Section R. 325.1924 - Reporting of incidents, quality review programRule 24.
(1) A home for the aged must implement and maintain a quality review program consistent with section 20175(8) of the act, MCL 333.20175, and the professional review function. The program is responsible for all of the following: (a) Reviewing and evaluating incidents.(b) Identifying effective means to correct any deficient practice.(c) Ensuring resident safety and quality of care.(d) Improving procedures.(2) The program must be reviewed annually by the administrator and governing body.(3) The program must be staffed by a multi-disciplinary team. The multi-disciplinary team shall consist of not less than 2 personnel that have training or experience with the type of the incident being evaluated.(4) The multi-disciplinary team shall meet not less than twice each calendar year or more frequently as needed to review an incident or incidents.(5) Records must be maintained that demonstrate incident reporting to the team, analyses, outcomes, corrective action taken, and evaluation to ensure that the expected outcome is achieved. These records must be maintained for 2 years.(6) The facility must have a policy and procedure to report an incident using a department approved form to the multi-disciplinary team responsible for the quality review program required under subrule (1) of this rule.(7) The facility must have a policy and procedure to ensure that an incident, once known by facility staff, is reported as soon as possible, but not later than 48 hours after the incident, to a resident's authorized representative or designated health care professional, as appropriate. Verbal or written notification must be documented in the resident's record to reflect the date, time, name of staff who made the notification, and name of the representative or professional who was notified.(8) If an elopement occurs, staff shall conduct a search to locate the resident. If the resident is not located within 30 minutes after the elopement occurred, staff shall comply with subrule (7) of this rule and contact the local police authority.(9) The department may review a quality review program during a renewal survey to confirm that a program is in place. During a complaint investigation, the licensee shall confirm if an incident was reviewed and if any corrective actions were taken, but the department shall not request any other case'specific information that was part of the quality review program. The department shall rely on other documents outside this professional review function as part of its investigation. The department shall maintain and protect these documents in accordance with state and federal laws, including privacy laws.Mich. Admin. Code R. 325.1924
2004 AACS; 2023 MR 6, Eff. 3/21/2023