Section 39. Quality Improvement

Each agency must establish an on-going quality improvement program to ensure an adequate and effective operation. To be considered on-going, the quality improvement program must document quarterly activity that addresses, but is not limited to: A. Clinical care: Assessment of patient/client goals and outcome, such as, diagnosis(es), plan of care, services provided, and standards of patient/client care. B. Operational activities: Assessment of the total operation of the agency, such as, policies and procedures, statistical data (i.e., admissions, discharges, total visits by discipline, etc.), summary of quality improvement activities, summary of patient/client complaints and resolutions, and staff utilization. C. Quality improvement action plan: Written responses to address existing or potential problems which have been identified. D. Documentation of activities: The results of the quality improvement activities shall be compiled annually in report format and formally reviewed and approved by the governing body and advisory group of the home health agency. No more than one year may lapse between evaluations of the same part. 8.370.22 NMAC 16 E. The licensing authority may, at its sole discretion, request quarterly activity summaries of an agency’s on-going quality improvement activities or may direct the agency to conduct specific quality improvement studies.