Title: Section 404.11 - Quality Assurance, Utilization Review and Incident Reporting

Effective Date

01/01/2015

Section 404.11 Quality Assurance, Utilization Review and Incident Reporting

(a) Quality Assurance

(1) Primary Care Services.

(i) Integrated services providers which provide primary 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 which provide 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 components of the integrated services provider, 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.

Volume

VOLUME C (Title 10)

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