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Policies and Procedures Residential and Assisted Living Communities Policy Title: Quality Assurance Policy Policy Number: AA01.60.08 Effective Date: 7/1/14 Revision Date: Approved By: Kevin Cox Page Number: Page 1 of 3POLICYThe purpose of the Quality Assurance Program is to insure that a comprehensive program ofservices is provided for residents and that these services are adequate and optimal for theavailable resources and consistent with those required by state licensure
OBJECTIVESThe objectives of this program are to: 1. Establish, maintain, support and document evidence of an ongoing Quality Assurance Program that includes effective mechanisms for monitoring and evaluating utilization and delivery of resident services and for appropriate response to any negative findings
2. To form a Quality Assurance Committee that is responsible for implementing and overseeing the program. To identify the lines of authority, responsibility and accountability within the committee to insure that adequate communication occurs among all departments and groups involved in the delivery of resident services, care and programs. The committee will identify resident services and programs that need improvement
3. Assist individual departments with the identification, analysis and resolution of problems that affect the residents in the community
4. Evaluate the results of corrective actions taken by individuals/departments. The program will maximize the use of resources available within the community and in the community at large, when appropriate, in order to resolve problems or improve resident services
ORGANIZATIONThe Administrator is responsible for coordinating the Quality Assurance Program. TheAdministrator will be the leader of the Quality Assurance Committee. A representative from eachdepartment will be chosen by the leader to participate in the Quality Assurance Committee
AUTHORITYThe Administrator will be responsible for implementing the Quality Assurance Program andestablishing the Quality Assurance Committee. The Administrator of the community shall assume Policies and Procedures Residential and Assisted Living Communities Policy Title: Quality Assurance Policy Policy Number: AA01.60.08 Effective Date: 7/1/14 Revision Date: Approved By: Kevin Cox Page Number: Page 2 of 3responsibility for assuring the Quality Assurance Program is in compliance with applicable state,federal, and local regulations
SCOPEQuality assurance activities will be integrated and coordinated among all departments within thecommunity. The program will be designed to minimize duplication of efforts and will be cost-effective. A member of each department will be included in the committee
PROGRAMThe Quality Assurance Committee will meet quarterly. Minutes of the Quality AssuranceCommittee meetings will be kept and filed in a Quality Assurance binder using the QualityAssurance Meeting Minutes form and maintained by the Quality Assurance Committee Leader
Decisions regarding corrective actions will be communicated to the staff by utilization of the 24book “memos” area or scheduled meetings as needed
Each Department will submit completed audit tools and reports to the committee, following theQuality Assurance Master Audit schedule, regarding identified service delivery problems. Thesereports will include suggested plans of correction and be outlined on the Quality AssuranceMeeting Minutes form. Each quarter, along with discussing newly identified problems, thecommittee will review all areas of study to determine if there are any new service deliveryproblems and to determine if previous plans of correction have been adequate to solve thepreviously identified problems
The committee will complete a quarterly self-assessment review using the Q/A audit tool andreview prior to the Quality Assurance Committee Meeting to insure that the community’smonitoring, evaluation and problem resolution activities have been effective. The committee willreview all resident and staff surveys
AREAS OF STUDY Evaluation of personal services - dressing, bathing, laundry, hygiene. (Action Rounds Form) Evaluation to determine if meals meet residents’ needs and preferences. (Resident Survey) Evaluation of internal and external fire and life safety drills
Evaluation of the infection control program. (Action Rounds Form) Evaluation of nursing services
Evaluation of medication services Policies and Procedures Residential and Assisted Living Communities Policy Title: Quality Assurance Policy Policy Number: AA01.60.08 Effective Date: 7/1/14 Revision Date: Approved By: Kevin Cox Page Number: Page 3 of 3 Evaluation of care planning
Evaluation of resident counsel
Evaluation of discharge planning
Evaluation of activity program
Evaluation of housekeeping services. (Resident Survey) Evaluation of maintenance services. (Resident Survey) Evaluation of transportation services. (Resident Survey Evaluation of basic reminder services. (Resident Survey) Evaluation of resident and staff accidents of injuries (incident reports)
When residents or staff members identify problems or concerns, they may submit theseconcerns to any Quality Assurance Committee member using the Grievance/Concerns form. Theproblem or concern will be addressed and discussed at the next committee meeting
PROCESSThe Quality Assurance Committee Leader will authorize a designee to complete the requireddepartment audits. The Quality Assurance Committee Leader will review the Quality AssuranceAudit Schedule monthly and assure all Audit Forms have been completed and returned timelyto the Quality Assurance Leader with trending identified and plans for correction outlined. TheQuality Assurance Leader will set a quarterly Quality Assurance Committee Meeting date andtime for audits and improvement plans to be reviewed. The minutes of the meeting will bedocumented on the Quality Assurance Meeting Minutes form. Quality Assurance audit formsare internal Q/A documents only and are to be kept and filed in the Quality Assurance binderunder the respective department tab per the Quality Assurance Binder Set up Protocol for 12rolling months and maintained by the Quality Assurance Committee Leader. Quality assuranceaudit tools are not to be shared with any non-employee unless the leader receives writtenpermission from the President or Vice President of Ageia Health Services
FORMSQA Meeting Minutes FormQA Assurance Binder Set UpQA Master Audit ScheduleQA Master Audit Spreadsheet
To form a Quality Assurance Committee that is responsible for implementing and overseeing the program. To identify the lines of authority, responsibility and QA Meeting Minutes Form QA …
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Quality Assurance Policies and Procedures 1 Quality Control Policy and Procedures: Terms to Know. ... 2 Quality Assurance Planning. ... 3 Policies on Quality Requirements. ... 4 Defining Roles and Responsibilities. ... 5 Defining Quality Assurance Procedures. ... 6 Defining Tasks Within QA Procedures. ...