Current through Register Vol. 46, No. 39, September 25, 2024
The facility shall establish and maintain a coordinated
quality assessment and assurance program which integrates the review activities
of all nursing home programs and services to enhance the quality of life and
resident care and treatment.
(a)
Facility-wide quality assurance. Quality assurance shall be the responsibility
of all staff, at every level, at all times. Supervisory personnel alone cannot
ensure quality of care and services. Such quality must be a part of each
individual's approach to his or her daily responsibilities.
(b) Quality assessment and assurance
committee. The facility shall maintain a quality assessment and assurance
committee consisting of at least the following:
(1) the administrator or his or her
designee;
(2) the director of
nursing services;
(3) a physician
designated by the facility;
(4) at
least one member of the governing body who is not otherwise affiliated with the
nursing home in an employment or contractual capacity; and
(5) at least three other members of the
facility's staff.
(c)
Committee functions. The quality assessment and assurance committee shall:
(1) meet at least quarterly to identify
issues with respect to which quality assessment and assurance activities are
necessary;
(2) have a written plan
for the quality assessment and assurance program which describes the program's
objectives, organization, responsibilities of all participants, scope of the
program and procedures for overseeing the effectiveness of monitoring,
assessing and problem-solving activities. Such plan shall also provide for the
development and implementation of quality improvement initiatives designed to
advance the quality of life, care and services in the facility;
(3) define methods for identification and
selection of clinical and administrative problems to be reviewed. The process
shall include but not be limited to:
(i) the
establishment of review criteria developed in accordance with current standards
of professional practice for monitoring and assessing resident care and
clinical performance;
(ii)
regularly scheduled reviews of clinical records, resident complaints and
suggestions, reported incidents and other documents pertinent to problem
identification;
(iii) consultation
on at least a quarterly basis with the Resident Council to seek recommendations
on quality improvements;
(iv)
documentation of all quality assessment and assurance activities, including but
not limited to the findings, recommendations and actions taken to resolve
identified problems; and
(v) the
timely implementation of corrective actions and periodic assessments of the
results of such actions;
(4) ensure that the outcomes of quality
assurance reviews are shared with appropriate staff to be used for the revision
or development of facility policies and practices and in granting or renewing
staff privileges, as appropriate;
(5) facilitate participation in the program
by administrative staff and health- care professionals representing each
professional service provided;
(6)
report its activities, findings and recommendations to the governing body as
often as necessary, but no less often than 4 times a year; and
(7) participate with the medical director in
implementing Public Health Law, section 2805-k.
