Title: Section 1007.9 - Quality Improvement Activities; Policies and Procedures

Section 1007.9 Quality Improvement Activities; Policies and Procedures

(a) A medical respite program shall implement a quality improvement program that provides for an annual or more frequent review of the medical respite program. The quality improvement program must evaluate, at a minimum, a profile of the characteristics of recipients admitted to the program, the services and degree of services most utilized, the length of stay and use rate, recipient need for care and services, recipient feedback about services received, and disposition upon discharge.

(b) The quality improvement process must:

(1) Include an evaluation of all services in order to enhance the quality of care and to identify actual or potential problems concerning medical respite services;

(2) Review accident and incident reports, recipient complaints and grievances, recipient feedback, and the actions taken to address problems identified by the process;

(3) Develop and implement revised policies and practices to address problems found and the immediate and systematic causes of those problems; and

(4) Assess the impact of the revisions implemented to determine if they were successful in preventing recurrence of past problems.

(c) The results of the quality improvement process shall be (1) reported to the chief executive officer of the operator of the medical respite program; (2) maintained at the facility; and (3) available for review and inspection by the department.  Nothing in this subdivision (c) shall be interpreted as prohibiting the operator from sharing the results of the quality improvement process with any other person or entity.  

(d) The medical respite program shall adopt policies and procedures as required by the department, which shall, at a minimum, include policies and procedures governing:

(1) Emergency/disaster response plan;

(2) Eligibility assessment and service plan; 

(3) Discharge planning and length of stay;

(4) Care coordination;

(5) Medication storage; and

(6) Infection control.