105 CMR, § 164.038
The Licensed or Approved Provider shall implement an evaluation plan that enables it to measure progress toward the achievement of its established goals and objectives. The evaluation plan shall be prepared annually by the Licensed or Approved Provider and reviewed with the governing body. The plan shall address methods for reviewing appropriateness of patient or resident care, utilization of service components, methods for achieving compliance with the federal and state disability laws, and other data and information necessary for analyzing and improving the efficiency and effectiveness of program services. The Licensed or Approved Provider shall designate the individual(s) responsible for completing the evaluation plan, and shall document the application of the evaluation findings to its efforts to improve program services.
105 CMR, § 164.038