State Nursing Home Quality Improvement Programs: Site Visit and Synthesis Report. Risk Management/Internal Quality Assurance


SB 1202 mandated that every facility establish an internal risk management and quality assurance program with a risk manager responsible for implementation and oversight. The regulation does not require that the risk manager have particular credentials. Each facility must also form a risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. This committee shall meet at least monthly. The statutory language contains specific duties for this committee, including a process for reporting adverse incidents to AHCA. The goal is to identify incidents occurring in health care facilities, which have an outcome of patient injury and may reflect error in the course of the delivery of health care services.

As mandated in SB1202, each facility must also establish a grievance procedure and must respond to all grievances within a reasonable time after submission to the facility. This procedure must be available to all residents and families and must include: an explanation of how to pursue redress of a grievance; the names, job titles and telephone numbers of the employees responsible for implementing the grievance procedure; the address and toll free telephone numbers of the Ombudsman and AHCA; a simple description of how a resident may, at any time, contact the toll free numbers to report an unresolved grievance; and a procedure to assist residents who cannot prepare a written grievance without help. A facility must maintain records of all grievances and must report to AHCA annually the total number of grievances handled, a categorization of the cases underlying the grievances and the final disposition of the grievances.

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