La. Admin. Code tit. 48 § I-8781

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-8781 - Quality Enhancement

A. An ABI facility shall develop, implement and maintain a quality enhancement (QE) plan that:

1. ensures that the facility is in compliance with federal, state, and local laws;

2. meets the needs of the facility's clients;

3. is attaining the goals and objectives established by the facility;

4. maintains systems to effectively identify issues that require quality monitoring, remediation and improvement activities;

5. improves individual client outcomes and individual client satisfaction;

6. includes plans of action to correct identified issues that:

a. monitor the effects of implemented changes; and

b. result in revisions to the action plan; and

7. is updated on an ongoing basis to reflect changes, corrections and other modifications.

B. The QE plan shall include:

1. a process for identifying on a quarterly basis the risk factors that affect or may affect the health, safety and/or welfare of the clients of the facility receiving services, that include, but is not limited to:

a. review and resolution of complaints;

b. review and resolution of incidents; and

c. incidents of abuse, neglect and exploitation;

2. a process to review and resolve individual client issues that are identified;

3. a process to review and develop action plans to resolve all system wide issues identified as a result of the processes above;

4. a process to correct problems that are identified through the program that actually or potentially affect the health and safety of the clients; and

5. a process of evaluation to identify or trigger further opportunities for improvement in identification of individual client care and service components.

C. The QE program shall hold bi-annual committee meetings to:

1. assess and choose which QE plan activities are necessary and set goals for the quarter;

2. evaluate the activities of the previous quarter; and

3. implement any changes that protect the clients from potential harm or injury.

D. The QE plan committee shall:

1. develop and implement the QE plan; and

2. report to the director any identified systemic problems.

E. The facility shall maintain documentation of the most recent 12 months of the QE plan.

La. Admin. Code tit. 48, § I-8781

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 432183 (11/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and 40:2120.31-40.