La. Admin. Code tit. 48 § I-8423

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

Section I-8423 - Operational Procedures

A. Each facility shall establish facility-specific, written policy and implement such policy in these areas:

1. procedures to ensure the health, safety, and well-being of patients;

2. The procedure to ensure sound patient care in conformity with current standards of practice;

3. protocols to assure uniform and quality assessment, diagnosis, evaluation, and referral to the appropriate level of care;

4. procedures to assure operational capability and compliance;

5. procedures to assure that only qualified personnel are providing care within their respective scope of practice;

6. procedures to assure that patient information is collected, maintained, and stored according to current standards of practice; and

7. standards of conduct for all personnel in the facility.

B. Continuous Quality Program (CQP). The facility shall:

1. have ongoing programs to assure that the overall function of the facility is in compliance with federal, state, and local laws, and is meeting the needs of the citizens of the area as well as attaining the goals and objectives developed from the mission statement established by the facility;

2. focus on improving patient outcomes and patient satisfaction;

3. have objective measures to allow tracking of performance over time to ensure that improvements are sustained;

4. develop and/or adopt quality indicators that are predictive of desired outcomes and can be measured, analyzed and tracked;

5. identify its own measure of performance for the activities that are identified as priorities in quality assessment and performance improvement strategy;

6. immediately correct problems that are identified through its quality assessment and improvement program that actually or potentially affect the health and safety of the patients;

7. develop and implement an annual internal evaluation procedure to collect necessary data for formulation of a plan. In addition, conduct quarterly meetings of a professional staff committee (at least 3 individuals) to select and assess continuous quality activities, to set goals for the quarter, to evaluate the activities of the previous quarter, and to immediately implement any changes that would protect the patients from potential harm or injury;

8. implement a quarterly utilization review of 5 percent of the active patient records (minimum of 10 records) by professional staff;

9. complete an annual documented review of policies, procedures, financial data, patient statistics, and survey data by the governing board/regional administrator; and

10. participate as requested with state and federal initiatives to assure quality care.

C. Operational Requirements. The facility shall:

1. be fully operational for the business of providing dialysis as indicated on the approved original application or notice of change;

2. be in compliance with R.S.40:2007, if the facility is operated within another health care facility;

3. have active patients at the time of any survey after the initial survey;

4. utilize staff to provide services based on the needs of their current patients;

5. have required staff present in the facility at all times whenever patients are undergoing dialysis;

6. develop, implement, and enforce policies and/or procedures that eliminate or greatly reduce the risk of patient care errors; and

7. develop procedures to communicate to staff and to respond immediately to market warnings, alerts, and recalls.

La. Admin. Code tit. 48, § I-8423

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 28:2194(October 2002).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153 and R.S. 40:2117.4.