37.106.1820 SPECIALTY MENTAL HEALTH FACILITY: QUALITY ASSURANCE
(1) The governing body of the facility must ensure that there is an effective, ongoing, facility wide written quality assurance program and implementation plan in effect which ensures, monitors, and evaluates the quality of the patient care provided there and which includes the following:
(a) Identification of all health and safety aspects of each patient's individual treatment plan;
(b) Development and documentation of indicators that are used to monitor and evaluate the health and safety aspects of patient treatment and care;
(c) Documentation and evidence that the findings, conclusions, and results of corrective actions to improve patient care which are identified through the quality assurance program are applied in a manner which improves patient treatment and care.
(d) Consideration and documentation by the facility's medical and professional staff of the findings of the evaluation and the taking of subsequent remedial action, if necessary.
(e) Evaluation, with complete documentation, of all services provided by contractors.
(f) The taking and documentation of appropriate remedial action to address deficiencies found through the quality assurance program, as well as documentation of the outcome of the remedial action.
(g) Periodic review of all quality assurance activities, at least semi-annually, which is submitted in writing to the governing body and also made a part of the facility's medical records file.