West Virginia Code of State Rules
Agency 78 - Human Services
Title 78 - LEGISLATIVE RULE DEPARTMENT OF HUMAN SERVICES BUREAU FOR SOCIAL SERVICES
Series 78-03 - Minimum Licensing Requirements for Residential Child Care and Treatment Facilities for Children and Transitioning Adults and Vulnerable and Transitioning Youth Group Homes and Programs in West Virginia
Section 78-3-6 - Continuous Quality Improvement
Universal Citation: 78 WV Code of State Rules 78-3-6
Current through Register Vol. XLI, No. 38, September 20, 2024
6.1. The organization shall describe in policy and procedure a well-defined process for assessing and improving its overall performance regarding safety, quality, and case review and compliance and shall identify standards that will promote quality outcomes for persons served.
6.1.1.
The continuous quality improvement procedure shall be annually reviewed and
updated by senior management and the governing body. Organizations may
designate committees or individuals to carry out the continuous quality
improvement process.
6.2. Safety.
6.2.1. The organization shall conduct a
quarterly review of the use of service modalities or other organizational
practices that involve risk or limit freedom of choice.
6.2.2. The organization shall conduct a
documented, quarterly safety review of all facilities and buildings to ensure
the safety, cleanliness, and appropriateness of each service environment.
Outdoor facilities shall have a monitoring procedure that shall review at least
quarterly all program environments and processes for safety and
sanitation.
6.3. Case Review.
6.3.1. The organization shall conduct
a quarterly case review consisting of at least 10 percent of all open cases and
of cases closed that quarter, chosen using a generally accepted standardized
sampling methodology. Records from all program or unit sites shall be
sampled.
6.3.2. Employees who
conduct case reviews shall evaluate quality and the presence or absence of
required documents, and the clarity and continuity of the documents.
6.3.3. Written procedures for case review
shall ensure that workers do not review cases in which they have been directly
involved.
6.3.4. Based on the case
record review, the reviewer shall prepare a document summarizing case record
areas of non-compliance. The organization is responsible for documenting
follow-up on areas of non-compliances.
6.3.5. The organization shall document
efforts to remediate identified patterns of non- compliance through re-training
or increased supervision efforts.
6.4. Quality.
6.4.1. The organization shall have a process
that establishes standards and measures outcomes relative to those standards
for each of its facilities on an ongoing basis.
6.4.2. The organization shall analyze outcome
data at least annually as part of a self-assessment in order to determine
program effectiveness. Results of findings shall be presented to the governing
body.
6.4.3. The organization shall
have a systematic, documented method of assessing child satisfaction.
6.5. Feedback Mechanisms.
6.5.1. The organization shall submit annual
summary results of the safety, case review and quality evaluation processes to
the governing body.
6.5.2. The
organization shall annually provide the results of all reviews including annual
financial audits, accreditation reviews and licensing reviews to the governing
body.
6.5.3. The organization shall
use the findings of its continuous quality improvement processes to:
6.5.3.a. Identify problems or service
deficits;
6.5.3.b. Determine
possible causes when data reveal issues of concern;
6.5.3.c. Problem solve and develop plans to
correct areas of concern or deficit;
6.5.3.d. Implement and monitor the
effectiveness of corrective plans; and
6.5.3.e. Modify the corrective plans, as
necessary.
Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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