(a)  The hospice shall develop and implement policies and a written plan for the implementation of a comprehensive assessment at least annually of its overall program and performance.  The quality and appropriateness of care provided shall be assessed with the findings used to verify policy implementation, to identify problems and to establish problem resolution and policy revision as necessary.

(b)  The hospice shall determine what individuals will carry out the evaluation.  Representatives of the governing body, hospice staff, the interdisciplinary care team, and other appropriate professionals may be used.

(c)  The evaluation shall include, as a minimum, a review of all policies and procedures and a medical record review.

(d)  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 the action taken by the agency as a result of the findings.


History Note:        Authority G.S. 131E‑202;

Eff. November 1, 1984;

Amended Eff. February 1, 1996; November 1, 1989.