(A) Each freestanding dialysis center governing body shall conduct an ongoing, comprehensive, integrated self-assessment of the quality and appropriateness of care provided by the facility, including:
(1) Adequacy of dialysis;
(2) Vascular access;
(3) Medical injuries and medical error identification;
(4) Infection control;
(5) Nutritional status;
(6) Mineral metabolism and renal bone disease;
(7) Anemia management;
(8) Hemodialysizer reuse program where applicable; and
(9) Patient satisfaction and grievance resolution.
(B) The dialysis center shall designate an individual or individuals to be responsible for the quality assessment and performance improvement program who shall be responsible for the following activities related to the quality of care and services provided by the dialysis center :
(1) Developing and implementing mechanisms for monitoring;
(2) Identifying and resolving issues;
(3) Providing suggestions to the governing body for improvement; and
(4) Reporting program activities and findings to the governing body.
(C) The dialysis center shall use the findings of the quality assessment and performance improvement program to set priorities for performance improvement, correct identified problems, and to revise policies and procedures as necessary.
(D) Identified performance problems that threaten the health or safety of patients shall be immediately corrected.
(E) As part of the quality assessment and performance improvement system required under rule 3701-83-12 of the Administrative Code, each freestanding dialysis center shall provide to the director, upon request, copies of data reports provided to the "renal network" designated by the centers for medicare and medicaid services to include the state of Ohio or any portion of the state of Ohio pursuant to 42 C.F.R. section 405.2112. All patient specific information submitted to the director under this paragraph that identifies a patient shall be maintained in a confidential manner.
Five Year Review (FYR) Dates: 02/16/2016 and 02/15/2021
Promulgated Under: 119.03
Statutory Authority: 3702.13, 3702.30
Rule Amplifies: 3702.12, 3702.13, 3702.30
Prior Effective Dates: 1/13/1996, 9/5/02, 4/24/11