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Q: What are the requirements of an agency's professional advisory committee (PAC)?

HCPRO Website, March 11, 2013

Q: What are the requirements of an agency’s professional advisory committee (PAC)?

A: The federal Conditions of Participation (CoP) mandate a group of professional personnel. They state “a group of professional personnel which includes at least one physician and one registered nurse (preferably a public health nurse), and with appropriate representation from other professional disciplines, establishes and annually reviews the agency’s policies governing scope of services offered, admission and discharge policies, medical supervision and plans of care, emergency care, clinical records, personnel qualifications, and program evaluation. At least one member of the group is neither an owner nor an employee of the agency.” They further require “the group of professional personnel meets frequently to advise the agency on professional issues, to participate in the evaluation of the agency’s program, and to assist the agency in maintaining liaison with other health care providers in the community and in the agency’s community information program. The meetings are documented by dated minutes.”

The regulations do not specify the frequency of a PAC’s meetings; they only say “frequently.” The PAC should meet two to four times a year and document those meetings through dated minutes. The PAC evaluates the agency’s professional service program, establishes and annually reviews the agencies policies, and advises the agency on professional issues. 

The PAC should be comprised of:

  • The agency’s administrator
  • The agency’s medical director
  • At least one member who is neither an owner nor an employee
  • At least one registered nurse (if the administrator is not a registered nurse)
  • Appropriate representation of each discipline for which the agency provides service
  • At least one consumer representative
  • Therapy and clinical supervisors can represent their multiple disciplines

The PAC also participates in the agency’s quality assessment and performance review program and receives, studies, and makes recommendations on case-mix, adverse event outcomes, and other outcome reports. The annual agency evaluation is one of the most important functions of the PAC.

Your PAC records and documentation will be evidence of your compliance with regulations. It’s recommended that you have a binder dedicated to your PAC. In that binder, place all meeting agendas, minutes, a list of current members, copies of your annual agency evaluations, and any other PAC-related documentation.

This is an excerpt from Beacon Health’s book The Homecare Administrator’s Field Guide. Learn more about this valuable resource today!