Current through Register Vol. XLI, No. 50, December 13, 2024
Section 78-3-6 - Continuous Quality Improvement6.1. The organization shall describe in policy and procedure a well-defined process for assessing and improving its overall performance regarding safety, quality, and case review and compliance and shall identify standards that will promote quality outcomes for persons served.6.1.1. The continuous quality improvement procedure shall be annually reviewed and updated by senior management and the governing body. Organizations may designate committees or individuals to carry out the continuous quality improvement process.6.2. Safety. 6.2.1. The organization shall conduct a quarterly review of the use of service modalities or other organizational practices that involve risk or limit freedom of choice.6.2.2. The organization shall conduct a documented, quarterly safety review of all facilities and buildings to ensure the safety, cleanliness, and appropriateness of each service environment. Outdoor facilities shall have a monitoring procedure that shall review at least quarterly all program environments and processes for safety and sanitation.6.3. Case Review.6.3.1. The organization shall conduct a quarterly case review consisting of at least 10 percent of all open cases and of cases closed that quarter, chosen using a generally accepted standardized sampling methodology. Records from all program or unit sites shall be sampled.6.3.2. Employees who conduct case reviews shall evaluate quality and the presence or absence of required documents, and the clarity and continuity of the documents.6.3.3. Written procedures for case review shall ensure that workers do not review cases in which they have been directly involved.6.3.4. Based on the case record review, the reviewer shall prepare a document summarizing case record areas of non-compliance. The organization is responsible for documenting follow-up on areas of non-compliances.6.3.5. The organization shall document efforts to remediate identified patterns of non- compliance through re-training or increased supervision efforts.6.4. Quality. 6.4.1. The organization shall have a process that establishes standards and measures outcomes relative to those standards for each of its facilities on an ongoing basis.6.4.2. The organization shall analyze outcome data at least annually as part of a self-assessment in order to determine program effectiveness. Results of findings shall be presented to the governing body.6.4.3. The organization shall have a systematic, documented method of assessing child satisfaction.6.5. Feedback Mechanisms. 6.5.1. The organization shall submit annual summary results of the safety, case review and quality evaluation processes to the governing body.6.5.2. The organization shall annually provide the results of all reviews including annual financial audits, accreditation reviews and licensing reviews to the governing body.6.5.3. The organization shall use the findings of its continuous quality improvement processes to: 6.5.3.a. Identify problems or service deficits;6.5.3.b. Determine possible causes when data reveal issues of concern;6.5.3.c. Problem solve and develop plans to correct areas of concern or deficit;6.5.3.d. Implement and monitor the effectiveness of corrective plans; and6.5.3.e. Modify the corrective plans, as necessary.