N.M. Admin. Code § 7.20.11.20

Current through Register Vol. 35, No. 23, December 10, 2024

Section 7.20.11.20 - QUALITY IMPROVEMENT AND UTILIZATION REVIEW

A. The agency has a continuous quality improvement process, reviewed annually, through which the agency systematically evaluates the effectiveness of services provided by determining whether its services meet pre-determined quality improvement expectations and outcomes, and corrects any observed deficiencies identified through the quality improvement process.

B. The agency explicitly details the desired expectations and service outcomes for each of its programs and has a written plan to achieve them.

C. The agency establishes a committee or other mechanism for the timely and regular evaluation of serious incidents, complaints, grievances, and related investigations. Committee evaluations include identification of events, trends and patterns that may affect client health, safety, and/or treatment efficacy. Committee evaluation findings and recommendations are documented and submitted to agency management for corrective action. Actions implemented and outcomes are documented, and trends are analyzed over time. The agency has a well-defined plan for correcting problems. When problems (or potential problems) are identified, the facility acts as soon as possible to avoid any risks to clients by taking corrective steps that may include, but are not limited to:

(1) changes in policies and/or procedures;

(2) staffing and assignment changes;

(3) additional education or training for staff;

(4) addition or deletion of services.

D. The agency develops a system to utilize its collected data regarding the outcome of its activities for delivering continuously improving services.

E. Formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices.

F. The agency collects and maintains information necessary to plan, manage, and evaluate its programs effectively. The outcomes are evaluated on a quarterly basis, the results of which are used continuously to improve performance.

G. The agency implements and maintains ongoing utilization review processes.

N.M. Admin. Code § 7.20.11.20

7.20.11.20 NMAC - Rp 7 NMAC 20.11.20, 03/29/02