Each quarterly quality assurance review shall include:

Each quarterly quality assurance review shall include: 1. A review of the protocols in each child’s Protocol of Care to assure that it clearly reflects the assessed needs of the child, to include but not be limited to, the evaluation, goals/expectation, treatment modalities and care provided, by each professional discipline serving the child; 2. A review of the steps, process, and success in achieving the goals; 3. Identification of goals not being achieved as expected, reasons for lack of achievement and plans to promote goal achievement; 4. When a child’s clinical status changes, either improvement or decline, that the protocol of care is revised to accommodate the child’s change in status as evidence by revised professional assessments and re-formulation of goals; 5. Within ten days of the review, the quality assurance committee will meet, discuss and ratify the report. Within fifteen days of the review, the quality assurance committee shall furnish copies of its report to the PPEC center medical and nursing directors. 6. The PPEC center shall develop a corrective action plan for each area in which the center failed to meet the established expectations and goals and shall assure implementation of measures, as appropriate, for correction of any deficient area. PPEC center management, to include the medical director and the director of nursing, shall sign the quality assurance report indicating awareness of the deficient findings and shall insure that measures are put into place to correct any deficient practice and/or to prevent the reoccurrence of any such practice.