a) The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following goals:

1. 1) Ongoing monitoring and evaluation of the quality and accessibility of care and services provided at the facility or under contract, including but not limited to:

   1. A) Admission of patients appropriate to the capabilities of the facility;
   2. B) Patient assessment;
   3. C) Development and implementation of appropriate comprehensive care plans;
   4. D) Patient satisfaction;
   5. E) Costs for delivery of services; and
   6. F) Infection control.
2. 2) Identification and analysis of problems.
3. 3) Identification and implementation of corrective action or changes in response to problems.

b) The program shall operate pursuant to a written plan, which shall include, but not be limited to:

1. 1) A detailed statement of its goals;
2. 2) The methodology and criteria that will be used to meet each stated goal;
3. 3) The action plans for addressing problems;
4. 4) Procedures for evaluating the effectiveness of action plans and revising action plans to prevent reoccurrence of problems;
5. 5) Procedures for documenting the activities of the program; and
6. 6) Identifying the persons responsible for administering the program.