- (1) The REH shall participate in the QAPI Program and shall be governed by the Board's Rules for Hospitals, Chapter 420-5-7, Ala. Admin. Code, with the exception of the provisions governing performance improvement projects. The REH must maintain and demonstrate evidence of its QAPI Program for review by the Department.
(2) If an REH is part of a system consisting of multiple separately certified hospitals, CAHs, and/or REHs using a system governing body that is legally responsible for the conduct of 2 or more hospitals, CAHs, and/or REHs, the system governing authority can elect to have a unified and integrated QAPI Program for all of its member facilities after determining that such a decision is in accordance with all applicable state and local laws. The system governing body is responsible and accountable for ensuring that each of its separately certified REHs meets all the requirements of this section. Each separately certified REH subject to the system governing authority must demonstrate that:
- (a) The unified and integrated QAPI Program is established in a manner that takes into account each member REH's unique circumstances and any significant differences in patient populations and services offered in each REH; and
- (b) The unified and integrated QAPI Program establishes and implements policies and procedures to ensure that the needs and concerns of each of its separately certified REHs, regardless of practice or location, are given due consideration, and that the unified and integrated QAPI Program has mechanisms in place to ensure that issues localized to particular REHs are duly considered and addressed.
Author: Dana H. Billingsley
Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.
History: New Rule: Published August 31, 2023; effective October 15, 2023.