Quality assessment and performance improvement

1. The agency shall develop, implement, and document an ongoing agencywide quality assessment program to monitor, evaluate, and improve the quality of patient care, administrative, and support services, including all contracted services, and to ensure services are provided in compliance with professional standards of practice. a. The quality assessment program must include a written plan that identifies a mechanism to identify problems, recommend appropriate action, implement recommendations, and monitor results. b. The administrator shall maintain a record of the activities of the quality assessment program and ensure findings, conclusions, and recommendations are reported to the governing body. 2. The agency shall complete a performance improvement project annually and documentation of the reviews must be maintained as a part of the administrative records.