N.Y. Comp. Codes R. & Regs. tit. 14 § 594.14

Current through Register Vol. 46, No. 45, November 2, 2024

Section 594.14 - Quality assurance

(a) Each provider of service shall develop a quality assurance plan. The plan shall include, but is not limited to:

(1) Each licensed housing program shall have a written utilization review procedure which includes but is not limited to, review of:

(i) appropriateness for admission to and continued stay in the licensed housing program;

(ii) appropriateness of the services provided by the licensed housing program; and

(iii) readiness for referral and transfer of youth who no longer meet criteria for the licensed housing program must be included.

(2) Utilization review must be carried out by staff who do not have primary responsibility for the resident under review.

(3) Each licensed housing programs shall have an internal incident reporting, investigation and management process. Licensed housing programs shall comply with Mental Hygiene Law and Part 524 of this Title which governs incident reporting by licensed mental health programs. The quality assurance plan shall contain written procedures for carrying out incident management and reporting.

(4) Each licensed housing program shall have procedures for internal monitoring of program performance. The results of this internal monitoring shall be used to identify problems in client care and opportunities to improve care and shall be regularly reviewed and acted on by the governing body.

(b) The Office of Mental Health shall have responsibility for monitoring the quality of licensed housing programs and services and will monitor licensed housing programs against the criteria as stated in the functional program description and in accordance with this Part.

(1) External program monitoring shall be carried out by the Office of Mental Health and/or its authorized agents. The Office of Mental Health will review program operations, quality assurance activities and the individual records of residents during periodic certification visits.

(2) External utilization review shall be carried out as necessary by the Office of Mental Health or other agents against the criteria contained in the licensed housing provider's functional description.

(3) The Office of Mental Health will conduct external review of licensed housing programs as necessary based on patterns or trends in reported incidents or on the occurrence of an individual incident of extreme gravity.

(c) Each licensed housing program shall have an Office of Mental Health approved consumer evaluation process, in which youth, and their parents, as well as other relevant individuals involved with the youth shall have an opportunity to give feedback about the program in a confidential manner. The information from this consumer process shall be summarized annually and submitted to the Office of Mental Health, the youth, their parents and all staff in the program. The confidentiality of residents, families and other impacted parties shall be protected.

(d) Upon a determination that a provider of service is in violation of this Part or upon a determination that a provider of service has failed to otherwise comply with the terms of its operating certificate or with the provisions of any applicable statute, standard, rule or regulation, the commissioner may revoke, suspend or limit the provider's operating certificate or impose fines in accordance withe Mental Hygiene Law, section 31.16 and Parts 53 and 503 of this Title.

N.Y. Comp. Codes R. & Regs. Tit. 14 § 594.14