Authority: IC 12-21-2-3; IC 12-25-1-2; IC 12-25-1-4

Affected: IC 12-25

Sec. 3. (a) The facility shall establish a planned, systematic, and organizational approach to process design, performance, analysis, and improvement. The plan must be interdisciplinary and involve all areas of the facility. Performance expectations shall be established, measured, aggregated, and analyzed on an ongoing basis, comparing performance over time and with other sources. Through this process, the facility identifies changes that will lead to improved performance that is achieved, is sustained, and reduces the risk of sentinel events.

(b) The process analyzes and makes necessary improvements to the following:

1. (1) All services, including the services of any contractor.

2. (2) All functions, including, but not limited to, the following:

   1. (A) Discharge and transfer.
   2. (B) Infection control.
   3. (C) Medication use.
   4. (D) Response to emergencies.
   5. (E) Restraint and seclusion.
   6. (F) Consumer injury.
   7. (G) Staff injury.
   8. (H) Any other areas that are high-risk, problem prone, or high volume incidents.
3. (3) All medical and treatment services performed in the facility with regard to appropriateness of diagnosis and treatments related to a standard of care and anticipated or expected outcomes.

(c) The facility shall take appropriate action to address the opportunities for improvement found through the quality assessment and improvement plan and shall ensure the following:

1. (1) The action shall be documented.
2. (2) The outcome of the action shall be documented as to the action's effectiveness, continued follow-up, and the impact on consumer care.

(Division of Mental Health and Addiction; 440 IAC 1.5-3-3; filed Oct 11, 2002, 11:26 a.m.: 26 IR 739; filed Aug 11, 2008, 3:40 p.m.: 20080910-IR-440070875FRA; readopted filed Nov 5, 2008, 3:50 p.m.: 20081119-IR-440080742RFA; readopted filed Aug 11, 2014, 11:21 a.m.: 20140910-IR-440140240RFA; readopted filed Nov 9, 2020, 3:09 p.m.: 20201209-IR- 440200502RFA)