Sec.19-13-D76. Quality assurance program

(a) An agency shall have a written quality assurance program which shall include but not be limited to the following components:

(1) Program evaluation;

(2) Quarterly clinical record review;

(3) Annual documentation of clinical competence;

(4) Annual process and outcome record audits.

(b) The professional advisory committee or a committee appointed by the governing authority and at least one person from administrative or supervisory staff shall implement, monitor and integrate the various components of the agency's quality assurance program.

(c) The committee and staff designated pursuant to regulation 19-13-D76 (b) shall:

(1) Annually analyze and summarize, in writing, all findings and recommendations of the quality assurance program;

(2) Present written reports of the findings of each component or a written summary report of the findings of the quality assurance program to the professional advisory committee and to the governing authority;

(3) Monitor implementation of the recommendations and actions directed by the governing authority based on said report(s);

(4) Within one hundred twenty (120) days of action on the report(s) by the governing authority, report in writing to the governing authority, administration and professional advisory committee the progress in implementation of the recommended actions;

(5) Ensure that a copy of the annual quality assurance report(s) and the progress report on implementation are maintained by the agency.

(d) The program evaluation shall include, but not be limited to:

(1) The extent to which the agency's objectives, policies and resources are adequate to maintain programs and services appropriate to community, patient and family needs;

(2) The extent to which the agency's administrative practices and patterns for delivery of services achieve efficient and effective community, patient and family services in a five (5) year cycle.

(e) At least quarterly, health professionals in active practice, representing at least the scope of the agency's home health care services shall review a sample of active and closed clinical records to assure that agency policies are followed in providing services. No person involved directly in service to a patient or family shall participate in the review of that patient or family's clinical record.

(1) At least once in each calendar quarter, the agency shall select records for review by a random sampling of all therapeutic cases. The agency's sampling methodology shall be defined in its quality assurance program policies and procedures after approval by the commissioner. The sample of clinical records reviewed each quarter shall be according to the following ratios:

(A) Eighty (80) or less cases; eight (8) records;

(B) Eighty-one (81) or more cases, ten percent (10%) of caseload for the quarter to maximum of twenty-five (25) records. One review form describing the areas to be assessed shall be completed for each record reviewed.

(f) Six (6) months after employment and annually thereafter, a written report shall be prepared on the clinical competence of each direct service staff member employed by or under individual contract to the agency by the employee's professional supervisor, which shall include but not be limited to:

(1) Direct observation of clinical performance;

(2) Patient and family management as recorded in clinical notes and reports prepared by the staff member;

(3) Case management conference performance;

(4) Participation in the agency's inservice education program;

(5) Personal continuing education;

(6) Each staff member shall review and sign a copy of his/her performance evaluation and the agency shall maintain copies of same in the employee's personnel file;

(7) Unsatisfactory performance of direct service staff shall require a plan for corrective action which shall be filed in the employee's personnel folder. In the case of a homemaker-home health aide, the corrective action shall include that the homemaker-home health aide may not perform any task rated as “unsatisfactory” without direct supervision by a registered nurse until after he or she receives training in the task for which he or she was evaluated as “unsatisfactory” and passes a subsequent evaluation with "'satisfactory.”

(g) Effective January 1, 1982, an agency shall:

(1) Include in its quality assurance program annual process and outcome audits of a sample of the clinical records of persons served during the previous twelve (12) months;

(2) Have defined outcome measures for at least two (2) of any diagnostic category representing five (5%) percent or more of its annual caseload. For each successive twelve (12) month period after January 1, 1982, the agency shall expand its outcome measures by one diagnostic category, until measures have been defined for each diagnostic category representing five (5%) percent or more of the agency's caseload; or

(3) Have received approval from the commissioner to use another patient classification system to define outcome measures.

(Effective December 28, 1992)