Section 220.3100  Quality Assessment and Improvement

a)         The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following goals:

1)         Ongoing monitoring and evaluation of the quality of services provided by the program, including but not limited to:

A)        Accomplishment of outcome goals;

B)        Accomplishment of program goals;

C)        Participant satisfaction; and

D)        Quality of life.

2)         Routine review of quality indicators to ensure identification of problem areas.

3)         Identification and implementation of corrective action to address problem areas.

b)         The licensee shall have a written quality assessment plan, which shall include but is not limited to:

1)         A statement of its mission and philosophy;

2)         A statement of its goals;

3)         Measurable objectives; and

4)         Identification of the persons responsible for administering the program.

c)         The Department and the Board shall have access to any materials or documents generated pursuant to the facility's quality assessment and improvement or that pertain to utilization and satisfaction, and financial viability of the facility.  Such information shall be used by the Department and the Board to evaluate and assess the facility in relation to the requirements of the Act and shall be confidential.