Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-29 - RULES AND REGULATIONS FOR HEALTH MAINTENANCE ORGANIZATIONS
Rule 111-8-29-.07 - Quality Assurance

Universal Citation: GA Rules and Regs r 111-8-29-.07

Current through Rules and Regulations filed through September 23, 2024

(1) Program Planning and Evaluation. The HMO shall have a formal organized plan for an ongoing quality assurance program. The purpose of the quality assurance plan is to assure that the quality of health care services is continually monitored, reviewed and evaluated for appropriate resource utilization, cost containment, and improvement of healthcare delivery. The written plan shall be approved by the governing body and implemented under the direction of the medical director of the HMO or the medical group. At a minimum, the plan shall include:

(a) The role and responsibilities of the medical director;

(b) An organizational structure created for the purpose of monitoring, reviewing, and evaluating the quality of health care services provided and appropriate resource utilization and cost containment;

(c) Mechanisms to collect data; identify problem areas and make recommendations for changes or improvements; develop plans for correction of identified problems; and follow-up;

(d) Arrangements for routine reporting of results of quality assurance program activities to the governing body and administration;

(e) Provision for maintenance of minutes and records of quality assurance program activities; and

(f) A peer review process which will evaluate and document the internal quality assurance program and the professional standards and practices of the providers, and services provided.

(2) Accessibility and Availability of Services.

(a) Basic health care services and supplemental health services for which enrollees have contracted shall be accessible (capable of being reached) to each enrollee and shall be readily available (present or ready for immediate use), within the defined service area of the HMO.

(b) An HMO shall provide or arrange for regular and reasonable hours during which an enrollee may receive services. An orderly system for scheduling services to enrollees is required and shall take into account the immediacy of the need for service.

(c) The HMO shall have a physician available or arrange for physician services to be available at all times to provide diagnostic and treatment services. The HMO shall assure that every enrollee seen for a medical complaint is evaluated by a physician or other qualified health professional pursuant to Georgia law. Each enrollee shall have the opportunity to select his primary care physician from among those available at the HMO.

(d) Medically necessary emergency services shall be available and accessible within the service area 24-hours a day, seven days a week.

(e) The ratio of enrollees to staff, including health professionals, administrative and other supporting staff, directly or through referrals, shall be such as to reasonably assume that all services offered by the HMO will be accessible without delays detrimental to the health of the enrollees. The HMO shall demonstrate an adequate ratio of primary care physicians to enrollees.

(f) The HMO shall provide for the availability and accessibility to services of medical specialists as determined to be medically necessary for the enrollee.

(g) Each HMO shall have a procedure for monitoring and evaluating availability and accessibility of its services, including a system for addressing problems that develop.

(3) Continuity of Care.

(a) Each provider shall establish and maintain an individual health record on each enrollee served, which shall contain information relating to the health care of that enrollee. These records shall be available to accommodate the flow of pertinent information to and from primary care physicians, as needed to assure continuity of care.

(b) The HMO shall offer counseling in dealing with the physical, emotional, and economic impact of illness and disability through services such as pre- and post-hospitalization planning, referral to services provided through community health, social and welfare agencies for family counseling, home health services, mental health services, health education, etc.

(4) Personnel.

(a) All HMO personnel and providers of services shall be currently licensed to perform the services they provide, when such services require licensure or registration under applicable State laws.

(b) The HMO shall assure that there is a sufficient number of health professionals to meet the needs of its enrollees. The specialty mix of licensed physicians shall be consistent with the projected health needs of the enrolled population. Emphasis shall be placed on having an adequate number of primary health care physicians.

(c) The HMO shall arrange for programs of continuing education for its staff and providers, either internally or by external organizations or agencies, to maintain and update skills and to assure quality of health care services.

(d) The HMO shall maintain an individual personnel folder on each employee and/or provider. This file shall include all personal information concerning the employee and/or provider, including applications and qualifications for employment. The employee's and/or provider's current license or registration number shall be included, if applicable.

(5) Facilities and Equipment.

(a) All facilities and equipment used for and in the delivery of services which are required to be licensed and/or certified by law, shall be so licensed and/or certified. This includes but is not necessarily limited to hospitals, nursing and intermediate care homes, clinical laboratories, pharmacies, psychiatric hospitals, and state- operated facilities.

(b) Providers shall have a functional, sanitary, and comfortable environment for patients, personnel, and the public. At all times the privacy and dignity of patients will be upheld.

(c) There shall be an adequate amount of space for services provided and disabilities treated, including waiting and reception areas, staff space, examining rooms, treatment areas, and storage.

Ga. L. 1964, pp. 499, 507, 523; Ga. L. 1979, p. 1148 et seq.; O.C.G.A. § 33-21-1et seq.

Disclaimer: These regulations may not be the most recent version. Georgia 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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