S.C. Code Regs. § ch. 61, 61-93, 61-93.1800

Current through Register Vol. 48, No. 10, October 25, 2024

Section 61-93.1800 - QUALITY IMPROVEMENT PROGRAM (II)

A. Facilities shall maintain a written, implemented Quality Improvement Program that provides effective self-assessment and implementation of changes designed to improve the treatment/care/services provided by the Facility.

B. The Quality Improvement Program, at a minimum, shall:

1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is regularly, systematically, and objectively accomplished;

2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;

3. Identify the action taken to correct deviations and prevent future deviation, and the person(s) responsible for implementation of these actions;

4. Establish ways to measure the quality of Patient care and Staff performance, as well as the degree to which the policies and procedures are followed;

5. Analyze the appropriateness of Individual Plans of Care and the necessity of treatment/care/services rendered;

6. Analyze the effectiveness of the fire plan;

7. Analyze all incidents and accidents to include Patient deaths;

8. Analyze any infection, epidemic outbreaks, or other unusual occurrences which threaten the health, safety, or well-being of the Patients; and

9. Establish a systematic method of obtaining feedback from Patients and other interested persons, e.g., family members and peer organizations, as expressed by the level of satisfaction with treatment/care/services received.

S.C. Code Regs. ch. 61, 61-93, 61-93.1800

Added by State Register Volume 44, Issue No. 06, eff. 6/26/2020.