New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 811 - END STAGE RENAL DISEASE DIALYSIS CENTERS
Section He-P 811.20 - Quality Improvement

Universal Citation: NH Admin Rules He-P 811.20

Current through Register No. 40, October 3, 2024

(a) The licensee shall develop and maintain a quality improvement program whose objectives shall be to reveal patterns and initiate action to provide an optimum quality of care for all clients.

(b) The quality improvement program shall include a quality improvement committee, which shall consist of:

(1) The medical director;

(2) The director of nursing;

(3) A social worker;

(4) A dietitian; and

(5) At least one other direct care staff provider.

(c) The quality improvement committee shall:

(1) Review within 24 hours:
a. All client cases where a medical emergency occurs; and

b. Client cases which require unexpected transfer to an acute care facility;

(2) Establish and implement a system for the monthly surveillance of dialysate water and reuse;

(3) Review all reports of unexpected occurrences involving clients, personnel, or visitors;

(4) Ensure that outside services such as laboratory services or water analysis are provided in accordance with federal and state laws and administrative rules;

(5) Ensure that individuals with appropriate qualifications maintain medical equipment;

(6) Establish an ongoing program to determine performance improvement projects, to carry out interventions to mitigate quality issues and to audit corrective actions; and

(7) Meet at least quarterly.

(d) Documentation of all quality improvement meetings shall be maintained on-site for at least 2 years.

#9963, eff 7-28-11

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