10A NCAC 13S .0324       QUALITY ASSURANCE

(a)  The governing authority shall establish a quality assurance program for the purpose of providing standards of care for the clinic. The program shall include the establishment of a committee that shall evaluate compliance with clinic procedures and policies.

(b)  The committee shall determine corrective action, if necessary to achieve and maintain compliance with clinic procedures and policies.

(c)  The committee shall consist of at least one physician who is not an owner, the chief executive officer or designee, and other health professionals. The committee shall meet at least once per quarter.

(d)  The functions of the committee shall include development of policies for selection of patients, approval for adoption of policies, review of credentials for staff privileges, peer review, tissue inspection, establishment of infection control procedures, and approval of additional procedures to be performed in the clinic.

(e)  Records shall be kept of the activities of the committee for a period not less than 10 years. These records shall include:

(1)           reports made to the governing authority;

(2)           minutes of committee meetings including date, time, persons attending, description and results of cases reviewed, and recommendations made by the committee; and

(3)           information on any corrective action taken.

(f)  The clinic shall conduct orientation, training, or education programs to correct deficiencies that are uncovered as a result of the quality assurance program.

History Note:        Authority G.S. 131E-153.5; 143B-165;

Codifier determined that findings of need did not meet criteria for emergency rule on October 30, 2023;

Emergency Rule Eff. November 14, 2023;

Temporary Adoption Eff. February 8, 2024.