Ga. Comp. R. & Regs. R. 111-8-37-.09 - Quality Management
(1)
The hospice must appoint an interdisciplinary quality management committee that
reflects the hospice's scope of services. The committee must develop and
implement a comprehensive, effective and ongoing quality management,
utilization, and peer review program that evaluates, maintains and improves the
quality of patient care provided, including the appropriateness of the level of
service received by patients, and submits required patient incident reports to
the Department.
(2) The quality
management, utilization, and peer review program must establish and use written
criteria as the basis to evaluate the provision of patient care. The written
criteria must be based on accepted standards of care and must include, at a
minimum, systematic reviews of:
(a)
Appropriateness of admissions, continued stay, and discharge;
(b) Appropriateness of professional services
and level of care provided;
(c)
Effectiveness of pain control and symptom relief;
(d) Patient injuries, such as those related
to falls, accidents, and restraint use;
(e) Errors in medication administration,
procedures, or practices that compromise patient safety;
(f) Infection control practices and
surveillance data;
(g) Patient and
family complaints and on-call logs;
(h) Inpatient hospitalizations;
(i) Staff adherence to the patients' plans of
care; and
(j) Appropriateness of
treatment.
(3) Findings
of the quality management utilization, and peer review program must be utilized
to correct identified problems, revise hospice policies, and improve the care
of patients.
(4) There must be an
ongoing evaluation of the quality management, utilization, and peer review
committee to determine its effectiveness, with the results of the evaluation
presented at least annually for review and appropriate action to the medical
staff and the governing body.
Notes
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