Section He-P 811.20 - Quality Improvement(a) The licensee shall develop and maintain a quality improvement program whose objectives shall be to reveal patterns and initiate action to provide an optimum quality of care for all clients.(b) The quality improvement program shall include a quality improvement committee, which shall consist of: (1) The medical director;(2) The director of nursing;(5) At least one other direct care staff provider.(c) The quality improvement committee shall:(1) Review within 24 hours:a. All client cases where a medical emergency occurs; andb. Client cases which require unexpected transfer to an acute care facility; (2) Establish and implement a system for the monthly surveillance of dialysate water and reuse;(3) Review all reports of unexpected occurrences involving clients, personnel, or visitors;(4) Ensure that outside services such as laboratory services or water analysis are provided in accordance with federal and state laws and administrative rules; (5) Ensure that individuals with appropriate qualifications maintain medical equipment; (6) Establish an ongoing program to determine performance improvement projects, to carry out interventions to mitigate quality issues and to audit corrective actions; and(7) Meet at least quarterly.(d) Documentation of all quality improvement meetings shall be maintained on-site for at least 2 years.N.H. Admin. Code § He-P 811.20
Amended by Volume XXXIX Number 32, Filed August 8, 2019, Proposed by #12827, Effective 7/20/2019, Expires 1/16/2020.Amended by Volume XL Number 7, Filed February 13, 2020, Proposed by # 12985, Effective 1/29/2020, Expires 1/29/2030.