(c)

1. (1) There shall be an annual written plan for performance improvement activities.

2. (2) The plan shall include, but not be limited to:

   1. (A) Outcomes management processes specific to each program component minimally measuring:

(i) Efficiency;

1. (ii) Effectiveness; and

   1. (iii) Beneficiary satisfaction;

   2. (B) A quarterly record review to minimally assess:

      1. (i) Quality of services delivered;
      2. (ii) Coordination with the Division of Children and Family Services and the Division of Youth Services, if appropriate;
      3. (iii) Appropriateness of services;
      4. (iv) Patterns of service utilization;
      5. (v) Beneficiaries, relevant to:

(b) (b) Their active involvement in making informed choices regarding the services they receive;

1. (vi) The beneficiary assessment information thoroughness, timeliness, and completeness;

   1. (vii) Treatment goals and objectives are based on:

(b) (b) Beneficiary input;

1. (viii) Services provided were related to the goals and objectives;

   1. (ix) Services are documented as prescribed by policy; and

      1. (x) The treatment plan is reviewed and updated as prescribed by policy;
   2. (C) Clinical privileging;

   3. (D) Fiscal management and planning, which shall include:

      1. (i) An annual budget that is approved by the governing authority and reviewed at least annually;
      2. (ii) The organization's capacity to generate needed revenue to produce desired beneficiary and other outcomes; and
      3. (iii) Monitoring beneficiary records to ensure documented dates of services provided coincide with billed service encounters; and

   4. (E) Review of critical incident reports and beneficiary grievances or complaints.

      1. (d) The residential community reintegration program shall:
2. (1) Monitor the implementation of the performance improvement plan on an ongoing basis; and
3. (2) Make adjustments as needed.

(e) Performance improvement findings shall be communicated and made available to, among others:

1. (1) The governing authority;
2. (2) Residential community reintegration program staff; and
3. (3) The Department of Human Services, if and when requested.