Evaluation of Quality

(A) Each unit shall establish an organized, comprehensive program that is adequate to regularly review and evaluate the quality of care provided. The program shall: (1) be defined in writing and approved by the governing body; (2) identify an individual to be responsible for the implementation and continuity of the program; (3) be reevaluated at least monthly; and (4) describe the mechanisms in effect to identify and resolve problems. (B) The findings of the program shall, as appropriate, be utilized in the revision of facility policies and procedures.