Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 53 - Level III Crisis Receiving Centers
Subchapter D - Provider Operations
Section I-5351 - Quality Improvement Plan
Universal Citation: LA Admin Code I-5351
Current through Register Vol. 50, No. 9, September 20, 2024
A. A CRC shall have a quality improvement (QI) plan that:
1. assures that the overall function of the
center is in compliance with federal, state, and local laws;
2. is meeting the needs of the citizens of
the area;
3. is attaining the goals
and objectives established in the center's mission statement;
4. maintains systems to effectively identify
issues that require quality monitoring, remediation and improvement
activities;
5. improves individual
outcomes and individual satisfaction;
6. includes plans of action to correct
identified issues that:
a. monitor the effects
of implemented changes; and
b.
result in revisions to the action plan;
7. is updated on an ongoing basis to reflect
changes, corrections and other modifications.
B. The QI plan shall include:
1. a sample review of client case records on
a quarterly basis to ensure that:
a.
individual treatment plans are up to date;
b. records are accurate, complete and
current; and
c. the treatment plans
have been developed and implemented as ordered;
2. a process for identifying on a quarterly
basis the risk factors that affect or may affect the health, safety and/or
welfare of the clients that includes, but is not limited to:
a. review and resolution of
grievances;
b. incidents resulting
in harm to client or elopement;
c.
allegations of abuse, neglect and exploitation; and
d. seclusion and restraint;
3. a process to correct problems
identified and track improvements; and
4. a process of improvement to identify or
trigger further opportunities for improvement.
C. The QI plan shall establish and implement an internal evaluation procedure to:
1.
collect necessary data to formulate a plan; and
2. hold quarterly staff committee meetings
comprised of at least three staff members, one of whom is the CRC manager,
nurse manager or clinical director, who evaluate the QI process and activities
on an ongoing basis.
D. The CRC shall maintain documentation of the most recent 12 months of the QI activity.
AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 28:2180.14.
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