N.H. Admin. Code § He-P 802.23

Current through Register No. 45, November 7, 2024

Section He-P 802.23 - Quality Assurance and Performance Improvement

(a) The licensee shall develop and implement a quality assurance and performance improvement program (QAPI) that reviews policies and services and maximizes quality by preventing and correcting identified problems.

(b) As part of its QAPI, an interdisciplinary quality assurance and performance improvement committee shall be created and required to:

(1) Meet at least quarterly to evaluate quality assurance and performance improvement activities;

(2) Generate dated, written minutes for each meeting;

(3) Maintain all QAPI activities, including minutes of meetings, for at least 2 years from the date the record was created; and

(4) Make recommendations to the governing body to improve the quality of care.

(c) QAPI activities shall include:

(1) Review of patterns and trends of activities which affect the quality of care;

(2) Ensuring that quality control logs are maintained for any laboratory controls and proficiency testing required;

(3) Ensuring that quality control logs for preventive maintenance and safety checks are maintained for all equipment according to manufacturer's recommendations or code requirements;

(4) Ensuring that the medical staff monitoring and evaluation of patient care recommendations referenced in He-P 802.16(d) , are considered by the full quality assessment and improvement committee; and

(5) Reviewing and making recommendations for improvement in areas such as:

a. Infection surveillance;

b. Drug usage evaluation;

c. Morbidity;

d. Risk assessment;

e. Mortality;

f. Environmental safety;

g. Monitoring of quality control practices in each service; and

h. Adverse events in accordance with He-P 802.15.

(d) For each QAPI activity, the committee shall:

(1) Determine the information to be monitored;

(2) Determine the frequency with which information will be reviewed;

(3) Determine the indicators that will apply to the information being monitored;

(4) Evaluate the information that is gathered;

(5) Determine the action that is necessary to correct identified problems;

(6) Recommend corrective actions to the licensee; and

(7) Evaluate the effectiveness of the corrective actions and determine additional corrective actions as applicable.

N.H. Admin. Code § He-P 802.23

#9580, eff 10-24-09

Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.

Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.