Current through Register Vol. 54, No. 7, April 4, 2022
(a) The QA plan
shall be implemented.
shall be routinely collected from ongoing monitoring activities and
periodically evaluated and analyzed, based on thresholds.
(c) Documented reports of all ongoing
monitoring and evaluation activities shall be produced. When ongoing monitoring
reveals that more intensive evaluation is required, documentation shall include
evidence of further assessment, conclusions drawn, and actions taken to improve
care and to resolve identified problems. Examples of possible actions that can
be taken are: implementation of inservice training, personnel action, changes
in policies and procedures, administrative actions.
(d) Status of previously identified problems
(follow-up) shall be documented. Problems identified and corrective actions
taken shall be monitored for a prescribed time frame.
(e) To the extent that the QA process
identifies issues that require medical staff input, review and response to such
referrals shall be documented. These referrals may include questionable
admissions and continued stays.
Documentation and evidence of QA monitoring activities to ensure client
involvement in treatment shall be provided, and shall include, at a minimum:
each client's active and informed participation in his or her treatment plan;
medication education; and application of clients' rights and the client
Documentation of monitoring of effectiveness of the PA's mechanisms to respond
to client complaints and suggestions shall be provided.
(h) In the case of hospital based PAs,
documented evidence of integration with the hospital QA program shall be
(i) There shall be
evidence that relevant QA findings are effectively communicated to all relevant
components of the PA, including clients.
When the PA has developed the QA program,
the following additional elements should be implemented:
1. Participation by medical staff on the QA
Documentation of analysis of aggregate QA findings to identify and address
patterns and trends related to client characteristics, treatment and service
3. Utilization of
responses to client satisfaction surveys and recommendations from clients and
family members; and
Documentation of the use of applicable QA findings in ongoing staff
development, supervision and performance evaluation.