(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;

   1. (iii) Client satisfaction;

      1. (iv) A quarterly record review to minimally assess quality of services delivered;
      2. (v) Appropriateness of services;
      3. (vi) Patterns of service utilization;
      4. (vii) Clients, relevant to their:

(b) (b) Active involvement in making informed choices regarding the services he or she receives;

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

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

(b) (b) Client input;

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

   1. (xi) That services are documented as prescribed by policy; and

      1. (xii) That the treatment plan is reviewed and updated as prescribed by policy;
   2. (B) Clinical privileging;

   3. (C) 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 client and other outcomes; and
      3. (iii) Monitoring client records to ensure documented dates of services provided coincide with billed service encounters; and

   4. (D) Review of critical incident reports and client grievances or complaints.

      1. (d)
2. (1) The crisis stabilization unit shall monitor the implementation of the performance improvement plan on an ongoing basis and make adjustments as needed.

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

   1. (A) The governing authority;
   2. (B) Crisis stabilization unit staff; and
   3. (C) The Department of Human Services, if and when requested.