Current through Register Vol. 56, No. 18, September 16, 2024
(a) Each psychiatric
community home for children shall maintain an ongoing and systematic process to
monitor and evaluate important aspects of care with participation by all levels of
staff. This process shall be written and referred to as the QA plan.
1. The QA plan shall describe outcome indicators,
evaluation criteria and procedures for monitoring problem correction.
2. The QA plan shall include the review of open
and closed records to evaluate the quality and appropriateness of treatment and
compliance with documentation requirements.
3. The QA plan shall describe the process,
frequency and criteria for case selection.
4. The QA plan shall identify the persons
responsible for QA activities and the administrative structure for QA oversight and
implementation.
(b) Each QA
plan shall include a risk management (RM) component, which shall address areas that
are deemed to be high risk, high volume or problem prone. The RM component shall
include, but is not limited to:
1. The monitoring
of the home's or agency's policies and procedures regarding the use of medication
and restrictive behavior management practices;
2. The monitoring of life/safety aspects of the
program site;
3. An incident review and
reporting procedure that will allow for the analysis of client and staff incidents
to identify patterns and trends or opportunities to improve client care, staff
safety and to reduce agency liability risks;
4. Development of an infection control policy and
monitoring of the implementation of the policy; and
5. The review and process to address client
complaints, grievances and suggestions.
(c) Each QA plan shall include a utilization
review (UR) component, which shall review the appropriateness of admissions and
continued stays in a program. The UR component shall include, but not be limited to:
1. Written criteria developed for admission and
continued stays for each program service;
2. Written criteria developed for the processing
of inappropriate admissions and continued stays. This shall include a description of
the process to appropriately terminate or transfer clients meeting the criteria of
inappropriate admission and continued stays;
3. Criteria developed to assess the length of
stay, using professionally accepted clinical treatment norms and the treatment
philosophy of the home or agency; and
4.
Documenting the reasons in the client's record for continued service for a client
who exceeds the identified length of stay.
(d) The QA plan shall be reviewed and evaluated
for effectiveness on an annual basis.
