N.M. Admin. Code § 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.
Notes
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