(a) The governing body in accordance with State Statute 35-2-910, shall ensure there is an effective, on-going, facility-wide, written quality improvement program which ensures and evaluates the quality of the patient care provided and includes:
(b) The taking and documentation of appropriate remedial action to address deficiencies found through the quality assurance program, as well as documentation of the outcome of remedial action.
048-14 Wyo. Code R. § 14-15