§ 23-17-12.11 - Nursing facility quality improvement program.
SECTION 23-17-12.11
§ 23-17-12.11 Nursing facility qualityimprovement program. – (a) Established. Each licensed nursing facility shall develop andimplement a quality improvement program and establish a quality improvementcommittee.
(b) Each licensed nursing facility shall designate aqualified individual, who shall be determined by the facility's administrator,to coordinate and manage the nursing facility's quality improvement program.
(1) The nursing facility's quality improvement committeeshall include at least the following members:
(i) The nursing facility administrator;
(ii) The director of nursing;
(iii) The medical director;
(iv) A social worker; and
(v) A representative of dietary services.
(2) The quality improvement committee shall:
(i) Meet at least quarterly;
(ii) Maintain records of all quality improvement activities;and
(iii) Keep records of committee meetings that shall beavailable to the department during any on-site visit.
(3) The quality improvement committee for a nursing facilityshall annually review and approve the quality improvement plan for the nursingfacility. Said plan shall be available to the public upon request.
(c) Each nursing facility shall establish a written qualityimprovement plan that shall be reviewed by the department during the facility'sannual survey and that:
(1) Provides criteria to monitor nursing care, includingmedication administration, prevention and treatment of decubitus ulcers,dehydration and nutritional status and weight loss or gain, accidents andinjuries, unexpected deaths, changes in mental or psychological status, and anyother data necessary to monitor quality of care; and
(2) Includes methods to identify, evaluate and correctproblems.
(d) The nursing facility administrator shall take appropriateremedial actions based on the recommendations of the nursing facility's qualityimprovement committee.
(e) The director may not require the quality improvementcommittee to disclose the records and the reports prepared by the committeeexcept as necessary to assure compliance with the requirements of this section.
(f) Good faith attempts by the quality improvement committeeto identify and correct quality deficiencies will not be used as a basis forsanctions.
(g) If the department determines that a nursing facility isnot implementing its quality improvement program effectively and that qualityimprovement activities are inadequate, the department may impose sanctions onthe nursing facility to improve quality of resident care including mandatedhiring of, directly or by contract, an independent quality consultant.