New York Codes, Rules and Regulations
Title 14 - DEPARTMENT OF MENTAL HYGIENE
Chapter XIII - Office of Mental Health
Part 584 - Operation Of Residential Treatment Facilities For Children And Youth
Section 584.17 - Quality assurance

Universal Citation: 14 NY Comp Codes Rules and Regs ยง 584.17

Current through Register Vol. 46, No. 39, September 25, 2024

(a) Each residential treatment facility shall have an organized quality assurance program designed to enhance resident care through the ongoing objective assessment of important aspects of resident care and the correction of identified problems. The quality assurance program shall provide for the following:

(1) identification of problems or concerns related to the care of residents;

(2) objective assessment of the cause and scope of the problems or concerns, including the determination of priorities for both investigating and resolving problems. Priorities shall be related to the degree of adverse impact on the care provided to residents that can be expected if the problems remain unresolved;

(3) implementation of decisions or actions that are designed to eliminate, insofar as possible, identified problems; and

(4) monitoring to assess whether or not the desired result has been achieved and sustained.

(b) Each residential treatment facility shall prepare a written quality assurance plan designed to ensure that there is an ongoing quality assurance program that includes effective mechanisms for reviewing and evaluating resident care and provides for appropriate response to findings. This quality assurance plan shall be subject to approval by the Office of Mental Health. The written quality assurance plan shall address at a minimum:

(1) the individual or group with the overall responsibility to administer or coordinate the quality assurance program;

(2) the activities or mechanisms for reviewing and evaluating resident care;

(3) the individuals or organizational entities to whom responsibility will be delegated for specific activities or mechanisms;

(4) the activities or mechanisms for assuring the accountability of the clinical staff for the care they provide;

(5) the individuals or organizational entities to whom responsibility will be delegated for responding to findings or implementing corrective actions designed to eliminate insofar as possible identified problems; and

(6) the activities or mechanisms for monitoring whether or not the corrective actions have been implemented, and whether or not the desired result has been achieved and sustained.

(c) As a component of the quality assurance program, each residential treatment facility shall establish a written plan for reviewing untoward incidents in accordance with Part 524 of this Title.

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