10A NCAC 14F .1303. CONTINUOUS QUALITY IMPROVEMENT

(a)  The cardiac rehabilitation program shall have an ongoing Continuous Quality Improvement (CQI) program which identifies quality deficiencies and addresses them with corrective plans of action, as indicated.

(b)  The CQI program shall evaluate the appropriateness, effectiveness, and quality of the cardiac rehabilitation program, with findings used to verify policy implementation, to identify problems, and to establish problem resolution and policy revision as necessary.

(c)  The CQI program shall consist of an overall policy and administration review, including admission and discharge policies, emergency care, patient records, personnel qualifications and program evaluation.  Data to be assessed shall include, at a minimum, the following:

(1)           number of patients in the program;

(2)           average length (weeks) patients are in the program;

(3)           patient clinical outcomes;

(4)           adequacy of staff to meet program/patient needs;

(5)           reasons for discharge; and

(6)           untoward events.

(d)  A sample of active and closed records shall be reviewed at least semi-annually to assure program policies are followed and the program is in compliance with the Article and the rules contained in this Subchapter.

(e)  Documentation of the CQI program shall include the criteria and methods used to collect and analyze data, identification of quality deficiencies, and any action(s) taken by the cardiac rehabilitation program as a result of CQI findings.

 

History Note:        Authority G.S. 131E-169;

Eff. July 1, 2000.