3701-19-37. Governing body; quality assessment and performance improvement

(A) The overall conduct and operation of the pediatric respite care program, including the quality of care and the provision of services, shall be the full legal responsibility of a clearly defined, organized governing body.

(B) The governing body of a licensed hospice care program may also provide governance for a pediatric respite care program if the programs are dually licensed and meet all requirements set forth in this rule and chapter.

(C) The governing body shall:

(1) Establish and review policies for the management, operation, and evaluation of the pediatric respite program, including, but not limited to:

(a) Qualifications of employees and independent contractors; and

(b) Policies and procedures to receive and respond to patient grievances regarding medical treatment, quality of care, the lack of respect for person or property, mistreatment, neglect, verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by any individual furnishing services on behalf of the pediatric respite care program. The policies and procedures developed by the governing body shall, at a minimum, include:

(i) Notification procedures for pediatric respite care patients, employees and contracted staff to report alleged violations to the pediatric respite care program administration;

(ii) Requirements for the immediate investigation of alleged violations;

(iii) Procedures for the reporting of verified violations to the appropriate state licensing authority and/or local authorities where appropriate; and

(iv) Requirements for timely corrective actions for all verified violations.

(2) Arrange for a physician to serve as medical director for the pediatric respite care program who:

(a) Should be knowledgeable about the psychological, social, and medical aspects of pediatric respite care as the result of training, experience, and interest; and

(b) Shall designate a physician to act in his or her absence; and

(c) The medical director may also may serve as the physician representative on an interdisciplinary team or teams or as an attending physician.

(3) Appoint a qualified individual to serve as the director of the pediatric respite care program who shall perform the following duties:

(a) Be responsible for the day-to-day management of the program and for assuring compliance with Chapter 3712. of the Revised Code, Chapter 3701-13, and this chapter of the Administrative Code;

(b) Implement the pediatric respite care program's policies and procedures regarding all activities and services provided by the pediatric respite care program;

(c) Designate an individual to act in his or her absence;

(d) Implement the pediatric respite care program's quality assessment and performance improvement program under rule 3701-19-52theAdministrativeCode; and

(e) Implement the pediatric respite care program's patient grievance program established under paragraph (A)(2) of this rule.

(4) Ensure that all services provided are consistent with accepted standards of practice for pediatric respite care.

(5) Evaluate the pediatric respite care program's quality assessment and performance improvement program on an annual basis.

(D) Each pediatric respite care program governing body shall conduct an ongoing, comprehensive, integrated, self-assessment of the quality and appropriateness of care provided by the program, including care provided under contracts with other persons or public agencies.

(E) The pediatric respite care program governing body shall designate an individual or individuals to be responsible for the quality assessment and performance improvement program. The designee or designees shall implement and report on activities and mechanisms for monitoring the quality of care, identify and resolve problems, and make suggestions for improving care. The designee or designees shall provide their reports to the governing body of the program. The pediatric respite care program shall use the findings of the quality assessment and performance improvement program to correct identified problems and to revise pediatric respite care program policies if necessary.

(F) The pediatric respite care program governing body shall use the findings of the quality assessment and performance improvement program to correct identified problems and to revise pediatric respite care program policies if necessary.

Five Year Review (FYR) Dates: 11/5/2018 and 11/05/2023
Promulgated Under: 119.03
Statutory Authority: 3712.031
Rule Amplifies: 3712.031 , 3712.041, 3712.051, 3712.061, 3712.09, 3712.99
Prior Effective Dates: 12/26/2013

Prior History: (Effective: 12/26/2013
R.C. 119.032 review dates: 12/01/2018
Promulgated Under: 119.03
Statutory Authority: 3712.031
Rule Amplifies: 3712.031, 3712.041, 3712.051, 3712.061, 3712.09, 3712.99)