Each CTC shall establish and maintain quality improvement
systems including policies and procedures for quality assurance and quality
improvement and have a quality committee.
A. The CTC shall establish a quality
committee comprised at a minimum of the administrator, clinical director,
director of nursing, licensed mental health professional, certified peer
support worker, and psychiatrist.
Other committee members may be specified by rules governing
payor requirements. Members may participate on the quality committee by
teleconference. The committee shall establish and implement quality assurance
and quality improvement systems that monitor and promote quality care to
clients. The systems are approved by the governing body and updated
annually.
(1) the quality improvement
systems must include:
(a) chart
reviews;
(b) annual review of
policies and procedures;
(c) data
collection, and other program monitoring processes;
(d) data analyses;
(e) identification of events, trends and
patterns that may affect client health, safety or treatment efficacy;
(f) identification of areas for
improvement;
(g) intervention
plans, including action steps, responsible parties, and completion time;
and,
(h) evaluation of the
effectiveness of interventions.
(2) when areas of concern or potential
problems are identified by the committee, the CTC shall act as soon as possible
to avoid and prevent risks to clients.
(3) the quality committee shall take and
maintain meeting minutes.
B. The quality committee shall review at a
minimum, the following:
(1) high-risk
situations and critical incidents (such as suicide, death, serious injury,
violence and abuse, neglect and exploitation) within 24 hours;
(2) medical emergencies;
(3) medication variance;
(4) infection control;
(5) emergency safety interventions including
any instances physical restraints; and
(6) environmental safety and
maintenance.
C. The
quality committee is responsible for the implementation of quality improvement
processes.
D. The quality committee
shall submit a quarterly report to the governing body for review and
approval.
E. The governing body
shall evaluate the CTC's effectiveness in improving performance.
Notes
N.M. Admin.
Code §
8.321.11.23
Adopted by
New
Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff.
7/1/2024
