Section 33-03-10.1-11 - Quality improvement and program evaluation1. The agency shall develop, implement, and document an ongoing agencywide quality improvement program to monitor, evaluate, and improve the quality of patient care, administrative, and support services, including all contracted services, and to ensure services are provided in compliance with professional standards of practice. a. The quality improvement program must include a written plan that identifies a mechanism to identify problems, recommend appropriate action, implement recommendations, and monitor results. b. Each quarter a sample of active and closed clinical records must be reviewed, by a group of appropriate professionals representing the home health services provided during the previous quarter, to determine whether established policies are followed in furnishing services directly or through contract. This review must be documented as a part of the quality improvement program. c. The clinical records for all patients must be reviewed each sixty-two-day period to determine adequacy of the plan of treatment and the appropriateness of continuance of care. d. The administrator shall maintain a record of the activities of the quality improvement program and ensure findings, conclusions, and recommendations are reported to the governing body. 2. The agency shall complete an overall evaluation of its program annually and documentation of the reviews must be maintained as a part of the administrative records. The evaluation must, at a minimum, include an overall policy review, administrative review, and a clinical record review. N.D. Admin Code 33-03-10.1-11
Effective January 1, 1998.General Authority: NDCC 23-01-04, 23-17.3-08
Law Implemented: NDCC 23-17.3-05, 23-17.3-08