
					 complaint, with a written response to all written complaints or oral
					 complaints, if requested by the individual making the oral complaint, to be
					 provided within 15 days of receipt of such complaint:
(a) describing the complaint investigation
					 findings and the decisions rendered to date by the agency; and
(b) advising the complainant of the right to
					 appeal the outcome of the agency's complaint investigation and the appeal
					 procedure to be followed;
(iii) an appeals process with review by a
					 member or committee of the governing authority within 30 days of receipt of the
					 appeal; and
(iv) notification to
					 the patient or his or her designee that if the patient is not satisfied by the
					 agency's response, the patient may complain to the Department of Health's
					 Office of Health Systems Management;
(9) provide an office facility or facilities
					 equipped and sufficient in size to permit efficient conduct of business,
					 including access to patient records by all personnel providing care and prompt
					 telephone contact to and from patients, referral agencies or facilities, and
					 other home care services agencies;
(10) ensure the development of a written
					 emergency plan which is current and includes procedures to be followed to
					 assure health care needs of patients continue to be met in emergencies which
					 interfere with delivery of services and orientation of all employees to their
					 responsibilities in carrying out such a plan;
(11) for certified home health agencies only,
					 ensure the provision of charity care in each fiscal year of the agency in an
					 amount no less than two percent of the total operating costs of the agency in
					 that fiscal year for not-for-profit and for-profit agencies and agencies
					 operated by public benefit corporations and three and one-third percent of
					 total operating costs of the agency for public agencies. Charity care is care
					 provided at no charge or reduced charge for the services the agency is
					 certified to provide to patients who are unable to pay full charges, are not
					 eligible for covered benefits under title XVIII or XIX of the Social Security
					 Act, are not covered by private insurance, and whose household income is less
					 than 200 percent of the Federal poverty level. Adjustments to the required
					 percentages of charity care may be made by the department upon recommendation
					 of the appropriate health systems agency to reflect significant county
					 variations from the state average with respect to the proportion of indigent
					 and medically uninsured persons to the total population;
(12) ensure continuous quality improvement
					 initiatives, by establishing and maintaining a coordinated quality assessment
					 and assurance program which integrates the review activities of all home care
					 services provided by the agency to enhance the quality of care and treatment.
					 Quality improvement shall be the responsibility of all personnel, at every
					 level, at all times. Supervisory personnel alone cannot ensure quality of care
					 and services. Such quality must be part of each individual's approach to his or
					 her daily responsibilities; and
(13) appoint a group of professional
					 personnel, which includes one or more physicians, registered professional
					 nurses, and representatives of the professional therapeutic services provided
					 by the agency to perform the activities required in subparagraph (ii) of this
					 paragraph. The findings and recommendations of this group shall be integrated
					 into the agency's quality assessment and assurance program described in
					 paragraph (12) of this subdivision:
(i) at
					 least one member of the group shall be neither an owner nor an employee
					 compensated by the agency;
(ii) the
					 group of professional personnel shall participate in the annual evaluation of
					 the agency's program and shall meet at least quarterly to:
(a) review policies pertaining to the
					 delivery of the health care and services provided by the agency and, when
					 revisions are indicated, recommend such policies to the governing authority for
					 adoption;
(b) make recommendations
					 to the governing authority on professional issues, including the adequacy and
					 appropriateness of services based on an assessment of health care resources in
					 the community, patients' needs, available reimbursement mechanisms and
					 availability of qualified personnel;
(c) assist the agency in maintaining liaison
					 with other health care providers in the community; and
(d) review a sample of both active and closed
					 clinical records to determine whether established policies are followed in
					 furnishing services directly or under arrangement; and
(14) ensure that, at least
					 annually, an overall evaluation of the agency's program is conducted;
(i) such evaluation shall be conducted by all
					 of the following:
(a) the group of
					 professional personnel (or a committee thereof) as described in paragraph (13)
					 of this subdivision;
(b) agency
					 personnel; and
(c) consumers or
					 other professional persons outside the agency working in conjunction with
					 consumers;
(ii) such
					 evaluation shall include but not be limited to:
(a) an overall policy and administrative
					 review to include the extent to which the agency:
(1) meets service area needs, including
					 underserved geographic areas;
(2)
					 meets the needs of special populations, including persons with intense service
					 needs; mentally, cognitively or physically disabled persons, and financially
					 indigent persons; and
(3)
					 coordinates patient care services with services provided by other community
					 agencies and organizations; and
(b) a review of the results and outcomes of
					 the clinical record review as specified in clause (13)(ii)(d) of this
					 subdivision.