| (a) The facility must maintain a Quality Assessment
and Assurance Committee consisting of:
(1) the director of nursing services;
(2) the medical director or designee;
(3) at least three other members of the facility's
staff, at least one of whom must be the administrator, a board member
or other individual in a leadership role; and
(4) effective November 28, 2019, the infection preventionist.
(b) The Quality Assessment and Assurance Committee
reports to the facility's governing body regarding its activities.
The committee must:
(1) meet at least quarterly to identify issues with
respect to which quality assessment and assurance activities are
necessary;
(2) develop and implement appropriate plans of action
to correct identified quality deficiencies; and
(3) regularly review and analyze data, including data
resulting from drug regimen reviews, and act on available data to
make improvements.
(c) The State of Texas or the Secretary of Health and
Human Services may not require disclosure of the records of the Quality
Assessment and Assurance Committee except insofar as such disclosure
is related to the compliance of the committee with the requirements
of subsection (b) of this section.
(d) Good faith attempts by the committee to identify
and correct quality deficiencies may not be used as a basis for sanctions.
(e) The Quality Assessment and Assurance Committee
must adopt and ensure implementation of a written policy to identify,
assess, and develop strategies to control risk of injury to residents
and nurses associated with the lifting, transferring, repositioning,
or moving of a resident. The policy must establish a process that
includes:
(1) analysis of the risk of injury to both residents
and nurses posed by the resident handling needs of the resident populations
served by the nursing facility and the physical environment in which
resident handling and moving occurs;
(2) annual in-service education of nurses in the identification,
assessment, and control of risk of injury to residents and nurses
during resident handling;
(3) evaluation of alternative ways to reduce risks
associated with resident handling, including evaluation of equipment
and the environment;
(4) restriction, to the extent feasible with existing
equipment and aids, of manual resident handling or moving of all or
most of a resident's weight to emergency, life-threatening, or otherwise
exceptional circumstances;
(5) collaboration with and an annual report to the
nurse staffing committee;
(6) specific procedures for nurses to refuse to perform
or be involved in resident handling or moving that the nurse believes
in good faith will expose a resident or a nurse to an unacceptable
risk of injury;
(7) submission of an annual report by the nursing staff
to the Quality Assessment and Assurance Committee on activities related
to the identification, assessment, and development of strategies to
control risk of injury to residents and nurses associated with the
lifting, transferring, repositioning, or moving of a resident; and
(8) in developing architectural plans for constructing
or remodeling a nursing facility or a unit of a nursing facility in
which resident handling and moving occurs, consideration of the feasibility
of incorporating resident handling equipment or the physical space
and construction design needed to incorporate that equipment at a
later date.
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| Source Note: The provisions of this §554.1917 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective June 1, 2006, 31 TexReg 4458; amended to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
