La. Admin. Code tit. 48 § I-8093

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8093 - Quality Assurance

A. The CRCC shall have an on-going comprehensive, integrated, self-assessment quality improvement process which provides assurance that patient care is provided at all times in compliance with accepted standards of professional practice.

B. The CRCC shall have written plans, policies and procedures addressing quality assurance.

C. The CRCC shall monitor and evaluate its resource allocation regularly to identify and resolve problems with the utilization of its services, facilities and personnel.

D. The CRCC shall follow a written plan for continually assessing and improving all aspects of operations which include:

1. goals and objectives;

2. the identity of the person responsible for the program;

3. a system to ensure systematic, objective regular reports are prepared and distributed to the governing body and any other committees as directed by the governing body;

4. the method for evaluating the quality and the appropriateness of care;

5. a method for resolving identified problems; and

6. a method for implementing practices to improve the quality of patient care.

E. The plan shall be reviewed at least annually and revised as appropriate by the governing body.

F. Quality assessment and improvement activities shall be based on the systematic collection, review, and evaluation of data which, at a minimum, includes:

1. services provided by professional and volunteer staff;

2. audits of patient charts;

3. reports from staff, volunteers, and clients about services;

4. concerns or suggestions for improvement in services;

5. organizational review of the CRCC program;

6. patient/family evaluations of care; and

7. high-risk, high volume and problem-prone activities.

G. When problems are identified in the provision of CRCC care, there shall be evidence of corrective actions, including ongoing monitoring, revisions of policies and procedures, educational intervention and changes in the provision of services.

H. The effectiveness of actions taken to improve services or correct identified problems shall be evaluated.

La. Admin. Code tit. 48, § I-8093

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 31:460 (February 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2175.14(B).