Section 300.7070   Quality Assessment and Improvement

The unit shall have a written plan that is part of the facility's overall quality assurance plan to assess residents' quality of care, quality of life, and overall well-being.

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 care and service provided at the facility, including, but not limited to:

A)        Admission of residents who are appropriate to the capabilities of the facility;

B)        Resident assessment;

C)        Development and implementation of appropriate individualized, ability-centered treatment plans;

D)        Resident satisfaction;

E)        Infection control;

F)         Appropriate numbers of staff; and

G)        Staff turnover.

2)         Identification and analysis of problems.

3)         Identification and implementation of corrective action or changes in response to problems.

b)         The program shall operate pursuant to a written plan that shall include, but not be limited to:

1)         A detailed statement of how problems will be identified, including procedures to elicit insights from residents, residents' families, and residents' representatives;

2)         The methodology and criteria that will be used to formulate action plans to address problems, which shall include the insights of residents, residents' families, and residents' representatives;

3)         Procedures for evaluating the effectiveness of action plans and revising action plans to prevent reoccurrence of problems;

4)         Procedures for documenting the activities of the program; and

5)         Identifying the persons responsible for administering the program.

c)         A copy of the plan shall be provided to residents, residents' families, or residents' representatives.

(Source:  Added at 28 Ill. Reg. 14623, effective October 20, 2004)