Section 118-5-5 - Quality Management5.1Performance Improvement. All programs shall have documentation of a performance improvement program that is a component of the quality management program. Performance improvement activities include routine attention to addressing processes that directly affect clinical outcomes and client satisfaction, including welcoming complex populations, access to services, COD-C development, retention in services, and continuity of care. 5.1.1 Program performance improvement plans shall be developed with evidence of input from clients and other interested parties, and must include some specific activities that will be aligned with performance improvement priorities developed by OSA each year.5.1.2 The findings, and actions taken as a result of findings, shall be documented and the plan shall be revised in accordance with the findings.5.2Critical Incidents Policies. Specific policies and procedures shall govern the evaluation of critical incidents. Critical incidents shall include, but not necessarily be limited to, adverse or potentially adverse occurrences that imperil life, limb or well-being, that seriously breach agency policy, or that breach client rights. Such policies shall include at least the following: 5.2.1 documentation of the event, using the approved Critical Incident Reporting Form. The form is a written document that reflects an occurrence, unusual problem, incident, or deviation from standard practice or situation, that requires follow-up and may require investigation.5.2.2 a decision tree to evaluate for the need for follow-up actions and opportunities for improvements in program or agency management and service delivery;5.2.3 documentation of follow-up actions, including submission of the approved Critical Incident Reporting Form to the Licensing Authority and the Office of Substance Abuse.5.3Reports of Abuse, Neglect or Exploitation. The agency shall maintain a specific policy and procedure governing the reporting, recording and review of allegations of abuse, neglect or exploitation of persons receiving services, in accordance with applicable laws and rules, including but not limited to the child and adult protective statutes ( 22 M.R.S.A. §4001 et seq., and 22 M.R.S.A. §3470 et seq.). 5.3.1 The agency must immediately take action to keep clients safe and submit a critical incident report to OSA, according to OSA guidelines.5.3.2 The policy and procedure shall detail the specific personnel actions to be taken pending the outcome of the investigation and those to be taken at the conclusion of the investigation.5.4Grievances. The agency shall maintain a specific policy and procedure governing the reporting of grievances of persons receiving services, the procedural follow-up and response on the part of the agency to the person making the complaint, and the documentation of the process and outcome. 5.4.1 Agencies shall develop the policy in accordance with5.4.1.1 Section 18.5 of these regulations;5.4.1.2 State and Federal statutes;5.4.1.3 State and Federal rules.5.5Reports of Licensing Violations. The agency shall maintain a specific policy and procedure governing the reporting, recording and review of alleged licensing violations.