Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 82 - Minimum Standards for Licensure of Hospice Agencies
Subchapter D - Administration
Section I-8239 - Quality Assurance/Performance Improvement

Universal Citation: LA Admin Code I-8239

Current through Register Vol. 50, No. 9, September 20, 2024

A. Agency shall have an on-going, comprehensive, integrated, self-assessment quality improvement process which provides assurance that patient care, including inpatient care, home care, and care provided by arrangement, is provided at all times in compliance with accepted standards of professional practice.

B. The hospice shall have written plans, policies and procedures addressing quality assurance and performance improvement.

C. Hospice shall monitor and evaluate its resource allocation regularly to identify and resolve problems with the utilization of its services, facilities and personnel.

D. Hospice shall follow a written plan for continually assessing and improving all aspects of operations which include:

1. goals and objectives;

2. the identity of the person responsible for the program;

3. a system to ensure systematic, objective regular reports are prepared and distributed to appropriate areas;

4. the method for evaluating the quality and the appropriateness of care;

5. a method for resolving identified problems; and

6. application to improving the quality of patient care.

E. The plan is reviewed at least annually and revised as appropriate.

F. The governing body and administration shall strive to create a work environment where problems can be openly addressed and service improvement ideas encouraged.

G. Quality assessment and improvement activities are based on the systematic collection, review, and evaluation of data which, at a minimum, includes:

1. services provided by professional and volunteer staff;

2. outcome audits of patient charts;

3. reports from staff, volunteers and patients about services;

4. concerns or suggestions for improvement in services;

5. organizational review of the hospice program;

6. patient/family evaluations of care; and

7. high-risk, high-volume and problem-prone activities.

H. When problems are identified in the provision of hospice care, there shall be evidence of corrective actions, including ongoing monitoring, revisions of policies and procedures, educational intervention and changes in the provision of services.

I. The effectiveness of actions taken to improve services or correct identified problems is evaluated.

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2181-2191.

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