N.J. Admin. Code § 10:37-9.4

Current through Register Vol. 56, No. 19, October 7, 2024

Section 10:37-9.4 - Quality assurance (QA) plan

(a) The scope, organization, monitoring, evaluation and problem correction activities of the QA program shall be written and will be referred to as the QA plan.

(b) The QA plan shall describe an ongoing, systematic process of monitoring and evaluation of important aspects of care with participation by all levels of staff.

(c) The QA plan shall include or cross-reference a description of indicators monitored in each program element. Indicators shall cover limited areas that are deemed to be high risk, high volume or problem prone.

(d) The QA plan shall include a description of outcome indicators monitored in each program element.

(e) The QA plan shall identify or cross-reference thresholds for evaluation for each indicator.

(f) The QA plan shall include procedures for monitoring problem correction.

(g) The QA plan shall describe monitoring activities to ensure client involvement in treatment.

(h) The QA plan shall describe the scope of client participation in the QA program.

(i) The QA plan shall describe reviews of open and closed client records for timely completion of required documentation.

(j) The QA plan shall describe the process for reviews of open and closed client records to evaluate the quality and appropriateness of treatment.

(k) The QA plan shall specify the required sample size for review of open and closed client records. The rationale for sample size selected shall also be described in the plan.

(l) The QA plan shall describe the process, frequency, and criteria for selection of problem, high risk, difficult cases for Special Case Review. Special Case Reviews include, but are not limited to, incidents and adverse medication reactions.

(m) The QA plan shall describe the organizational structure, including lines of authority and how the QA program fits into this structure.

(n) The QA plan shall describe the persons responsible for QA activities.

(o) The QA plan shall describe the extent of medical staff participation in the QA program.

(p) The QA plan shall describe the organization and composition of the committee responsible for QA oversight.

(q) The QA plan shall describe the required frequency of committee meetings in which QA oversight occurs.

(r) In the case of hospital-based PAs, the QA plan shall describe the process for integration with the hospital QA program.

(s) The QA plan shall describe how QA findings are effectively communicated to all relevant components of the organization.

(t) The QA plan shall describe how supervision is utilized to identify and resolve QA issues.

(u) The QA plan shall describe how relevant findings are shared with clients.

N.J. Admin. Code § 10:37-9.4