(a) Each facility shall have a quality assurance program designed to monitor and evaluate the quality and appropriateness of patient care, pursue alternatives to improve patient care and resolve identified problems.
(b) The Quality Assurance Program shall be implemented by a Quality Assurance Committee imposed of the Administrator, Medical Director, Director of Nursing, two physicians from participating surgery programs and a staff nurse.
(c) The Quality Assurance Committee shall adopt written procedures, for fulfilling their responsibilities. The procedures shall be reviewed by the Administrator and the Medical Director, and approved by the Governing Body and the Office.
(d) The Quality Assurance Committee shall:
(1) Review the appropriateness of the medical and nursing care provided in the facility.
(2) Identify opportunities for improving patient care.
(3) Review the pharmaceutical service and the appropriateness of medication usage for patients in the facility in conjunction with the consultant pharmacist.
(4) Identify and review the records of all patients requiring a third day of care.
(5) Review within 72 hours all patient cases where medical emergencies or deaths occur. The Quality Assurance Committee shall submit to the Office a written report of their findings in such cases.
(6) Review the availability of resources necessary to respond to medical emergencies.
(7) Review the procedures or surveillance techniques for minimizing the source and transmission of infection.
(8) Review the accuracy and completeness of information contained in the patients' medical records.
(9) Review the appropriateness of patient admissions to the facility.
(e) The Quality Assurance Committee shall meet at least quarterly and report its findings and activities to the facility's governing body and medical staff. The medical staff shall assure that appropriate follow-up and action results. Notes shall be taken at each meeting and retained at the facility. Such notes shall be made available to the Office.
Credits
Note: Authority cited: Section 1250.9, Health and Safety Code. Reference: Section 1250.9, Health and Safety Code.
1. New section filed 3-7-88 as an emergency; operative 3-7-88 (Register 88, No. 12). No Certificate of Compliance required pursuant to the provisions of Health and Safety Code section 1250.9(m).
2. Editorial correction of History No. 1 (Register 90, No. 21).
This database is current through 5/10/24 Register 2024, No. 19.
Cal. Admin. Code tit. 22, § 97530.13, 22 CA ADC § 97530.13
