LAC 48:I.8781
LAC 48:I.8781. Quality Enhancement
Cite as La. Admin. Code tit. 48, pt. I, § 8781
A. An ABI facility shall develop, implement and maintain a quality enhancement (QE) plan that:
1. ensures that the facility is in compliance with federal, state, and local laws;
2. meets the needs of the facility’s clients;
3. is attaining the goals and objectives established by the facility;
4. maintains systems to effectively identify issues that require quality monitoring, remediation and improvement activities;
5. improves individual client outcomes and individual client satisfaction;
6. includes plans of action to correct identified issues that:
a. monitor the effects of implemented changes; and
b. result in revisions to the action plan; and
7. is updated on an ongoing basis to reflect changes, corrections and other modifications.
B. The QE plan shall include:
1. a process for identifying on a quarterly basis the risk factors that affect or may affect the health, safety and/or welfare of the clients of the facility receiving services, that include, but is not limited to:
a. review and resolution of complaints;
b. review and resolution of incidents; and
c. incidents of abuse, neglect and exploitation;
2. a process to review and resolve individual client issues that are identified;
3. a process to review and develop action plans to resolve all system wide issues identified as a result of the processes above;
4. a process to correct problems that are identified through the program that actually or potentially affect the health and safety of the clients; and
5. a process of evaluation to identify or trigger further opportunities for improvement in identification of individual client care and service components.
C. The QE program shall hold bi-annual committee meetings to:
1. assess and choose which QE plan activities are necessary and set goals for the quarter;
2. evaluate the activities of the previous quarter; and
3. implement any changes that protect the clients from potential harm or injury.
D. The QE plan committee shall:
1. develop and implement the QE plan; and
2. report to the director any identified systemic problems.
E. The facility shall maintain documentation of the most recent 12 months of the QE plan.