A hospice must conduct an annual comprehensive self-assessment of the quality and appropriateness of care provided, including inpatient care. The findings are to be used by the hospice to correct identified problems and to revise hospice policies, if necessary. A mechanism must be established in writing for the collection of pertinent data to assist in the evaluation process. The data to be considered shall include, but are not limited to:
N.M. Admin. Code § 8.370.19.24