New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES
Part 11 - CRISIS TRIAGE CENTERS
Section 8.321.11.23 - QUALITY IMPROVEMENT SYSTEMS

Universal Citation: 8 NM Admin Code 8.321.11.23

Current through Register Vol. 35, No. 18, September 24, 2024

Each CTC shall establish and maintain quality improvement systems including policies and procedures for quality assurance and quality improvement and have a quality committee.

A. The CTC shall establish a quality committee comprised at a minimum of the administrator, clinical director, director of nursing, licensed mental health professional, certified peer support worker, and psychiatrist.

Other committee members may be specified by rules governing payor requirements. Members may participate on the quality committee by teleconference. The committee shall establish and implement quality assurance and quality improvement systems that monitor and promote quality care to clients. The systems are approved by the governing body and updated annually.

(1) the quality improvement systems must include:
(a) chart reviews;

(b) annual review of policies and procedures;

(c) data collection, and other program monitoring processes;

(d) data analyses;

(e) identification of events, trends and patterns that may affect client health, safety or treatment efficacy;

(f) identification of areas for improvement;

(g) intervention plans, including action steps, responsible parties, and completion time; and,

(h) evaluation of the effectiveness of interventions.

(2) when areas of concern or potential problems are identified by the committee, the CTC shall act as soon as possible to avoid and prevent risks to clients.

(3) the quality committee shall take and maintain meeting minutes.

B. The quality committee shall review at a minimum, the following:

(1) high-risk situations and critical incidents (such as suicide, death, serious injury, violence and abuse, neglect and exploitation) within 24 hours;

(2) medical emergencies;

(3) medication variance;

(4) infection control;

(5) emergency safety interventions including any instances physical restraints; and

(6) environmental safety and maintenance.

C. The quality committee is responsible for the implementation of quality improvement processes.

D. The quality committee shall submit a quarterly report to the governing body for review and approval.

E. The governing body shall evaluate the CTC's effectiveness in improving performance.

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