NAC449.540. Program of quality assurance; recordation of accidents and incidents; reporting of certain events.

     1. Each facility shall:

     (a) Conduct a systematic and comprehensive review of the facility and the care provided to each patient of the facility; and

     (b) Adopt and comply with a program to ensure the quality of the facility. The program must be based on information concerning the facility provided to the facility by the End-Stage Renal Disease Network.

     2. The facility shall demonstrate through quality assurance activities that the members of the staff of the facility have:

     (a) Evaluated the care and services provided by the facility to the patients of the facility;

     (b) Established goals concerning the treatment of those patients;

     (c) Identified any available opportunities to improve the care and services provided to those patients;

     (d) Developed and carried out a plan to improve the care and services specified in paragraph (c); and

     (e) Evaluated the effectiveness of the plan specified in paragraph (d) until a resolution of any problems is obtained.

     3. Each core staff member of the facility shall actively participate in the quality assurance activities conducted pursuant to the provisions of this section. As used in this subsection, “core staff member” means the medical director, supervising nurse, dietitian, social worker and administrator of a facility.

     4. Not less than once each quarter, each facility shall conduct a meeting concerning the quality of the facility. The facility shall:

     (a) Prepare written minutes of each meeting held; and

     (b) Maintain the written minutes in the business office of the facility.

     5. If an accident or incident occurs at a facility, including, without limitation, any error in providing medication to a patient of the facility or any adverse reaction of a patient to a drug administered to the patient at the facility, the facility shall immediately prepare a written record of the accident or incident. A written record prepared pursuant to this subsection must be maintained by the facility and be made available for review by the Bureau.

     6. A facility shall report each of the following events to the Bureau within 7 days after the event occurs:

     (a) Each accident or incident concerning a patient of the facility that:

          (1) Occurs during dialysis treatment of the patient; and

          (2) Results in the death of the patient or requires the admission of the patient to a hospital overnight;

     (b) The occurrence of any fire at the facility; or

     (c) If a member of the staff of the facility or a patient of the facility converts to positive for the hepatitis B surface antigen.

     (Added to NAC by Bd. of Health by R130-99, eff. 8-1-2001)