Kan. Admin. Regs. § 28-34-142

Current through Register Vol. 43, No. 45, November 7, 2024

Section 28-34-142 - Risk management

(a) Each applicant and each licensee shall develop and implement a written risk management plan.

(b) The risk management plan shall be reviewed and approved annually by the licensee.

(c) Findings, conclusions, recommendations, actions taken, and results of actions taken shall be documented and reported through procedures established within the risk management plan.

(d) All patient services, including those services provided by outside contractors or consultants, shall be periodically reviewed and evaluated in accordance with the risk management plan.

(e) Each risk management plan shall include the following:

(1) Section I. A description of the system implemented by the facility for investigation and analysis of the frequency and causes of reportable incidents within the facility;

(2) Section II. A description of the measures used by the facility to minimize the occurrence of reportable incidents and the resulting injuries within the facility;

(3) Section III. A description of the facility's implementation of a reporting system based upon the duty of all medical staff members staffing the facility and all agents and staff members of the facility directly involved in the delivery of health care services to report reportable incidents; and

(4) Section IV. A description of the organizational elements of the plan, including the following:

(A) Name and address of the facility;

(B) name and title of the facility's risk manager; and

(C) description of involvement and organizational structure of medical staff members as related to the risk management program, including names and titles of medical staff members involved in investigation and review of reportable incidents.

(f) The standards-of-care determinations shall include the following:

(1) Each facility shall assure that analysis of patient care incidents complies with the definition of a "reportable incident." Each facility shall use categories to record its analysis of each incident, and those categories shall be in substantially the following form:

(A) Standards of care met;

(B) standards of care not met, but with no reasonable probability of causing injury;

(C) standards of care not met, with injury occurring or reasonably probable; or

(D) possible grounds for disciplinary action by the appropriate licensing agency.

(2) Each reported incident shall be assigned an appropriate standard-of-care determination. Separate stan-dard-of-care determinations shall be made for each involved medical staff member and each clinical issue reasonably presented by the facts. Any incident determined to meet paragraph (f)(1)(C) or (D) of this regulation shall be reported to the appropriate licensing agency.

Kan. Admin. Regs. § 28-34-142

Authorized by and implementing L. 2011, ch. 82, sec. 9; effective, T-28-7-1-11, July 1, 2011; effective Nov. 14, 2011.