7 Alaska Admin. Code § 12.323

Current through September 25, 2024

Section 7 AAC 12.323 - Quality improvement plan

(a) A full-service hospice agency shall conduct an ongoing comprehensive self-assessment of the quality and appropriateness of care provided, including inpatient care and care provided under contract. The agency shall document the findings from its self-assessment and use them to correct identified problems and to revise hospice policies as necessary.

(b) A full-service hospice agency shall establish a quality improvement plan for continually

(1) monitoring and evaluating care provided;

(2) identifying existing and potential issues; and

(3) proposing and implementing improvements, and reevaluating care provided to determine if further improvement is possible or necessary.

(c) The plan required under (b) of this section must include an analysis of

(1) a quarterly clinical record review conducted as required under (f) of this section;

(2) data derived from client assessments;

(3) current clinical practice guidelines and professional practice standards applicable to clients in the home;

(4) utilization of services;

(5) measures of staff performance;

(6) medical and other professional evaluation of the agency's caregiving system;

(7) client and family satisfaction surveys; and

(8) client complaints and the resolution process for those complaints.

(d) The quality improvement program must include problem identification, corrective action, and subsequent monitoring of identified problems.

(e) A full-service hospice agency shall review a client's clinical record at least every 30 days during which the client receives hospice services to determine the adequacy of the plan of care and appropriateness of continued care.

(f) The quarterly clinical review required under (c)(1) of this section must be conducted by a multidisciplinary team of health professionals representing the services provided by the hospice agency. The review must consist of at least 10 percent of both active and closed records in that quarter to determine if applicable state laws and agency policies are properly followed.

7 AAC 12.323

Eff. 5/24/2007, Register 182

Authority:AS 47.32.010

AS 47.32.030