(a) Quality Assurance (QA) Program. A licensed abortion facility shall maintain a QA program in the facility which shall be implemented by a QA committee. The QA program shall be ongoing and have a written plan of implementation. This plan shall be reviewed and updated or revised at least annually by the QA Committee. The QA program shall include measures for quality improvement in the measurement of the facility's delivery of service. Quality assurance documents pertinent to the facility shall be kept within the facility.
(b) QA committee membership. At a minimum, the QA committee shall consist of at least:
  (1) the medical consultant designated by the facility;
  (2) an advanced practice registered nurse, a physician assistant, a registered nurse, or a licensed vocational nurse; and
  (3) at least two other members of the facility's staff.
(c) Frequency of QA committee meetings. The QA committee, by consensus, shall meet at least quarterly to identify issues with respect to which quality assurance activities are necessary.
(d) Minimum responsibilities. The QA committee shall:
  (1) evaluate all organized services related to patient care, including services furnished by contract;
  (2) ensure that there is a review of any abortion procedure complication(s), and shall make use of the findings in the development and revision of facility policies;
  (3) address issues of unprofessional conduct by any member of the facility's staff (including contract staff);
  (4) monitor infection control as outlined in §139.49 of this title (relating to Infection Control Standards) and post-procedure infections as outlined in §139.41 of this title (relating to Policy Development and Review);
  (5) address medication therapy practices;
  (6) address the integrity of surgical instruments, medical equipment, and patient supplies; and
  (7) address services performed in the facility as they relate to appropriateness of diagnosis and treatment.
(e) Patient care and service issues. The QA committee shall identify and address patient care services and information issues and implement corrective action plans as necessary.
  (1) Identifying issues that necessitate corrective action. The QA committee shall be responsible for identifying issues that necessitate corrective action by the committee, such as issues which negatively affect care or services provided to patients.
  (2) Plan of corrective action. The QA committee shall develop and implement plans of action to correct identified deficiencies.
  (3) Remedial action. The QA committee shall take and document remedial action to address deficiencies found through the QA program. The facility shall document the outcome of the remedial action.
(f) Departmental review.
  (1) The department shall not use good faith efforts by the QA committee to identify and correct deficiencies as a basis for deficiency(ies), citation(s), or sanction(s).
  (2) Department surveyors shall verify that:
    (A) the facility has a QA committee which addresses concerns; and
    (B) the facility staff know how to access that process.

Source Note: The provisions of this §139.8 adopted to be effective June 28, 2009, 34 TexReg 4125