12 Va. Admin. Code § 35-105-620 - Monitoring and evaluating service quality
A. The provider shall develop and implement
written policies and procedures for a quality improvement program sufficient to
identify, monitor, and evaluate clinical and service quality and effectiveness
on a systematic and ongoing basis.
B. The quality improvement program shall
utilize standard quality improvement tools, including root cause analysis, and
shall include a quality improvement plan.
C. The quality improvement plan shall:
1. Be reviewed and updated at least annually ;
2. Define measurable goals and
objectives;
3. Include and report on
statewide performance measures, if applicable, as required by DBHDS;
4. Monitor implementation and effectiveness
of approved corrective action plans pursuant to
12VAC35-105-170;
and
5. Include ongoing monitoring
and evaluation of progress toward meeting established goals and
objectives.
D. The
provider 's policies and procedures shall include the criteria the provider will
use to:
1. Establish measurable goals and
objectives;
2. Update the
provider 's quality improvement plan; and
3. Submit revised corrective action plans to
the department for approval or continue implementing the corrective action plan
and put into place additional measures to prevent the recurrence of the cited
violation and address identified systemic deficiencies when reviews determine
that a corrective action was fully implemented but did not prevent the
recurrence of the cited regulatory violation or correct a systemic deficiency
pursuant to
12VAC35-105-170.
E. Input from individuals receiving services
and their authorized representatives, if applicable, about services used and
satisfaction level of participation in the direction of service planning shall
be part of the provider 's quality improvement plan. The provider shall
implement improvements, when indicated.
Notes
Statutory Authority: §§ 37.2-302 and 37.2-400 of the Code of Virginia.
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