Section 20. Quality Improvement And Utilization Review

A. The agency has a continuous quality improvement process, reviewed annually, through which the agency systematically evaluates the effectiveness of services provided by determining whether its services meet pre- determined quality improvement expectations and outcomes, and corrects any observed deficiencies identified through the quality improvement process. B. The agency explicitly details the desired expectations and service outcomes for each of its programs and has a written plan to achieve them. C. The agency establishes a committee or other mechanism for the timely and regular evaluation of serious incidents, complaints, grievances, and related investigations. Committee evaluations include identification of events, trends and patterns that may affect client health, safety, and/or treatment efficacy. Committee evaluation findings and recommendations are documented and submitted to agency management for corrective action. Actions implemented and outcomes are documented, and trends are analyzed over time. The agency has a well-defined plan for correcting problems. When problems (or potential problems) are identified, the facility acts as soon as possible to avoid any risks to clients by taking corrective steps that may include, but are not limited to: (1) changes in policies and/or procedures; (2) staffing and assignment changes; (3) additional education or training for staff; (4) addition or deletion of services. D. The agency develops a system to utilize its collected data regarding the outcome of its activities for delivering continuously improving services. E. Formal and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices. F. The agency collects and maintains information necessary to plan, manage, and evaluate its programs effectively. The outcomes are evaluated on a quarterly basis, the results of which are used continuously to improve performance. G l and informal feedback from consumers of services and other collateral sources is aggregated and used to improve management strategies and service delivery practices. F. The agency collects and maintains information necessary to plan, manage, and evaluate its programs effectively. The outcomes are evaluated on a quarterly basis, the results of which are used continuously to improve performance. G. The agency implements and maintains ongoing utilization review processes. [7.20.11.20 NMAC - Rp 7 NMAC 20.11.20, 03/29/02] 7.20.11.21 LEGAL, REGULATORY, AND ACCREDITATION COMPLIANCE FOR PROGRAM OPERATION, INCLUDING HEALTH, SAFETY AND PHYSICAL PLANT REQUIREMENTS: A. The agency promotes and protects the health and safety of its clients, demonstrates compliance with all applicable laws and regulations, adheres to the requirements of its accrediting bodies, if any, and possesses all applicable licenses required by law and departmental policy. (1) License(s) required: The agency possesses a license(s) and complies with applicable licensing requirements for each service required by state and local law and departmental regulation including, but not limited to the following: (a) Each treatment foster care child placement agency is licensed by the protective services division of the department as a child placement agency. (b) All residential facilities are licensed by the department. Each maintains a separate license. (c) Day treatment services are licensed as day treatment centers by the department. Each day treatment services facility maintains a separate license. Exception: day treatment services provided in a public school facility do not require licensure by the department. (2) Residential treatment services and group home services are certified only when provided in a facility licensed by the LCA for 16 beds or fewer per unit. B. An agency accredited by an accrediting organization recognized by the LCA complies with the current requirements of the accrediting organization tment services provided in a public school facility do not require licensure by the department. (2) Residential treatment services and group home services are certified only when provided in a facility licensed by the LCA for 16 beds or fewer per unit. B. An agency accredited by an accrediting organization recognized by the LCA complies with the current requirements of the accrediting organization. The accrediting organizations recognized by the LCA are: 7.20.11 NMAC 20 (1) Council on accreditation for children and family services (COA); (2) Joint commission on accreditation of healthcare organizations (JCAHO); and (3) Council on accreditation of rehabilitation facilities (CARF).