Section He-P 818.20 - Quality Improvement(a) The ADP shall develop and implement a quality improvement program that reviews policies and services and maximizes quality by preventing or correcting identified problems.(b) As part of its quality improvement program, a quality improvement committee shall be established.(c) The licensee shall determine the size and composition of the quality improvement committee based on the size of the ADP and the care and services offered.(d) The quality improvement committee shall: (1) Determine the information to be monitored, which at a minimum shall include; b. Complaints, to include resident, family, guardian, and staff concerns;d. Participant and staff conflicts; and(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 ADP; and(7) Evaluate the effectiveness of the corrective actions and determine additional corrective actions as applicable.(e) If the ADP utilizes nurse delegation for the task of medication administration to an individual not licensed to administer medications, a quarterly written report containing the following information shall be completed and submitted to the quality improvement committee for review, including: (1) The participant average daily census;(2) The number of unlicensed personnel administering medications via nurse delegation;(3) Categories of medications administered;(4) Route of administration; and(5) Any incidents or medication errors and actions taken.(f) The quality improvement committee shall meet at least quarterly.(g) The quality improvement committee shall generate dated, written minutes after each meeting.(h) Documentation of all quality improvement activities, including minutes of meetings, shall be maintained on-site for at least 2 years.N.H. Admin. Code § He-P 818.20
Amended by Volume XXXVI Number 45, Filed November 10, 2016, Proposed by #12006, Effective 10/15/2016, Expires 4/13/2017.Amended by Volume XXXVII Number 23, Filed June 8, 2017, Proposed by #12198, Effective 6/2/2017, Expires 6/2/2027.