N.J. Admin. Code § 8:43A-18.2

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43A-18.2 - Quality assurance activities

(a) There shall be an ongoing process for monitoring and evaluating patient care services, staffing, infection prevention and control, housekeeping, sanitation, safety, maintenance of physical plant and equipment, patient care statistics, and discharge planning services.

(b) Evaluation of patient care throughout the facility shall be criteria-based, so that certain review actions are taken or triggered when specific quantified, predetermined levels of outcomes or potential problems are identified.

(c) The quality assurance process shall incorporate periodic review of patient medical records.

(d) The quality assurance process shall include evaluation by patients of care and services provided by the facility. If the families of patients are routinely involved in the care and services provided by the facility, the quality assurance process shall include a means for obtaining input from families of patients.

(e) The administrator shall follow up on the findings of the quality assurance program to ensure that effective corrective actions have been taken, including at least policy revisions, procedural changes, educational activities, and follow-up on recommendations, or that additional actions are no longer indicated or needed.

(f) The quality assurance program shall identify and establish indicators of quality care specific to the facility, which shall be monitored and evaluated.

(g) The results of the quality assurance program shall be submitted to the governing authority at least annually and shall include at least deficiencies found and recommendations for corrections or improvements. Deficiencies which jeopardize patient safety shall be reported to the governing authority immediately.

N.J. Admin. Code § 8:43A-18.2