Section He-Hea 2102.10 - Quality Improvement Program(a) Each facility shall establish and maintain a comprehensive, ongoing, facility wide quality improvement program which involves assessment of all quality improvement activities conducted in the provision of its health care programs and services at all levels which includes no less than: (1) Establishment of standards and criteria for the assessment of the quality of health care services provided and the appropriateness of the resources utilized;(2) Assessment of outcomes;(3) Ongoing review of programs and services by physicians and other health professionals; and(4) A mechanism to assure the utilization of systematic data collection based on valid samples of the total patient population to measure performance and patient results, and to make recommendations to physicians and departments of needed changes.(b) Each facility shall establish and maintain a current and complete clinical record for every patient treated.(c) Each applicant currently operating a LTACH and those filing an application for additional services shall provide a copy of its quality improvement program which indicates how the existing and additional services comply with standards required by this section and:(1) JCAHO, if accredited;(4) Other accrediting body that has received deeming authority from CMS.(d) An applicant who does not currently provide LTACH services but files an application for a CON shall: (1) Develop the proposed quality improvement program in accordance with this section;(2) Include a copy of such plan in its application for a CON; and(3) Develop each service specified in such plan in accordance with: a. JCAHO, if accreditation will be sought;d. Other accrediting body that has received deeming authority from CMS.N.H. Admin. Code § He-Hea 2102.10