Current through Register Vol. 46, No. 39, September 25, 2024
The facility shall establish and maintain a coordinated
quality assessment and assurance program that integrates the review activities
of facility services to enhance the quality of life and registrant 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 program
director;
(2) the licensed master
social worker;
(3) a registered
nurse designated by the facility;
(4) at least three other members of facility
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, 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 registrant 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 Consumer Advisory Board, 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; and
(5) facilitate participation in the program
by administrative staff and health-care professionals representing each
professional service provided; and
(6) report its activities, findings and
recommendations to the governing body as often as necessary, but no less than 4
times a year.
