Quality Systems Requirements

Section 2060.340  Quality Systems Requirements a)         The organization shall design and implement a quality improvement plan that incorporates all requirements specified in this Part.  The quality improvement plan shall be approved by the authorized organization representative or management designee and, if applicable, controlling ownership or board of directors and annually reviewed and revised as necessary. b)         The quality improvement plan shall be written and shall contain, at a minimum: 1)         A mission statement for the organization's DHS/SUPR licensed services; 2)         A method of evaluation to assess achievement of the organization's mission; 3)         Identified strategies designed to achieve successful intervention and treatment outcomes; 4)         A policy and procedure for obtaining and responding to feedback from persons served and community stakeholders; 5)         A method to review and evaluate the use of medications utilized in any level of care that are directly provided by the organization; 6)         A method of risk management that, at a minimum, includes: A)        Review and analysis of any incident or significant incidents and the correct reporting procedure as specified in Section 2060.385; B)        Design and implementation of necessary procedures to address any identified risks; and C)        As applicable to Opioid Treatment Programs that are licensed by DHS/SUPR to dispense Methadone, a "Diversion Control Plan" in accordance with the requirements specified in Section 2060.420(g)(5); and 7)         A utilization management plan, as specified in subsection (c), for the ongoing review and assessment of delivered services and outcomes. Utilization management is required for all authorized treatment and intervention licenses for designated programs, and DUI evaluation licensees.  It is not required for intervention licenses for DUI risk education or recovery home licensees. c)         Utilization management shall be conducted by a person who did not deliver or supervise the services under review.  This person can work directly for the organization or be a contractor.  In all cases, utilization management for treatment services shall be conducted by persons who meet the qualifications specified in Section 2060.320(a) or (b) for DUI evaluation or designated program services.  Utilization management shall be conducted at least quarterly in accordance with the following: 1)         For treatment licensees, a random sample of a minimum 15% or 50 patient records (whichever is less) that received services or were closed during the applicable quarter and that are representative of all authorized levels of care and locations.  Utilization management for these records shall review the following: A)        The medical or clinical necessity supporting the placement or continued service in the current level of care; B)        The appropriateness and clinical necessity for treatment plan goals and objectives as they relate to assessed need; C)        Verification of the time, date, and duration of all services and the signature requirements in each patient record as specified in this Part; and D)        Timely delivery of assessed clinical and case management services. 2)         For DUI evaluation or designated program intervention licensees, a random sample of a minimum 15% or 20 client records (whichever is less) that received services or were closed during the applicable quarter and that are representative of each authorized service and location.  Utilization management for these records shall review the following: A)        The appropriateness of the diagnosis or risk category assignment, as applicable, based upon the established criteria specified in this Part for the applicable authorized services provided by an intervention licensee relative to an SUD assessment or risk category assignment; and B)        The appropriateness of the subsequent recommended intervention or referral for treatment, based upon the diagnosis or risk assignment, as applicable. 3)         If the random sampling of client or patient records indicates incorrect information, the organization shall develop and implement a corrective action plan to address the identified problems. 4)         The organization shall issue a report, at least quarterly, that documents the findings from utilization management and make all such reports available, at least annually, to all credentialed staff, controlling ownership, and board of directors. d)         All organizations shall develop and maintain a written policies and procedures manual that describes all operational procedures.  At a minimum, the manual shall contain an organization chart and a description of the process the organization will use to ensure compliance with all applicable rules referenced in this Part and any other local, State, and federal regulatory requirements.  This manual shall be approved by controlling ownership or the board of directors, and any new or revised policies shall be reviewed annually.  The organization shall also ensure that staff receive and review updated sections to the manual at least annually. e)         Treatment licensees who are not otherwise required to report data electronically shall maintain statistics that, at a minimum, summarize the demographic information specified in Section 2060.370(d)(9) and that summarize for each licensed treatment facility: 1)         Total number of patients, by level of care; 2)         The average length of time between initial date of contact and the first treatment service; 3)         Total number of assessments and admissions, by level of care; 4)         Total number of substance use diagnoses, by type; 5)         The average length of stay in each level of care; and 6)         Discharges by type and level of care. f)         The statistics maintained pursuant to subsection (e) shall be made available upon request by DHS/SUPR and/or during inspections.