Current through Register Vol. 46, No. 3, March 25, 2022

A. There shall be a written, implemented quality improvement program that provides effective self-assessment and implementation of changes designed to improve the care and services provided by the Facility.
B. The quality improvement program, at a minimum, shall:
1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is regularly, systematically, and objectively accomplished;
2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;
3. Identify the action taken to correct deviations and prevent future deviation, and the person(s) responsible for implementation of these actions;
4. Analyze the appropriateness of Individual Plans of Care and the necessity of care and services rendered;
5. Analyze all incidents and accidents, to include all medication errors and Patient deaths;
6. Analyze any infection, epidemic outbreaks, or other unusual occurrences which threaten the health, safety, or well-being of the Patients; and
7. Establish a systematic method of obtaining feedback from Patients and other interested persons, as expressed by the level of satisfaction with care and services received.


Added by State Register Volume 44, Issue No. 06, eff. 6/26/2020.

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