1. (a) The ALR-RC shall develop and implement a quality improvement program that reviews policies and services and maximizes quality by preventing or correcting identified problems.
2. (b) As part of its quality improvement program, a quality improvement committee shall be established.
3. (c) The ALR-RC shall determine the size and composition of the quality improvement committee based on the size of the facility and the care and services provided.

4. (d) The quality improvement committee shall:

   1. (1) Determine the information to be monitored:
   2. (2) Determine the frequency with which information will be reviewed;
   3. (3) Determine the indicators that will apply to the information being monitored;
   4. (4) Evaluate the information that is gathered;
   5. (5) Determine the action that is necessary to correct identified problems;
   6. (6) Recommend corrective actions to the ALR-RC; and
   7. (7) Evaluate the effectiveness of the corrective actions and determine additional corrective actions as applicable.
5. (e) The quality improvement committee shall meet at least quarterly.
6. (f) The quality improvement committee shall generate dated, written minutes after each meeting.
7. (g) Documentation of all quality improvement activities, including minutes of meetings, shall be maintained on-site for at least 2 years from the date the record was created.

Source. #12414, eff 11-3-17