The program director shall assure that written policies and procedures are adopted by the program, approved by the medical director, and available to and implemented by staff. At a minimum, these policies and procedures shall include the following areas:

1. (1) admission of patients and orientation to the program;
2. (2) patient assessment, care planning, and implementation of therapies;
3. (3) patient follow-up evaluations, including progress toward cardiac rehabilitation goals;
4. (4) patient discharge;
5. (5) medical records, in accordance with Rule .2002 of this Subchapter;
6. (6) orientation of all program personnel;
7. (7) maintenance of personnel records which include job descriptions, verification of credentials, continuing education and current competencies;
8. (8) use and orientation of volunteers;
9. (9) communication with patient's referral and personal physicians;
10. (10) provisions for reporting and investigating complaints and accidental events regarding patients, visitors and personnel (incidents) and corrective action taken;
11. (11) emergency procedures;
12. (12) a preventative maintenance program to assure all equipment is maintained in safe and proper working order and in accordance with the manufacturer's recommendations; and
13. (13) quality improvement program.

History Note: Authority G.S. 131E-169;
Eff. July 1, 2000;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 6, 2016.