Section He-P 806.18 - Quality Improvement(a) The licensee shall develop and implement a quality improvement program that reviews policies and services and maximizes quality by preventing and correcting identified problems.(b) As part of its quality improvement program, a quality improvement committee shall be established.(c) The NEWCC shall determine the size and composition of the quality improvement committee based on the size of the facility and the care and services provided.(d) The quality improvement 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 NEWCC; and(7) Evaluate the effectiveness of the corrective actions and determine additional corrective actions as applicable;(8) Ensure that quality control logs are maintained for any laboratory quality control testing; and(9) Ensure that quality control logs for preventive maintenance and safety checks are maintained for all equipment according to manufacturer's recommendations.(e) The quality improvement committee shall meet at least quarterly.(f) The quality improvement committee shall generate dated, written minutes after each meeting.(g) Documentation of all quality improvement activities shall be maintained on-site for at least 2 years.N.H. Admin. Code § He-P 806.18
Amended by Volume XXXVIII Number 50, Filed December 13, 2018, Proposed by 12674, Effective 11/20/2018, Expires 5/20/2019.Amended by Volume XXXIX Number 24, Filed June 13, 2019, Proposed by #12795, Effective 5/30/2019, Expires 5/30/2029.