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Title: Section 759.12 - Quality assessment and assurance

Effective Date


759.12  Quality assessment and assurance. The facility shall establish and maintain a coordinated quality assessment and assurance program that integrates the review activities of facility services to enhance the quality of life and registrant care and treatment.

(a) Facility-wide quality assurance. Quality assurance shall be the responsibility of all staff, at every level, at all times. Supervisory personnel alone cannot ensure quality of care and services. Such quality must be a part of each individual's approach to his or her daily responsibilities.

(b) Quality assessment and assurance committee. The facility shall maintain a quality assessment and assurance committee consisting of at least the following:

(1) the program director;

(2) the licensed master social worker;

(3) a registered nurse designated by the facility;

(4) at least three other members of facility staff.

(c) Committee functions. The quality assessment and assurance committee shall:

(1) meet at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary;

(2) have a written plan for the quality assessment and assurance program which describes the program's objectives, organization, responsibilities of all participants, scope of the program, procedures for overseeing the effectiveness of monitoring, assessing and problem-solving activities. Such plan shall also provide for the development and implementation of quality improvement initiatives designed to advance the quality of life, care and services in the facility;

(3) define methods for identification and selection of clinical and administrative problems to be reviewed. The process shall include but not be limited to:

(i) the establishment of review criteria developed in accordance with current standards of professional practice for monitoring and assessing registrant care and clinical performance;

(ii) regularly scheduled reviews of clinical records, resident complaints and suggestions, reported incidents and other documents pertinent to problem identification;

(iii) consultation, on at least a quarterly basis with the Consumer Advisory Board, to seek recommendations on quality improvements;

(iv) documentation of all quality assessment and assurance activities, including but not limited to, the findings, recommendations and actions taken to resolve identified problems; and

(v) the timely implementation of corrective actions and periodic assessments of the results of such actions;

(4) ensure that the outcomes of quality assurance reviews are shared with appropriate staff to be used for the revision or development of facility policies and practices and in granting or renewing staff privileges, as appropriate; and

(5) facilitate participation in the program by administrative staff and health-care professionals representing each professional service provided; and

(6) report its activities, findings and recommendations to the governing body as often as necessary, but no less than 4 times a year.






VOLUME E (Title 10)