Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 93 - Hospitals
Subchapter I - Quality Assessment and Improvement
Section I-9401 - Clinical Plan

Universal Citation: LA Admin Code I-9401

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

A. There is a written plan for assessing and improving quality that describes the objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation, and improvement activities. All organized services related to patient care, including services furnished by a contractor, shall be evaluated. Nosocomial infections and medication therapy shall be evaluated. All medical and surgical services and other invasive procedures performed in the hospital shall be evaluated as they relate to appropriateness of diagnosis and treatment. The services provided by each practitioner with hospital privileges shall be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness.

B. Each department or service of the hospital shall address:

1. patient care problems;

2. cause of problems;

3. documented corrective actions; and

4. monitoring or follow-up to determine effectiveness of corrective actions taken.

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2100-2115.

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