NAC449.793. Evaluation by governing body; periodic review of contracts, operations, policies and procedures.

     1. The governing body of an agency is responsible for providing for an evaluation of the agency once a year. The purpose of the evaluation is to audit, review policies and procedures, recommend additions or changes and ensure that the policies and regulations are being met.

     2. A committee shall review all contracts and charters held by the agency to ascertain that:

     (a) Existing contracts are legal and up to date.

     (b) The existing contracts meet the needs of all parties involved.

     3. A committee shall review the management and office procedures of the agency to ascertain that:

     (a) The agency is being operated in the most effective and economical means while still giving quality service.

     (b) All office procedures are up to date, filing is correctly done and bookkeeping is meeting accepted accounting procedures and is current.

     (c) Equipment is in good repair and adequately meets operational needs.

     4. The committee shall submit a report to the governing body with any recommendations for changes and pertinent observations as it deems necessary.

     5. A committee shall review the medical and personnel policies to ensure that the policies are being fulfilled and necessary changes or additions are effected.

     6. The governing body shall provide for a quarterly review of 10 percent of the records of patients who have received services during the preceding 3 months in each service area. The members of the committee must include an administrative representative, a physician, a registered nurse and a clerk or librarian who keeps records. The clerk or librarian shall review the clinical records to ensure that they are complete, that all forms are properly filled out and that documentation complies with good medical practices. The committee shall determine whether the services have been provided to the patients in an adequate and appropriate manner by all levels of service. The committee shall record any deficiencies and make necessary recommendations to the administrator. If the branch offices are small, two or more offices may establish one committee to review cases from each area. Each subunit agency must establish a committee to review cases within its area. Minutes of the committee’s meetings must be documented and available for review.

     [Bd. of Health, Home Health Agencies Part II Chap. III § J, eff. 1-10-74]—(NAC A 11-13-96)—(Substituted in revision for NAC 449.803)