Section 280.2090  Quality Assurance Program

a)         The hospice program must conduct a quality assurance program in accordance with the standards for certification under the Medicare program set forth in the Conditions of Participation in 42 CFR 418.  (Section 8(m) of the Act)

b)         Each hospice shall establish a written quality assurance plan for review of the services delivered.  The plan must include:

1)         A process for identification of quality assurance issues.  The person or persons responsible for coordinating quality assurance shall review all summaries of individual assessments at least quarterly and prepare a written report addressing any problems with care, treatment services, availability of services, and methods of care delivery.

2)         A system to report to the governing body findings and recommendations for improving the quality of care delivered.  The quality assurance reports shall be reviewed by the hospice administrator and the governing body. 

3)         The minutes of the meetings of the governing body, which shall indicate that the reports have been reviewed at least annually.

(Source:  Amended at 32 Ill. Reg. 2330, effective January 23, 2008)