N.M. Admin. Code § 8.370.22.39 - QUALITY IMPROVEMENT
Each agency must establish an on-going quality improvement program to ensure an adequate and effective operation. To be considered on-going, the quality improvement program must document quarterly activity that addresses, but is not limited to:
A.
Clinical care: Assessment of patient/client goals and outcome, such as,
diagnosis(es), plan of care, services provided, and standards of patient/client
care.
B. Operational activities:
Assessment of the total operation of the agency, such as, policies and
procedures, statistical data (i.e., admissions, discharges, total visits by
discipline, etc.), summary of quality improvement activities, summary of
patient/client complaints and resolutions, and staff utilization.
C. Quality improvement action plan: Written
responses to address existing or potential problems which have been
identified.
D. Documentation of
activities: The results of the quality improvement activities shall be compiled
annually in report format and formally reviewed and approved by the governing
body and advisory group of the home health agency. No more than one year may
lapse between evaluations of the same part.
E. The licensing authority may, at its sole
discretion, request quarterly activity summaries of an agency's on-going
quality improvement activities or may direct the agency to conduct specific
quality improvement studies.
Notes
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