N.Y. Comp. Codes R. & Regs. tit. 14, § 511-2.14 – Quality improvement.

(a) The provider of service shall have an organized quality assurance program designed to enhance individual care through the ongoing objective assessment of important aspects of the child’s care and the correction of identified problems. The quality assurance program shall provide for the following:
1. (1) identification of problems or concerns related to the care of individuals including, but not limited to, compliance with the treatment plan;
2. (2) objective assessment of the cause and scope of the problems or concerns, including the determination of priorities for both investigating and resolving problems and concerns. Priorities shall be related to the degree of adverse impact on the care provided to individuals that can be expected if the problems or concerns remain unresolved;
3. (3) recommendations related to implementation of decisions or actions that are designed to eliminate, insofar as possible, identified problems; and
4. (4) monitoring to assess whether or not the desired result has been achieved and sustained.
(b) Each provider of service 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 individual care and provides for appropriate response to findings. The written quality assurance plan shall address at a minimum:
1. (1) the individual or group with the overall responsibility to administer or coordinate the quality assurance program;
2. (2) the individuals or organizational entities to whom responsibility will be delegated for specific activities or mechanisms;
3. (3) the activities or mechanisms for reviewing and evaluating care;
4. (4) the activities or mechanisms for assuring the accountability of the staff for the care they provide;
5. (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. (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) CMHRS programs shall have procedures for internal monitoring of program performance. Performance should be monitored against the criteria stated in the program's functional program. 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.
(d) The Office of Mental Health shall have responsibility for monitoring the quality of CMHRS programs. 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 with Mental Hygiene Law, section 31.16 and Parts 53 and 503 of this Title.