Kan. Admin. Regs. § 28-52-1

Current through Register Vol. 43, No. 49, December 5, 2024

Section 28-52-1 - General requirements

(a) Each medical care facility shall establish a written plan for risk management and patient care quality assessment on a facility-wide basis.

(b) The plan shall be approved and reviewed annually by the facility's governing body.

(c) Findings, conclusions, recommendations, actions taken, and results of actions taken shall be documented and reported through procedures established within the risk management plan.

(d) All patient services including those services provided by outside contractors or consultants shall be periodically reviewed and evaluated in accordance with the plan.

(e) Plan format. Each submitted plan shall include the following:

(1) Section I a description of the system implemented by the facility for investigation and analysis of the frequency and causes of reportable incidents within the facility;

(2) Section II a description of the measures used by the facility to minimize the occurrence of reportable incidents and the resulting injuries within the facility;

(3) Section III a description of the facility's implementation of a reporting system based upon the duty of all health care providers staffing the facility and all agents and employees of the facility directly involved in the delivery of health care services to report reportable incidents to the chief of the medical staff, chief administrative officer, or risk manager of the facility;

(4) Section IV, organization a description of the organizational elements of the plan including:

(A) Name and address of the facility;

(B) name and title of the facility's risk manager;

(C) description of involvement and organizational structure of medical staff as related to risk management program, including names and titles of medical staff members involved in investigation and review of reportable incidents;

(D) organizational chart indicating position of the facility's review committee as defined in K.S.A. 65-4923 and L. 1986, Ch. 229, New Section 4(a)(2); and

(E) mechanism for ensuring quarterly reporting of incident reports to proper licensing agency.

(5) Section V a description of the facility's resources allocated to implement the plan; and

(6) Section VI documentation that the plan as submitted has been approved by the facility's governing body.

(f) Plan submittal. On and after November 1, 1986, each medical care facility shall submit the plan to the department at least 60 days prior to the license renewal date. After an initial plan is approved, any amendments to the plan shall be submitted to the department.

(g) Departmental review. Upon review of the facility's risk management plan or any amendments the department shall notify the facility in writing if the plan of amendments have been approved or disapproved. The written notification will specify the reason for disapproval.

(h) Revised plan. Within 60 days of the date the facility receives notification the plan has been disapproved, the facility shall submit a revised plan to the department.

(i) Plan publication. The plan shall be disseminated to personnel in accordance with the plan.

Kan. Admin. Regs. § 28-52-1

Authorized by and implementing L. 1986, Chapter 229, Sec. 3; effective, T-87-50, Dec. 19, 1986; effective May 1, 1987.