Quality Assessment and Improvement

Section 300.7070  Quality Assessment and Improvement The unit shall have a written plan that is part of the facility's overall quality assurance plan to assess residents' quality of care, quality of life, and overall well-being. a)         The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following goals: 1)         Ongoing monitoring and evaluation of the quality of care and service provided at the facility, including, but not limited to: A)        Admission of residents who are appropriate to the capabilities of the facility; B)        Resident assessment; C)        Development and implementation of appropriate individualized, ability-centered treatment plans; D)        Resident satisfaction; E)        Infection control; F)         Appropriate numbers of staff; and G)        Staff turnover. 2)         Identification and analysis of problems. 3)         Identification and implementation of corrective action or changes in response to problems. b)         The program shall operate pursuant to a written plan that shall include, but not be limited to: 1)         A detailed statement of how problems will be identified, including procedures to elicit insights from residents, residents' families, and residents' representatives; 2)         The methodology and criteria that will be used to formulate action plans to address problems, which shall include the insights of residents, residents' families, and residents' representatives; 3)         Procedures for evaluating the effectiveness of action plans and revising action plans to prevent reoccurrence of problems; 4)         Procedures for documenting the activities of the program; and 5)         Identifying the persons responsible for administering the program. c)         A copy of the plan shall be provided to residents, residents' families, or residents' representatives.