Regulation .65 Quality Assurance Plan.
Regulation .65 Quality Assurance Plan.LinkCopy Citation
A.
The nursing home’s quality assurance committee shall develop and implement a quality assurance plan that includes procedures for:
(1)
Concurrent review;
(2)
Ongoing monitoring;
(3)
Resident complaints;
(4)
Accidents and incidents; and
(5)
Abuse and neglect.
B.
Concurrent Review. The quality assurance plan shall include:
(1)
The procedures for conducting concurrent review of each resident including:
(a)
Criteria to determine any change in a resident's condition;
(b)
A method to document the concurrent review; and
(c)
Identification of the licensed nurse or nurses conducting the concurrent review;
(2)
The procedures to evaluate clinical data for any resident with a change in condition including at least:
(a)
Medications;
(b)
Laboratory values;
(c)
Intake and output;
(d)
Skin breakdown;
(e)
Noted weights;
(f)
Appetite;
(g)
Injuries resulting from accidents or incidents; and
(h)
Any other relevant parameters that may affect the resident's physical or mental status;
(3)
Procedures to take action when there is a change in the resident’s condition, including:
(a)
Communicating changes to the director of nursing or the resident’s attending physician; and
(b)
Changing the resident’s plan of care as necessary; and
(4)
Procedure for referring data to the quality assurance committee, when appropriate.
C.
Ongoing Monitoring. The quality assurance plan shall include:
(1)
A description of the measurable criteria for ongoing monitoring of all aspects of resident care including:
(a)
Medication administration;
(b)
Prevention of pressure ulcers, dehydration, and malnutrition;
(c)
Nutritional status and weight loss or weight gain;
(d)
Accidents and injuries;
(e)
Unexpected death; and
(f)
Changes in physical or mental status;
(2)
The methodology for collecting data;
(3)
The methodology for evaluating and analyzing data to determine trends and patterns;
(4)
A description of the thresholds and performance parameters that represent acceptable care for the measured criteria;
(5)
Time frames for referral to the quality assurance committee;
(6)
A description of the plan for follow-up to determine effectiveness of the recommendations; and
(7)
A description of how the quality assurance activities will be documented.
D.
Resident Complaints. The quality assurance plan shall include:
(1)
A description of a complaint process that effectively addresses resident and family concerns including:
(a)
The designated person or persons and their phone numbers to receive complaints and concerns;
(b)
The method to be used to acknowledge complaints received; and
(c)
The time frames for investigating complaints, depending on the nature or seriousness of the complaint;
(2)
A description of a logging system that will be used including the:
(a)
Name of the complainant;
(b)
Date the complaint was received;
(c)
Nature of the complaint; and
(d)
Date that the complainant was notified of the disposition or resolution of the complaint; and
(3)
The procedures for:
(a)
Notifying residents of their right to file a complaint with the Office of Health Care Quality;
(b)
Informing residents, families, or guardians of the complaint process upon admission; and
(c)
Posting the complaint process or making it available without the need to request it.
E.
Accidents and Injuries. The quality assurance plan shall include:
(1)
A definition of accident and injury that is appropriate to the type of resident served by the nursing home;
(2)
A description of the process for reporting accidents and injuries including:
(a)
Who shall report incidents;
(b)
The time frame for reporting incidents; and
(c)
The procedure for reporting incidents;
(3)
A policy statement that ensures that incidents can be reported without fear of reprisal;
(4)
A description of how internal investigations of accidents and injuries will be handled including:
(a)
Assessment of any injury;
(b)
Interview of the resident, staff, and any witnesses;
(c)
Review of any relevant records including the resident's medical records, discharge summary, hospital records, etc.; and
(d)
Time frames for conducting the investigation;
(5)
A description of the process for notifying a family or guardian about the incident;
(6)
A description of the process for the ongoing evaluation of patterns and trends in accidents and injuries; and
(7)
A description of how relevant information will be referred to the quality assurance committee.
F.
Abuse and Neglect. The quality assurance plan shall include:
(1)
The process for implementing COMAR 10.07.09.15 concerning abuse of residents;
(2)
A description of the process for providing immediate notification to the family, guardian, or responsible party about the incident;
(3)
A description of the process for the ongoing evaluation of validated incidents of abuse and neglect to determine patterns and trends; and
(4)
A description of how relevant information will be referred to the quality assurance committee.