1801. General (II).

A.There shall be a written, implemented quality improvement program that provides effective self-assessment and implementation of changes designed to improve the care/services provided by the facility.

B.The quality improvement program, as a minimum, shall:
1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is regularly,
systematically, and objectively accomplished;
2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;
3. Identify the action taken to correct deviations and prevent future deviation, and the person(s)
responsible for the implementation of these actions;
4. Analyze the appropriateness of ICP’s and the necessity of care/services rendered;
5. Analyze all incidents and accidents, including all medication errors and resident deaths;
6. Analyze any infection, epidemic outbreaks, or other unusual occurrences which threaten the health,
safety, or well-being of the residents;
7. Establish a systematic method of obtaining feedback from residents and other interested persons,
e.g., family members and peer organizations, as expressed by the level of satisfaction with care/services