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 111-8-37 - RULE AND REGULATIONS FOR HOSPICES
Rule 111-8-37-.09 - Quality Management

Universal Citation: GA Rules and Regs r 111-8-37-.09

Current through Rules and Regulations filed through September 23, 2024

(1) The hospice must appoint an interdisciplinary quality management committee that reflects the hospice's scope of services. The committee must develop and implement a comprehensive, effective and ongoing quality management, utilization, and peer review program that evaluates, maintains and improves the quality of patient care provided, including the appropriateness of the level of service received by patients, and submits required patient incident reports to the Department.

(2) The quality management, utilization, and peer review program must establish and use written criteria as the basis to evaluate the provision of patient care. The written criteria must be based on accepted standards of care and must include, at a minimum, systematic reviews of:

(a) Appropriateness of admissions, continued stay, and discharge;

(b) Appropriateness of professional services and level of care provided;

(c) Effectiveness of pain control and symptom relief;

(d) Patient injuries, such as those related to falls, accidents, and restraint use;

(e) Errors in medication administration, procedures, or practices that compromise patient safety;

(f) Infection control practices and surveillance data;

(g) Patient and family complaints and on-call logs;

(h) Inpatient hospitalizations;

(i) Staff adherence to the patients' plans of care; and

(j) Appropriateness of treatment.

(3) Findings of the quality management utilization, and peer review program must be utilized to correct identified problems, revise hospice policies, and improve the care of patients.

(4) There must be an ongoing evaluation of the quality management, utilization, and peer review committee to determine its effectiveness, with the results of the evaluation presented at least annually for review and appropriate action to the medical staff and the governing body.

O.C.G.A. §§ 31-7-170et seq.

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