Objective

To determine whether the Office of Addiction Services and Supports (OASAS) properly monitored residential services to ensure conditions are safe and secure for patients. The audit covered the period from April 2017 through February 2021, and also included the most recent recertification review performed at each Program, some of which were prior to April 2017. In addition, we included publicly available COVID-19–related information through June 2021.

About the Program

OASAS provides services for over 680,000 individuals annually through its approximately 1,700 prevention, treatment, and recovery programs. OASAS’ mission is to improve the lives of New Yorkers by leading a comprehensive system of addiction services for prevention, treatment, and recovery. OASAS oversees Chemical Dependence Residential Services delivered by certified providers, including Community Residential (CR) and Supportive Living (SL) services. A CR program provides supervised services to people who are transitioning into abstinent living. An SL program is designed to promote independent living in a supervised setting. As of December 22, 2020, there were 64 CR and 32 SL programs (Programs) in New York State.

OASAS is responsible for certifying residential services and issuing operating certificates, pursuant to requirements established in State law and New York Codes, Rules and Regulations (Regulations). A Program’s eligibility for certification is contingent on the results of an OASAS inspection of the Program’s compliance with all applicable laws, rules, and regulations. Depending on their compliance rating, Programs may be certified to operate for a 6-month or 1-, 2-, or 3-year period before their next recertification review is due. OASAS suspended all on-site recertification reviews due to the COVID-19 disaster emergency.

For Programs whose certification is due for renewal, OASAS is required to conduct recertification reviews before the expiration date of the current certification. Recertification reviews are unannounced and include an on-site inspection of facility conditions and safety, review of patient records, examination of staffing patterns and staff qualifications, and assessment of compliance with reporting requirements. OASAS has developed procedures for completing recertification reviews, including a tool used by regional office staff that encompasses all the requirements of the review and the steps that must be performed during the review. Where OASAS identifies any regulatory deficiencies, the Program is required to take all actions necessary to correct them and submit a corrective action plan of the specific actions planned or taken to bring the Program into compliance.

In addition to recertification reviews, OASAS performs interim or focused reviews to determine whether Program residences are operating in a manner that is safe and suitable for residents and whether several key policies, procedures, and methods are up to date, fully implemented, and being adhered to.

Key Findings

OASAS is not adequately monitoring the Programs, as prescribed in the Regulations. OASAS is not meeting the recertification review requirements, and many Programs’ operating certificates are past their end date. In addition, OASAS is not always conducting appropriate follow-up of Programs to verify that all deficiencies have been addressed – including obtaining documentation from Programs supporting that corrective action has been taken. This lack of oversight and action poses an increased risk to the safety and security of the conditions of Programs and the vulnerable populations served. Specifically, we found that:

• Of the 76 Programs due for recertification during our audit period, all 76 had a recertification review that was past due. Of these 76 Programs, 49 (64%) were more than a year past due for a recertification review prior to the COVID-19 disaster emergency. Therefore, in addition to already being overdue for recertification, these 76 residential Programs operated without a recertification review for at least an additional 15 months during the disaster emergency period.
• For a judgmental sample of 25 Programs, we determined 10 (40%) did not receive any type of documented on-site visit during the recertification period. For this same judgmental sample of 25 Programs, OASAS had identified a total of 243 regulatory deficiencies at the last recertification review. We determined that, for 98 (40%) of the deficiencies, the Programs did not provide adequate documentation of specific actions planned or taken to achieve compliance, nor did OASAS follow up with the Programs to obtain documentation or verify that actions had been taken.

Key Recommendations

• Perform recertification reviews for all Programs that are overdue.
• Implement an effective monitoring system to ensure that all recertification reviews are performed timely.
• Implement procedures to ensure that OASAS staff conduct appropriate follow-up of Programs with deficiencies identified during recertification reviews.