10A NCAC 13J .1004        EVALUATION

(a)  The agency's governing body or its designee shall, at least annually, conduct a comprehensive evaluation of the agency's total operation.

(b)  The evaluation shall assure the appropriateness and quality of the agency's services with findings used to verify policy implementation, to identify problems, and to establish problem resolution and policy revision as necessary.

(c)  The evaluation shall consist of an overall policy and administration review, including the scope of services offered, arrangements for services with other agencies or individuals, admission and discharge policies, supervision and plan of care, emergency care, service records, personnel qualifications and program evaluation.  Data to be assessed shall include at a minimum the following:

(1)           number of clients receiving each services;

(2)           number of visits or hours for each service;

(3)           client outcomes;

(4)           adequacy of staff to meet client needs;

(5)           numbers and reasons for nonacceptance of clients; and

(6)           reasons for discharge.

(d)  An evaluation of the agency's client records shall be carried out at least quarterly by appropriate professionals representing the scope of the agency's program.  The evaluation shall include a review of sample active and closed client records to ensure that agency policies are followed in providing services, both direct and under arrangement, and to assure that the quality of service is satisfactory and appropriate.  The review shall consist of a representative sample of all home care services provided by the agency.

(e)  Documentation of the evaluation shall include the names and qualifications of the persons carrying out the evaluation, the criteria and methods used to accomplish it, and any action taken by the agency as a result of its findings.


History Note:        Authority G.S. 131E‑140;

Eff. July 1, 1992;

RRC Objection due to lack of statutory authority Eff. November 16, 1995;

Amended Eff. February 1, 1996.