§295.2060. Quality Improvement Program

a)         The establishment shall establish an effective quality improvement program that encompasses oversight and monitoring, resident satisfaction, and ongoing quality improvement and implementation of any plan that addresses improved quality services.  The quality improvement process implemented by the establishment must benchmark performance, be customer centered, be data driven, and focus on resident satisfaction.  (Section 30(a) of the Act)  For the purpose of this Section, "benchmark" means creating points of reference from which measurements can be made.

 

b)         A system shall be in place to facilitate the detection of issues and problems, to expedite the implementation of action, and to resolve problems.

 

1)         Data analysis shall be used to identify and implement changes that will improve performance or reduce the risk of additional events.

 

2)         The establishment shall maintain documentation that shows that data analysis has occurred and that actions, as appropriate, have been implemented to address identified issues and to resolve problems, as well as any follow-up actions taken by the establishment.

 

c)         The existence, results, and process of a quality improvement program cannot be used as evidence in any civil or criminal court proceeding.

 

d)         The result of the quality improvement program cannot be the sole basis for citing a violation.