S.C. Code Regs. § § 61-91.1600.1601

Current through Register Vol. 48, No. 11, November 22, 2024

Section 61-91.1600.1601 - General (II)

A. There shall be a written, implemented quality improvement program that provides effective self-assessment and implementation of changes designed to improve the care, treatment, procedures, surgery, and/or services provided by the facility.

B. The quality improvement program, at a minimum, shall:

1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is systematically, objectively, and regularly accomplished at a frequency as determined by the facility to ensure that policies and procedures and this regulation are met, but not less than every three months;

2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;

3. Identify the action taken to correct deviations and prevent future deviation, and the person(s) responsible for implementation of these actions;

4. Establish ways to measure the quality of patient care and staff performance as well as the degree to which the policies and procedures are followed;

5. Analyze the necessity of care, treatment, procedures, surgery, and/or services rendered;

6. Analyze the effectiveness of the fire plan;

7. Analyze all serious incidents and accidents, to include all patient deaths and significant medication errors;

8. Analyze any other unusual occurrences that threaten the health, safety, or well-being of the patients;

9. At least every three months, review an established percentage of patient records to verify the accuracy and integrity of the system, and take corrective action as needed;

10. Establish a systematic method of obtaining feedback from patients and other interested persons, e.g., family members and peer organizations, as expressed by the level of satisfaction with care, treatment, procedures, surgery, and/or services received.

C. The governing body must ensure the quality improvement program:

1. Is defined, implemented, and maintained by the Facility;

2. Addresses the Facility's priorities and that all improvements are evaluated for effectiveness;

3. Specifies data collection methods, frequency, and details;

4. Clearly establishes its expectations for safety; and

5. Adequately allocates sufficient staff, time, information systems, and training to implement the quality improvement program.

S.C. Code Regs. § 61-91.1600.1601

Amended by State Register Volume 39, Issue No. 06, eff. 6/26/2015; State Register Volume 48, Issue No. 06, eff. 6/28/2024.