QUALITY IMPROVEMENT
§ 5240.61. Quality improvement requirements.
(a) An IBHS agency shall establish and implement a written quality improvement plan that meets the following requirements:
(1) Provides for an annual review of the quality, timeliness and appropriateness of services that includes the following:
(i) Review of individual records.
(ii) Review of individual and family satisfaction information.
(iii) Assessment of the outcomes of services delivered and if ITP goals have been completed.
(iv) Evaluation of compliance with the agency’s approved service description and licensure requirements in this chapter.
(2) Identifies the methodology for the review of agency and individual records that includes the following:
(i) Method for establishing sample size of agency and individual records.
(ii) Frequency of review of the agency and individual records to prepare for the annual quality review in subsection (a)(1).
(iii) Staff’s qualifications who perform the review.
(b) An IBHS agency shall prepare an annual quality report that includes the following:
(1) Analysis of the findings of the annual quality review required under subsection (a)(1).
(2) Identification of the actions to address annual review findings.
(c) An IBHS agency shall make annual quality reports available to the public upon request.
(d) An IBHS agency shall provide written notification that a copy of the annual quality report may be requested by a youth, young adult or parent, legal guardian or caregiver of a child, youth or young adult upon admission to services.
Cross References This section cited in 55 Pa. Code § 5240.42 (relating to agency records).
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