South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-78 - Standards for Licensing Hospices
Sec2 61-78.1500 - QUALITY IMPROVEMENT PROGRAM (II)

Universal Citation: SC Code Regs 61-78.1500

Current through Register Vol. 48, No. 9, September 27, 2024

A. There shall be a written, implemented quality improvement program that provides effective self-assessment and implementation of changes designed to improve the care, treatment, and services provided by the Hospice.

B. The quality improvement program, at a minimum, shall:

1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is regularly, systematically, and objectively accomplished;

2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;

3. Identify the action taken to correct deviations and prevent future deviation, and the person(s) responsible for implementation of these actions;

4. Establish ways to measure the quality of patient care and staff performance as well as the degree to which the policies and procedures are followed;

5. Analyze the appropriateness of the POC and the necessity of care, treatment, and services rendered;

6. Analyze the effectiveness of the fire plan (hospice facility only);

7. Analyze all accidents and incidents, to include all medication errors and unexpected patient deaths;

8. Analyze any infection, epidemic outbreaks, or other unusual occurrences which threaten the health, safety, or well-being of the patients.

C. A Hospice shall establish a method of obtaining feedback from patients, families, and other interested persons regarding the level of satisfaction with services, treatment, and care provided by the Hospice.

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