N.M. Admin. Code § 8.370.18.23

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.370.18.23 - QUALITY ASSURANCE

All facilities licensed pursuant to these regulations must have an ongoing, comprehensive self-assessment of the services provided by the facility. The assessment must include the total operation of the facility.

A. To be considered comprehensive the assessment for quality assurance must include, but is not limited to the following:

(1) condition of patients and services rendered;

(2) completeness of patient records;

(3) organization of the facility;

(4) administration;

(5) staff utilization and training; and

(6) policies and procedures.

B. Where problems (or potential problems) are identified, the facility must act as soon as possible to avoid any risks to patients such as, but not limited to the following:

(1) changes in policies and procedures;

(2) staffing and assignment changes;

(3) additional education and training for the staff;

(4) changes in equipment or physical plant; or

(5) deletion or addition of services.

C. The governing body of the facility shall ensure that the effectiveness of the quality assurance program is evaluated by medical and administrative staff at least once a year. If the evaluation is not done all at once, no more than a year must lapse between evaluations of the same parts.

D. Documentation of the quality assurance program must be maintained by the facility.

N.M. Admin. Code § 8.370.18.23

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024