Sec. 10.07.02.65. Quality Assurance Plan

A. The nursing home’s quality assurance committee shall develop and implement a quality assurance plan that includes procedures for:

(1) Concurrent review;

(2) Ongoing monitoring;

(3) Resident complaints;

(4) Accidents and incidents; and

(5) Abuse and neglect.

B. Concurrent Review. The quality assurance plan shall include:

(1) The procedures for conducting concurrent review of each resident including:

(a) Criteria to determine any change in a resident's condition;

(b) A method to document the concurrent review; and

(c) Identification of the licensed nurse or nurses conducting the concurrent review;

(2) The procedures to evaluate clinical data for any resident with a change in condition including at least:

(a) Medications;

(b) Laboratory values;

(c) Intake and output;

(d) Skin breakdown;

(e) Noted weights;

(f) Appetite;

(g) Injuries resulting from accidents or incidents; and

(h) Any other relevant parameters that may affect the resident's physical or mental status;

(3) Procedures to take action when there is a change in the resident’s condition, including:

(a) Communicating changes to the director of nursing or the resident’s attending physician; and

(b) Changing the resident’s plan of care as necessary; and

(4) Procedure for referring data to the quality assurance committee, when appropriate.

C. Ongoing Monitoring. The quality assurance plan shall include:

(1) A description of the measurable criteria for ongoing monitoring of all aspects of resident care including:

(a) Medication administration;

(b) Prevention of pressure ulcers, dehydration, and malnutrition;

(c) Nutritional status and weight loss or weight gain;

(d) Accidents and injuries;

(e) Unexpected death; and

(f) Changes in physical or mental status;

(2) The methodology for collecting data;

(3) The methodology for evaluating and analyzing data to determine trends and patterns;

(4) A description of the thresholds and performance parameters that represent acceptable care for the measured criteria;

(5) Time frames for referral to the quality assurance committee;

(6) A description of the plan for follow-up to determine effectiveness of the recommendations; and

(7) A description of how the quality assurance activities will be documented.

D. Resident Complaints. The quality assurance plan shall include:

(1) A description of a complaint process that effectively addresses resident and family concerns including:

(a) The designated person or persons and their phone numbers to receive complaints and concerns;

(b) The method to be used to acknowledge complaints received; and

(c) The time frames for investigating complaints, depending on the nature or seriousness of the complaint;

(2) A description of a logging system that will be used including the:

(a) Name of the complainant;

(b) Date the complaint was received;

(c) Nature of the complaint; and

(d) Date that the complainant was notified of the disposition or resolution of the complaint; and

(3) The procedures for:

(a) Notifying residents of their right to file a complaint with the Office of Health Care Quality;

(b) Informing residents, families, or guardians of the complaint process upon admission; and

(c) Posting the complaint process or making it available without the need to request it.

E. Accidents and Injuries. The quality assurance plan shall include:

(1) A definition of accident and injury that is appropriate to the type of resident served by the nursing home;

(2) A description of the process for reporting accidents and injuries including:

(a) Who shall report incidents;

(b) The time frame for reporting incidents; and

(c) The procedure for reporting incidents;

(3) A policy statement that ensures that incidents can be reported without fear of reprisal;

(4) A description of how internal investigations of accidents and injuries will be handled including:

(a) Assessment of any injury;

(b) Interview of the resident, staff, and any witnesses;

(c) Review of any relevant records including the resident's medical records, discharge summary, hospital records, etc.; and

(d) Time frames for conducting the investigation;

(5) A description of the process for notifying a family or guardian about the incident;

(6) A description of the process for the ongoing evaluation of patterns and trends in accidents and injuries; and

(7) A description of how relevant information will be referred to the quality assurance committee.

F. Abuse and Neglect. The quality assurance plan shall include:

(1) The process for implementing COMAR 10.07.09.15 concerning abuse of residents;

(2) A description of the process for providing immediate notification to the family, guardian, or responsible party about the incident;

(3) A description of the process for the ongoing evaluation of validated incidents of abuse and neglect to determine patterns and trends; and

(4) A description of how relevant information will be referred to the quality assurance committee.