LAC 48:I.4971. Program Evaluation

A. The provider must develop and implement a continuous Quality Improvement Plan that is designed to objectively assess and improve the quality of services for consumers which includes the following components: 1. the capability to identify, assess, and correct problems, a time line for correction of deficiency and follow-up on the results of corrective action; 2. procedures to allow immediate response to identified problems. B. Pertinent findings of quality improvement activities must be reported to the governing body, executive/provider director. C. The chief administrator must have the responsibility for the implementation and coordination of the quality improvement process. Duties must be specified. D. Administrative review and any required corrective action must be conducted as required. E. The Quality Improvement Plan and process must be reviewed at least annually to determine the need for and the mechanisms for improving the plan. F. A program evaluation system must be maintained to identify the results of services and the effects of services on the consumer which meets the following criteria: 1. measures outcomes of programs and services; 2. regularly measures the progress of the consumers in relation to the program goals; and 3. evaluates post-discharge information, if applicable; 4. information gained from the system must be used to improve the program. 5. there must be a means to determine when performance is less than acceptable which includes the following: a. the reasons must be identified when performance falls below the acceptable level; b. management must take prompt action to improve program performance to an acceptable level; and c. follow-up and monitoring of corrective actions must be performed at specific times with results documented.