8009.1 Each provider shall establish and adhere to policies and procedures governing quality improvement (“Quality Improvement Policy”).

8009.2 The Quality Improvement Policy shall require the provider to adopt a written quality improvement (“QI”) plan describing the objectives and scope of its QI program and require provider staff, individual, and family involvement in the QI program.

8009.3 The Department shall review and approve each provider’s QI program at a minimum as part of the certification and recertification process. The QI program shall submit data to the Department upon request.

8009.4 The QI program shall be directed by a coordinator (“QI Coordinator”) who has direct access to the Program Director. In addition to directing the QI program’s activities as detailed in § 8009.5, the QI Coordinator shall also review unusual incidents, deaths, and other sentinel events; monitor and review utilization patterns; and track individuals’ complaints and grievances. The QI Coordinator shall be:

1. (a) A Physician;
2. (b) A Psychologist;
3. (c) A Licensed Independent Clinical Social Worker (“LICSW”);
4. (d) An Advanced Practice Registered Nurse (“APRN”);
5. (e) A Licensed Professional Counselor (“LPC”);
6. (f) A Licensed Marriage and Family Therapist (“LMFT”);
7. (g) A Registered Nurse (“RN”);
8. (h) A Licensed Independent Social Worker (“LISW”);
9. (i) A Licensed Graduate Professional Counselor (“LGPC”);
10. (j) A Licensed Graduate Social Worker (“LGSW”);
11. (k) A Certified Addiction Counselor (“CAC”) I or II;

12. (l) A Physician Assistant (“PA”); or

13. (m) An individual with a Bachelors' Degree and a minimum of two (2) years of relevant, qualifying experience, such as experience in behavioral health care delivery or health care quality improvement initiatives.8009.5 The QI program shall be operational and shall measure and ensure at least the following:- (a) Easy and timely access and availability of services;

14. (b) Close monitoring and review of high volume or repeat utilizers of behavioral health stabilization services;
15. (c) Coordination of care with Core Service Agencies ('CSAs'), Assertive Community Treatment ('ACT') providers, Community Based Intervention ('CBI') providers, Clubhouse providers, and/or substance use treatment and recovery provider, when applicable;
16. (d) Compliance with all certification standards;
17. (e) Adequacy, appropriateness, and quality of care for individuals in the program;
18. (f) Efficient utilization of resources;
19. (g) Individual and family satisfaction with services; and
20. (h) Any other indicators that are part of the Department QI program for the larger system.8009.6 When the provider identifies a significant problem or quality of service issue, the provider shall notify the Department, act to correct the problem or improve the effectiveness of service delivery, or both, and shall assess corrective or supportive actions through continued monitoring.

SOURCE: Final Rulemaking published at 68 DCR 1623 (February 5, 2021).