N.J. Admin. Code § 10:37-9.5

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

Section 10:37-9.5 - Quality assurance (QA) implementation

(a) The QA plan shall be implemented.

(b) Data shall be routinely collected from ongoing monitoring activities and periodically evaluated and analyzed, based on thresholds.

(c) Documented reports of all ongoing monitoring and evaluation activities shall be produced. When ongoing monitoring reveals that more intensive evaluation is required, documentation shall include evidence of further assessment, conclusions drawn, and actions taken to improve care and to resolve identified problems. Examples of possible actions that can be taken are: implementation of inservice training, personnel action, changes in policies and procedures, administrative actions.

(d) Status of previously identified problems (follow-up) shall be documented. Problems identified and corrective actions taken shall be monitored for a prescribed time frame.

(e) To the extent that the QA process identifies issues that require medical staff input, review and response to such referrals shall be documented. These referrals may include questionable admissions and continued stays.

(f) Documentation and evidence of QA monitoring activities to ensure client involvement in treatment shall be provided, and shall include, at a minimum: each client's active and informed participation in his or her treatment plan; medication education; and application of clients' rights and the client grievance procedure.

(g) Documentation of monitoring of effectiveness of the PA's mechanisms to respond to client complaints and suggestions shall be provided.

(h) In the case of hospital based PAs, documented evidence of integration with the hospital QA program shall be available.

(i) There shall be evidence that relevant QA findings are effectively communicated to all relevant components of the PA, including clients.

(j) When the PA has developed the QA program, the following additional elements should be implemented:

1. Participation by medical staff on the QA oversight committee;

2. Documentation of analysis of aggregate QA findings to identify and address patterns and trends related to client characteristics, treatment and service utilization;

3. Utilization of responses to client satisfaction surveys and recommendations from clients and family members; and

4. Documentation of the use of applicable QA findings in ongoing staff development, supervision and performance evaluation.

N.J. Admin. Code § 10:37-9.5