§ 5320.71. Quality improvement program.
The provider shall have a written quality improvement (QI) plan and program that the program director reviews for the quality and appropriateness of services provided and monitors for compliance with standards of treatment and care. The plan shall:
(1) Specify who has responsibility for QI activities, to whom findings are reported, the frequency of reviews, what critical indicators are to be evaluated and acceptable levels for the critical indicators.
(2) Have indicators of quality care that include at least the following:
(i) The level of resident satisfaction and program input.
(ii) The level of family satisfaction and program input.
(iii) Appropriateness, completeness, timeliness and implementation of the treatment plans.
(iv) Case and trend review of crisis events and unusual situations.
(v) Direct-care staff performance.
(vi) Clinical case or peer reviews, quarterly or more often as indicated.
(vii) Medications management, including errors and adverse effects.
(viii) The appropriate documentation in the resident’s record.
(3) Include the names of the individuals who participated in the quality improvement activities and plans of correction.
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