Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 141.000 - Licensure of Hospice Programs
Section 141.210 - Quality Assurance
Universal Citation: 105 MA Code of Regs 105.141
Current through Register 1518, March 29, 2024
(A) The hospice shall develop and implement, through an interdisciplinary committee, an ongoing quality assurance program. One member of the committee shall be designated to be responsible for coordinating quality assurance.
(B) The quality assurance program shall include an evaluation of all services, including any services provided to patients under contractual arrangements. The hospice shall offer contracted hospice providers the opportunity to participate in the quality assurance program.
(C) Each hospice shall establish a written quality assurance plan for review of services delivered. The plan shall include:
(1) A procedure for
evaluating care provided on individual cases. At least quarterly, members of
professional disciplines representing at least the scope of the hospice program
shall review a 10% sample of both active and inactive clinical records of care
delivered to hospice patients and families. A written summary shall be prepared
for each individual review commenting on the amount and kind of care delivered
and including statements addressing any unmet needs.
(2) A process for program evaluation and the
identification of problems. At least quarterly, all summaries of individual
reviews shall be reviewed by the person responsible for coordinating quality
assurance. A written report will be prepared addressing any identified problems
with care, treatment, services, availability of services, and methods of care
delivery.
(3) A system to report to
the governing body the findings and recommendations for improving the quality
of care delivered. The quality assurance reports shall be submitted to the
hospice administrator and governing body. There shall be evidence in the
governing body's meeting minutes that the reports have been reviewed by the
governing body at least annually.
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