N.J. Admin. Code § 8:43A-24.18

Current through Register Vol. 56, No. 24, December 18, 2024

Section 8:43A-24.18 - Renal dialysis quality assurance plan

(a) In addition to the requirements set forth in N.J.A.C. 8:43A-18, the facility shall develop a quality assurance plan that includes all areas of service, management and operations, which shall be monitored by the governing body.

(b) The governing body is responsible for the following:

1. Establishment of program goals and objectives;

2. Oversight of program implementation, revision and effectiveness;

3. Allocation of sufficient time and resources to accomplish objectives and attain goals;

4. Inclusion of all attending physicians and other categorical key personnel in program operation; and

5. Quality assurance activities shall demonstrate that facility staff evaluate the provision of dialysis care and patient services, set treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate implementation until resolution is achieved.

(c) At a minimum, the quality assurance plan shall analyze those indicators required by the TransAtlantic Renal Council (109 South Main Street, Suite 21, Cranbury, NJ 08512, http://www.tarcweb.org). These indicators can be found in the Medicare ESRD Network Organizations Manual (Revision 2, September 12, 2003), incorporated herein by reference, as amended and supplemented, which is available for download from the Centers for Medicare and Medicaid Services website at http://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/downloads/R2ESRD.pdf and http://www.cms.gov.

(d) Meetings of the quality assurance and performance improvement committee shall be held at least quarterly and shall be separate from other patient care or management meetings. Written minutes of each meeting shall be maintained; these minutes shall include a formal agenda, attendance record, items considered, action decided and review of actions implemented. Minutes and other material considered during the meeting shall be kept on file, provided to the governing body in a timely manner, and readily available for at least the previous seven quarters.

N.J. Admin. Code § 8:43A-24.18

Amended by 54 N.J.R. 60(a), effective 1/3/2022