Title: Section 415.27 - Quality assessment & assurance

415.27 Quality assessment & assurance. The facility shall establish and maintain a coordinated quality assessment and assurance program which integrates the review activities of all nursing home programs and services to enhance the quality of life and resident care and treatment.

(a) Facility-wide quality assurance. Quality assurance shall be the responsibility of all staff, at every level, at all times. Supervisory personnel alone cannot ensure quality of care and services. Such quality must be a part of each individual's approach to his or her daily responsibilities.

(b) Quality assessment and assurance committee. The facility shall maintain a quality assessment and assurance committee consisting of at least the following:

(1) the administrator or his or her designee;

(2) the director of nursing services;

(3) a physician designated by the facility;

(4) at least one member of the governing body who is not otherwise affiliated with the nursing home in an employment or contractual capacity; and

(5) at least 3 other members of the facility's staff.

(c) Committee functions. The quality assessment and assurance committee shall:

(1) meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary;

(2) have a written plan for the quality assessment and assurance program which describes the program's objectives, organization, responsibilities of all participants, scope of the program and procedures for overseeing the effectiveness of monitoring, assessing and problem-solving activities. Such plan shall also provide for the development and implementation of quality improvement initiatives designed to advance the quality of life, care and services in the facility.

(3) define methods for identification and selection of clinical and administrative problems to be reviewed. The process shall include but not be limited to:

(i) the establishment of review criteria developed in accordance with current standards of professional practice for monitoring and assessing resident care and clinical performance;

(ii) regularly scheduled reviews of clinical records, resident complaints and suggestions, reported incidents and other documents pertinent to problem identification;

(iii) consultation on at least a quarterly basis with the Resident Council to seek recommendations on quality improvements;

(iv) documentation of all quality assessment and assurance activities, including but not limited to the findings, recommendations and actions taken to resolve identified problems; and

(v) the timely implementation of corrective actions and periodic assessments of the results of such actions.

(4) ensure that the outcomes of quality assurance reviews are shared with appropriate staff to be used for the revision or development of facility policies and practices and in granting or renewing staff privileges, as appropriate;

(5) facilitate participation in the program by administrative staff and health-care professionals representing each professional service provided;

(6) report its activities, findings and recommendations to the governing body as often as necessary, but no less often than 4 times a year; and

(7) participate with the medical director in implementing Public Health Law 2805-k.