Quality Assurance

(A) The hospice shall develop and implement, through an interdisciplinary committee, an ongoing quality assurance program. One member of the committee shall be designated to be responsible for coordinating quality assurance. (B) The quality assurance program shall include an evaluation of all services, including any services provided to patients under contractual arrangements. The hospice shall offer contracted hospice providers the opportunity to participate in the quality assurance program. (C) Each hospice shall establish a written quality assurance plan for review of services delivered. The plan shall include: (1) A procedure for evaluating care provided on individual cases. At least quarterly, members of professional disciplines representing at least the scope of the hospice program shall review a 10% sample of both active and inactive clinical records of care delivered to hospice patients and families. A written summary shall be prepared for each individual review commenting on the amount and kind of care delivered and including statements addressing any unmet needs. (2) A process for program evaluation and the identification of problems. At least quarterly, all summaries of individual reviews shall be reviewed by the person responsible for coordinating quality assurance. A written report will be prepared addressing any identified problems with care, treatment, services, availability of services, and methods of care delivery. (3) A system to report to the governing body the findings and recommendations for improving the quality of care delivered. The quality assurance reports shall be submitted to the hospice administrator and governing body. There shall be evidence in the governing body's meeting minutes that the reports have been reviewed by the governing body at least annually.