a) The licensee shall ensure that the facility's executive director and the governing body develop, implement and maintain a data-driven quality assessment and performance improvement (QAPI) program. The program shall emphasize quality structures, processes and activities, with a goal of improved behavioral health outcomes that enable consumers to transition to the most integrated community-based settings possible. The written program shall be updated annually and shall require the following:

1. 1) An ongoing program for quality improvement and consumer safety as a priority for facility management that is communicated throughout the facility;
2. 2) A quality improvement committee that shall regularly review and evaluate all QAPI activities and progress;
3. 3) At all levels of service in a facility, the priorities for improved quality of care and consumer safety are identified and addressed, and all improvement actions are evaluated for efficacy;
4. 4) Written benchmarks, targets and standards of care for safety and quality of care that, for each indicator, shall be well established and communicated throughout the facility. Outcomes shall be regularly reviewed to measure them against the benchmarks and targets;
5. 5) The allocation of adequate resources for measuring, assessing, improving and sustaining the facility's performance in complying with the Act and this Part;
6. 6) A method for investigating, monitoring and tracking incidents and accidents, with a written action plan to prevent reoccurrences;
7. 7) That the facility share the results of the QAPI activities with the consumer's advisory council. Results of data collections and performance improvement projects (PIPs) shall be shared with the consumers' advisory council, and input and recommendations from the consumers' advisory council shall be shared with the governing body;
8. 8) A method for conducting annual PIPs, with the report of the PIP and recommendations for process improvements shared with the executive director and the governing body; and
9. 9) A data collection and reporting process that assures the submission, at least quarterly, of all reports or other required data within prescribed time frames.

b) Quality improvement indicators for triage, crisis stabilization, transitional living and rehabilitation and recovery services shall include, at a minimum:

1. 1) Verification that prior-authorizations and re-authorizations were secured as applicable for appropriate care and service delivery;
2. 2) Verification that assessments and treatment plans have been conducted to meet consumer needs;
3. 3) Verification that evidence-based practices and person-centered treatment plans are being performed to meet consumer needs as applicable;
4. 4) Verification that appropriate licensed and certified IDT professionals are performing duties as required;
5. 5) Verification that planning and community linkage has occurred to facilitate consumer-community integration;
6. 6) Verification that care coordination and case management systems are in place to achieve quality treatment outcomes and community integration;
7. 7) Verification that facility policy and procedures are established, documented, implemented and evaluated;
8. 8) Verification that consumer records contain all relevant information, including, but not limited to, demographic information, historical information, medical information, nutrition and dietary information, social information, psycho-social information, treatment plans, therapy information, assessments, discharge plans, and community support services; and
9. 9) Verification of training to the administration, to the supervisory staff, and to the direct care staff.

c) The quality improvement committee shall:

1. 1) Review all performance indicators, data from consumer quality of life surveys, staff surveys, findings from root cause analyses, performance improvement projects, and other relevant sources of data. The quality improvement committee shall make recommendations to the facility leadership and governing body based on the facility's performance of the indicators in subsection (b). The quality improvement committee shall be composed of members of the facility management team. Procedures for the operation of the quality improvement committee shall be included in the written QAPI program plan; and
2. 2) Conduct a root cause analysis when an in-depth understanding is needed of an incident or accident, or a violation, in the facility, including its causes and implications. The quality improvement committee shall develop policies and procedures for the use of root cause analyses to examine issues across systems in the facility to prevent future serious incidents and accidents and violations, and to promote sustained improvement. The findings of root cause analyses shall be available to the Department, DHS-DMH and the Department of Healthcare and Family Services upon request.