Quality Assessment Program

(A) A CHC must have in effect a program for internal quality assessment that is based on written policies, standards, and procedures, and that includes the following: (1) a review of the CHC's performance including, but not limited to, adequacy of recordkeeping, referral procedures and follow-up, medication review, quality of patient care, and identification of deficient areas of performance; (2) recommendations for correcting any deficiencies identified in the review; and (3) a review of any such corrective action. (B) These reviews must be conducted at least twice a year by a committee composed of the professional services director, representatives of each professional discipline on the CHC's staff, consumers, and, if possible, health professionals not employed at the CHC. Activities of the committee must be documented in minutes or a report and made available to the MassHealth agency upon request.