Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 391. Regulations for the Licensure of Hospice
9/21/2020

12VAC5-391-260. Quality Improvement.

A. The hospice program shall implement an on-going, comprehensive, integrated, self-assessment program of the quality and appropriateness of care provided, including services provided under contract. The quality improvement program shall address actual patient outcomes (results of care), clinical, administrative, and cost-of-care issues. The findings shall be used to correct identified problems and revise policies and practices, as necessary. Exclusive concentration on administrative or cost-of-care issues does not fulfill this requirement.

B. The following areas shall be evaluated to identify unacceptable or unexpected trends or occurrences that influence patient outcomes (results of care):

1. Staffing patterns and clinical performance;

2. Admissions and discharges;

3. Supervision appropriate to the level of service;

4. Emergency preparedness plan;

5. Medical records;

6. Appropriateness and effectiveness of pain management;

7. Patient satisfaction and complaint resolution;

8. Infection control;

9. Staff concerns; and

10. Provision of services appropriate to patient needs.

C. The administrator or governing body shall designate a quality improvement committee, which is responsible for the oversight and supervision of the quality improvement program. The committee shall consist of:

1. A physician with association with the hospice program;

2. A member of the administrative staff;

3. Representatives of each of the services provided by the hospice program, including contracted services; and

4. An individual with demonstrated ability to represent the rights and concerns of patients. The individual may be a member of the hospice program's staff, a patient, or a patient's family member.

In selecting members of this committee, consideration shall be given to a candidate's abilities and sensitivity to issues relating to confidentiality, quality of care and services provided to hospice patients.

D. Measures shall be implemented to resolve important problems or concerns that have been identified. Health care practitioners, as well as administrative staff, shall participate in the resolution of the problems or concerns that are identified.

E. Results of the quality improvement program shall be reported annually in writing to the governing body and the administrator, and to the staff as appropriate. The report shall be acted upon by the governing body and the hospice program. All corrective actions shall be documented.

Statutory Authority

§§ 32.1-12 and 32.1-162.5 of the Code of Virginia.

Historical Notes

Derived from Volume 21, Issue 23, eff. November 1, 2005.

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