Section 260.2500  Quality Assessment and Improvement

a)         The facility 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 and accessibility of care and services provided at the facility or under contract, including but not limited to:

A)        Admission of children appropriate to the capabilities of the facility;

B)        Family satisfaction survey;

C)        Clinical costs per day;

D)        Infection control and safety; and

E)        Medication administration.

2)         Identification and analysis of safety event reporting; and

3)         Identification of serious safety events and implementation of corrective action plan within 30 days after the event.

b)         The quality assessment and improvement program shall operate pursuant to a written plan supported by detailed policies and procedures, which shall include, but not be limited to:

1)         A detailed statement of goals and objectives;

2)         The methodology and criteria that will be used to meet each stated goal;

3)         The action plans for addressing problems;

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

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

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

c)         The facility shall report to the Department, no later than 5 p.m. the next business day, any serious incident or accident involving a child.  The report shall include the name of the child, a description of the incident or accident, and the date and time of the incident or accident.  Incidents or accidents include, but are not limited to:

1)         A serious injury to a child, including while in a restraint;

2)         A serious medication error resulting in medical intervention or hospitalization; or

3)         A child's death while the child is a resident in the facility.

d)         The facility shall afford the Department and the Board access to any materials or documents generated pursuant to the facility's quality assessment and improvement program or that otherwise relate to client demand, utilization and satisfaction; cost effectiveness; financial viability of the facility; and access to services.

(Source:  Amended at 45 Ill. Reg. 13925, effective October 25, 2021)