La. Admin. Code tit. 48 § I-8239

Current through Register Vol. 50, No. 12, December 20, 2024

Section I-8239 - Quality Assurance/Performance Improvement

A. Agency shall have an on-going, comprehensive, integrated, self-assessment quality improvement process which provides assurance that patient care, including inpatient care, home care, and care provided by arrangement, is provided at all times in compliance with accepted standards of professional practice.

B. The hospice shall have written plans, policies and procedures addressing quality assurance and performance improvement.

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

D. Hospice 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 appropriate areas;

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

5. a method for resolving identified problems; and

6. application to improving the quality of patient care.

E. The plan is reviewed at least annually and revised as appropriate.

F. The governing body and administration shall strive to create a work environment where problems can be openly addressed and service improvement ideas encouraged.

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

1. services provided by professional and volunteer staff;

2. outcome audits of patient charts;

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

4. concerns or suggestions for improvement in services;

5. organizational review of the hospice program;

6. patient/family evaluations of care; and

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

H. When problems are identified in the provision of hospice 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.

I. The effectiveness of actions taken to improve services or correct identified problems is evaluated.

La. Admin. Code tit. 48, § I-8239

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 15:482 (June 1989), amended LR 24:2273 (December 1998), Amended by the Department of Health, Bureau of Health Services Financing, LR 44601 (3/1/2018).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2181-2191.