(a) The governing body, in accordance with W.S. 35-2-910, shall ensure there is an effective, on-going, facility-wide, written quality improvement program which ensures and evaluates the quality of patient care provided and includes an annual review of the following:
(b) The initiation and documentation of appropriate remedial action to address deficiencies found through the quality improvement program, as well as documentation of the outcome of remedial action.
048-17 Wyo. Code R. § 17-16