Pascal Bergeron
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A manager shall ensure that:
1. A plan is established, documented, and implemented for an ongoing quality management
program that, at a minimum, includes:
a. A method to identify, document, and evaluate incidents;
b. A method to collect data to evaluate services provided to residents;
c. A method to evaluate the data collected to identify a concern about the delivery
of services related to resident care;
d. A method to make changes or take action as a result of the identification of a
concern about the delivery of services related to resident care; and
e. The frequency of submitting a documented report required in subsection (2) to
the governing authority;
2. A documented report is submitted to the governing authority that includes:
a. An identification of each concern about the delivery of services related to
resident care, and
b. Any change made or action taken as a result of the identification of a concern
about the delivery of services related to resident care; and
3. The report required in subsection (2) and the supporting documentation for the report are
maintained for at least 12 months after the date the report is submitted to the governing
authority

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