Section He-P 823.19 - Quality Improvement(a) The HHCP shall develop and implement a quality improvement program that reviews policies and all care and services provided to patients and maximizes quality by preventing or correcting identified problems.(b) As part of the HHCP quality improvement program, a quality improvement committee shall be established.(c) The HHCP 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 licensee; and(7) Evaluate the effectiveness of the corrective actions.(e) If the HHCP 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: (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 shall be maintained on-site at the primary location for at least 2 years.N.H. Admin. Code § He-P 823.19
Amended by Volume XXXVII Number 19, Filed May 11, 2017, Proposed by #12168, Effective 4/29/2017, Expires 10/26/2017.Amended by Volume XXXVIII Number 45, Filed November 8, 2018, Proposed by #12642, Effective 10/9/2018, Expires 10/9/2028.