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
Universal Citation: 14 NY Comp Codes Rules and Regs ยง 825.11
Current through Register Vol. 46, No. 39, September 25, 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.
(2) Behavioral Health Services
(i) Integrated services providers of mental
health and/or substance use disorder services shall comply with all
requirements of 14 NYCRR Part 599 or 822, as applicable, relating to quality
assurance.
(ii) Integrated services
providers of mental health and/or substance use disorder services shall prepare
an annual report and submit it to its governing authority. This report must
document the effectiveness and efficiency of the ambulatory care program in
relation to its goals and quality assurance plan and indicate any
recommendations and plans for improvement in its services to patients, as well
as recommended changes in its policies and procedures.
(iii) Utilization review.
(a) Integrated services providers of mental
health and/or substance use disorder services shall establish and implement a
utilization review plan. The utilization review plan must include participation
by all primary care and behavioral health providers, as applicable.
(b) Integrated services providers of mental
health and/or substance use disorder services may use a utilization review
process developed by the state licensing agency or may develop its own
utilization review process that is subject to approval by the state licensing
agency.
(c) Integrated services
providers of mental health and/or substance use disorder services may perform
its utilization review process internally; or it may enter into an agreement
with another organization, competent to perform utilization review, to complete
its utilization review process.
(d)
Utilization review must be conducted by at least one clinical staff member. No
member shall participate in utilization review decisions relative to any
patient he or she is treating directly.
(e) The utilization review plan must include
procedures for ensuring that retention criteria are met and services are
appropriate. The utilization review plan must consider the needs of a
representative sample of patients for continued treatment, the extent of the
behavioral health problem, and the continued effectiveness of, and progress in,
treatment. At a minimum, utilization review must include separate random
samples based upon a patient's length of stay, with larger samples for patients
with longer lengths of stay. Utilization review must also be conducted for all
active cases within the twelfth month after admission and every 90 days
thereafter.
(f) Documentation of
utilization review must be maintained providing evidence that the
deliberations:
(1) were based on current
progress in treatment relative to the applicable functional areas identified in
the patient's comprehensive treatment/recovery plan;
(2) determined the appropriateness of
continued stay at the outpatient level of care and intensity of services, as
well as whether co-occurring disorder(s) require referral to outside
services;
(3) determined the
reasonable expectation of progress towards the accomplishment of the goals and
objectives articulated in the patient's treatment/recovery plan, based on
continued treatment at this level of care and intensity of services;
and
(4) resulted in a recommendation
regarding continuing stay, intensity of care and/or referral of this
case.
(b) Incident Reporting
(1) Mental health behavioral care host
providers shall report incidents involving patients receiving mental health
services in accordance with the provisions of 14 NYCRR Part 524.
(2) Substance use disorder behavioral care
host providers shall report incidents involving patients receiving substance
use disorder services in accordance with the provisions of 14 NYCRR Part
836.
(3) Primary care host providers
shall report incidents in accordance with the provisions of 10 NYCRR section
405.8 or 10 NYCRR section 751.10, as applicable.
Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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