Each applicant/provider must establish, maintain, and document a quality improvement program, to include:

1. (1) Evidence-based practices;

2. (2)

   1. (A) Use of agency-wide outcome measures to improve both client care and clinical practice that are approved by the agency’s national accrediting organization.

   2. (B) The following must be documented:

      1. (i) Measured outcomes;
      2. (ii) Sample report; and
      3. (iii) Collection of outcomes, beginning at the initial mental health diagnosis service, which would be completed very close to the client’s intake;
3. (3) Requirements for informing all clients and clients’ responsible parties of the client’s rights while accessing services; and

4. (4) Regular (at least quarterly) quality assurance meetings that include:

   1. (A)

      1. (i) Clinical record reviews.
      2. (ii) Medical record reviews of a minimum number of randomly selected charts.
      3. (iii) The minimum number is the lesser of a statistically valid sample yielding ninety-five percent (95%) confidence with a five percent (5%) margin of error, or ten percent (10%) of all charts open at any time during the past three (3) months; and

   2. (B) Program and services reviews that:

      1. (i) Assess and document whether care and services meet client needs;
      2. (ii) Identify unmet behavioral health needs; and
      3. (iii) Establish and implement plans to address unmet needs.