(c) There shall be an annual written plan for performance improvement activities. The plan shall include, but not be limited to:

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

   1. (A) Efficiency;
   2. (B) Effectiveness; and
   3. (C) Client satisfaction;

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

   1. (A) Quality of services delivered;
   2. (B) Appropriateness of services;
   3. (C) Patterns of service utilization;
   4. (D) Clients, relevant to their:

(i) Orientation to the therapeutic community and services being provided; and

1. (ii) Active involvement in making informed choices regarding the services they receive;

   1. (E) The client assessment information thoroughness, timeliness, and completeness;

   2. (F) Treatment goals and objectives are based on:

      1. (i) Assessment findings; and
      2. (ii) Client input;
   3. (G) Services provided were related to the goals and objectives;
   4. (H) Services are documented as prescribed by policy; and
   5. (I) The treatment plan is reviewed and updated as prescribed by policy;
2. (3) Clinical privileging;

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

   1. (A) An annual budget that is:

      1. (i) Approved by the governing authority; and
      2. (ii) Reviewed at least annually;
   2. (B) The organization's capacity to generate needed revenue to produce desired client and other outcomes; and
   3. (C) Monitoring client records to ensure documented dates of services provided coincide with billed service encounters; and

4. (5) Review of:

   1. (A) Critical incident reports; and

   2. (B) Client grievances or complaints.

      1. (d) The therapeutic community shall:
5. (1) Monitor the implementation of the performance improvement plan on an ongoing basis; and
6. (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) Therapeutic community staff; and
3. (3) The Department of Human Services, if and when requested.