Current through Reg. 49, No. 38; September 20, 2024
(a)
The facility must maintain a Quality Assessment and Assurance Committee
consisting of:
(1) the director of nursing
services;
(2) the medical director
or designee;
(3) at least three
other members of the facility's staff, at least one of whom must be the
administrator, a board member or other individual in a leadership role;
and
(4) effective November 28,
2019, the infection preventionist.
(b) The Quality Assessment and Assurance
Committee reports to the facility's governing body regarding its activities.
The committee must:
(1) meet at least
quarterly to identify issues with respect to which quality assessment and
assurance activities are necessary;
(2) develop and implement appropriate plans
of action to correct identified quality deficiencies; and
(3) regularly review and analyze data,
including data resulting from drug regimen reviews, and act on available data
to make improvements.
(c) The State of Texas or the Secretary of
Health and Human Services may not require disclosure of the records of the
Quality Assessment and Assurance Committee except insofar as such disclosure is
related to the compliance of the committee with the requirements of subsection
(b) of this section.
(d) Good faith
attempts by the committee to identify and correct quality deficiencies may not
be used as a basis for sanctions.
(e) The Quality Assessment and Assurance
Committee must adopt and ensure implementation of a written policy to identify,
assess, and develop strategies to control risk of injury to residents and
nurses associated with the lifting, transferring, repositioning, or moving of a
resident. The policy must establish a process that includes:
(1) analysis of the risk of injury to both
residents and nurses posed by the resident handling needs of the resident
populations served by the nursing facility and the physical environment in
which resident handling and moving occurs;
(2) annual in-service education of nurses in
the identification, assessment, and control of risk of injury to residents and
nurses during resident handling;
(3) evaluation of alternative ways to reduce
risks associated with resident handling, including evaluation of equipment and
the environment;
(4) restriction,
to the extent feasible with existing equipment and aids, of manual resident
handling or moving of all or most of a resident's weight to emergency,
life-threatening, or otherwise exceptional circumstances;
(5) collaboration with and an annual report
to the nurse staffing committee;
(6) specific procedures for nurses to refuse
to perform or be involved in resident handling or moving that the nurse
believes in good faith will expose a resident or a nurse to an unacceptable
risk of injury;
(7) submission of
an annual report by the nursing staff to the Quality Assessment and Assurance
Committee on activities related to the identification, assessment, and
development of strategies to control risk of injury to residents and nurses
associated with the lifting, transferring, repositioning, or moving of a
resident; and
(8) in developing
architectural plans for constructing or remodeling a nursing facility or a unit
of a nursing facility in which resident handling and moving occurs,
consideration of the feasibility of incorporating resident handling equipment
or the physical space and construction design needed to incorporate that
equipment at a later date.
