La. Admin. Code tit. 48 § I-5273

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5273 - Quality Assurance

A. All PDHC facilities shall have a quality assurance program and shall conduct quarterly reviews of the facility's medical records for at least a fourth of the children served by the PDHC facility at the time of the quality assurance review. The quarterly review sample shall be randomly selected so each child served at the center has an equal opportunity to be included in the review.

B. Each facility shall establish a quality assurance committee comprised of the following members:

1. the medical director;

2. the administrator;

3. the director of nursing; and

4. three other committee members as determined by each PDHC facility.

C. The quality assurance review shall be conducted by at least two members of the quality assurance committee. Within 15 calendar days of its review, the quality assurance committee shall furnish copies of its report to the PDHC facility medical and nursing directors.

D. Each quarterly quality assurance review shall include:

1. a review of the goals in each child's nursing plan of care;

2. a review of the steps, process, and success in achieving the goals;

3. identification of goals not achieved as expected;

4. reasons for lack of goal achievement;

5. plans to promote goal achievement;

6. recommendations to be implemented; and

7. a review of previous recommendations or revisions to determine if such were implemented and effective.

E. The quality assurance review will also ascertain and assure the presence of the following documents in each child's medical record:

1. a properly executed consent form;

2. a medical history for the child including notations from visits to health care providers; and

3. documentation of immunizations, allergies and special precautions.

F. The PDHC facility medical and nursing directors shall review the quality assurance committee report within 10 days. The medical director in consultation with the prescribing physician shall approve and order implementation of revisions to the plan of care as appropriate.

G. The PDHC facility shall ensure the plan of care has been revised to implement the approved recommendations of the quality assurrance report.

1. Evidence that the plan of care has been revised shall be forwarded to the quality assurance committee within 10 calendar days of receipt of the quality assurance committee report.

2. Implementation of revisions to the plan of care shall be documented in the child's record.

La. Admin. Code tit. 48, § I-5273

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 35:2776 (December 2009).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2193-40:2193.4.