Quality assurance

Each hospice program must conduct a comprehensive self-assessment of the quality and appropriateness of care provided to the patient and family in the home and inpatient services. 1. The governing body shall delegate in writing responsibilities for implementation and maintenance of a planned process for reviewing and evaluating the appropriateness of patient and family care, as well as resolving identified problems. 2. The goals, objectives, methods for implementation, and responsibilities for monitoring and evaluating for effectiveness and efficiency of patient and family care must be specified in a written quality assurance plan which is reevaluated at least annually. 3. The hospice program, through the quality assurance program, must implement and report on activities and mechanisms for monitoring the quality of patient care, identify and resolve problems, and suggest improvements in patient care. 4. There must be documentation relating to the findings from and conclusions of the monitoring, evaluating, and problem solving activities, and the actions taken to resolve problems and improve patient and family services as defined in the quality assurance plan.