Appalachian District Health Department

Policy and Procedure Policy Name Quality Improvement Policy Topic Clinical Programs

Section 300

Approved Date:11-10-89

Chapter 303

Revision Date: 5-8-15

Purpose: To provide guidance and direction for best practice for all clinical Programs provided by Appalachian District Health Department. Policy: It is the policy of Appalachian District Health Department that all clinical Programs follow guidelines outlined in current contract addenda and/or policy manuals for those specific programs. Procedure: 1. Quality Assurance teams will consist of nursing staff from each county, including one lead nurse for the specific audited program, nursing supervisor assigned to that program and one provider. 2. Program manuals, policies and procedures will be reviewed, revised or updated annually by the Quality Assurance team for that program. 3. District audits will be conducted annually unless otherwise determined. 4. The program lead nurse in each county will select the client records to be audited. A member of management support will pull all correlated superbills for the audited visits. Records will be selected for patients who have been seen for audited program in the past three to six months, or as designated by state guidelines. Records pulled should include both Medicaid and non-Medicaid, to ensure that documentation is present and meets standards for billing, if indicated in the program. 5. The Nursing Supervisor assigned to the audited program will provide the results to each member of the audit team, nursing director and the health director. The Nursing Supervisor, in conjunction with the QI Coordinator, will provide ongoing and systematic documentation of quality assurance activities. 6. A corrective action plan will be developed for any parameter that falls below 90%. 7. The District corrective action plan will include problem, timeline and method of corrective action. A standard corrective action plan tool will be used in each audit. 8. Corrective action plans are due one month from when the audit was done. A re-audit must be completed in three months. 9. The Nursing Supervisor assigned to the audited program will be responsible to tally the audit results and inform appropriate staff of strengths and corrective action items. The program lead nurse in each county will complete the CAP and train other clinical staff and providers on the corrective actions. 10. District corrective action plan and internal audit results from each county will be reviewed at the next program audit. 11. Parameters that continue to fall below the 90% will be evaluated and a revised corrective action plan will be developed. 12. Interruption of services or inability to meet quality assurance deliverables will be reported within 14 days to the appropriate Regional Program Nurse Consultant. 1|Quality Improvement – Clinical Programs

Appalachian District Health Department

Policy and Procedure Policy Name Quality Improvement Policy Topic Clinical Programs

Section 300

Approved Date:11-10-89

Chapter 303

Revision Date: 5-8-15

15. Regional Nursing Consultants for Program will perform on site monitoring visits as determined by the state to include review of policies and procedures and other items identified or required.

2|Quality Improvement – Clinical Programs