Pa. Code 5320.71

Quality improvement program

Providers must maintain a written quality improvement (QI) plan and program, reviewed by the program director, that monitors service quality and compliance with treatment and care standards. The plan must specify responsibilities, reporting structures, review frequency, and critical indicators—including resident and family satisfaction, treatment plan appropriateness, crisis event reviews, staff performance, clinical peer reviews, medication management, and documentation. This section is part of a chapter governing community support programs licensed by Pennsylvania's OMHSAS.

55 Pa. Code § 5320.71 - Quality improvement program 

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The provider shall have a written quality improvement
 (QI) plan and program that the program director reviews for the quality and
 appropriateness of services provided and monitors for compliance with standards
 of treatment and care. The plan shall:

(1)
 Specify who has responsibility for QI
 activities, to whom findings are reported, the frequency of reviews, what
 critical indicators are to be evaluated and acceptable levels for the critical
 indicators.

(2)
 Have indicators of
 quality care that include at least the following: 
 
(i)
 The level of resident satisfaction and
 program input.

(ii)
 The level of
 family satisfaction and program input.

(iii)
 Appropriateness, completeness,
 timeliness and implementation of the treatment plans.

(iv)
 Case and trend review of crisis events
 and unusual situations.

(v)

 Direct-care staff performance.

(vi)

 Clinical case or peer reviews, quarterly or more often as indicated.

(vii)
 Medications management, including
 errors and adverse effects.

(viii)

 The appropriate documentation in the resident's record.

(3)
 Include the names of the individuals who
 participated in the quality improvement activities and plans of
 correction.

Notes

55

 Pa. Code §
 
5320.71

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