Section 557.2. Plan

(a) The ASF shall have a written plan for the quality assurance and improvement program that describes the program’s objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and problem solving activities.

(b) The written plan shall be endorsed by the governing body and the medical director who are responsible for establishment and direction of the program and which indicates the staff person responsible for implementation of the program.

(c) The plan shall emphasize the ongoing nature of the quality assurance program and the comprehensiveness of the scope of the program which shall include monitoring and evaluation of the following:

(1) Medical staff functions including:

(i) Peer-based review of clinical performance of individuals with clinical privileges.

(ii) Surgical case and tissue review.

(2) Anesthesia services.

(3) Nursing services.

(4) Pharmaceutical services.

(5) Pathology and radiology services.

(6) Infection control procedures.

(7) Procedures performed in the ASF and their necessity.

(8) Reports of accidents, injuries and safety hazards.

(d) The plan shall include participation of practitioners and other health care personnel.

The provisions of this § 557.2 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256569).