(1) The youth care facility (YCF) shall implement and maintain an active quality assessment program for improving policies, procedures, and services. At a minimum, the quality assessment program must include procedures for:
(a) conducting youth satisfaction surveys at least annually which are maintained and filed at the facility;
(b) maintaining records on the occurrence, duration, and frequency of physical restraints used; and
(c) reviewing, on an ongoing basis, serious incident reports, grievances, complaints, medication errors, and the use of physical restraints with special attention given to identifying patterns and making necessary changes in how services are provided.
(2) The YCF shall prepare and maintain on file an annual report including improvements made as a result of the quality assessment activities specified in this rule.