(i) The facility shall have an active quality improvement program to ensure
effective utilization and delivery of resident care services.
(A) A member of the facility’s staff shall be designated to coordinate
the quality improvement program.
(B) The quality improvement program shall encompass a review of all
services and programs provided for all residents. The program shall have:
(I) A written description;
(II) Problem areas identified;
(III) Monitor identification;
(IV) Frequency of monitoring;
(V) A provision requiring the facility to complete annually a
self assessment survey of compliance with the regulations; and
(VI) A satisfaction survey shall be provided to the resident,
resident’s family, or resident’s responsible party at least annually.
(C) Problems identified during the annual survey or the quality
improvement process shall be addressed with appropriate written corrective actions.
(D) The quality improvement program shall be re-evaluated at least