1. (a) The licensee shall develop and maintain a quality improvement program that reviews policies and all care and services provided to patients and whose objectives shall be to reveal patterns and initiate action to provide an optimum quality of care for all patients.

2. (b) The quality improvement program shall include a quality improvement committee, which shall consist of:

   1. (1) The medical director;
   2. (2) The director of nursing;
   3. (3) A social worker;
   4. (4) A dietitian; and
   5. (5) At least one other direct care staff provider.

3. (c) The quality improvement committee shall:

   1. (1) Review within 24 hours:

      1. a. All patient cases where a medical emergency occurs; and
      2. b. Patient cases which require unexpected transfer to an acute care facility;
   2. (2) Determine the information to be monitored;
   3. (3) Determine the frequency with which the information will be reviewed;
   4. (4) Determine the indicators that will apply to the information being monitored;
   5. (5) Evaluate the information that is gathered;
   6. (6) Establish and implement a system for the monthly surveillance of dialysate water and reuse;
   7. (7) Review all reports of unexpected occurrences involving patients, personnel, or visitors;
   8. (8) Ensure that outside services such as laboratory services or water analysis are provided in accordance with federal and state laws and administrative rules;
   9. (9) Ensure that individuals with appropriate qualifications maintain medical equipment;
   10. (10) Determine the action that is necessary to correct identified problems;
   11. (11) Recommend corrective actions to the licensee;
   12. (12) Evaluate the effectiveness of the corrective actions;
   13. (13) Establish an ongoing program to determine performance improvement projects, to carry out interventions to mitigate quality issues and to audit corrective actions; and
   14. (14) Meet at least quarterly.
4. (d) Documentation of all quality improvement meetings shall be maintained on-site for at least 2 years.

Source. #9963, eff 7-28-11; ss by #12827, INTERIM, eff 7-20-19, EXPIRED: 1-16-20 New. #12985, eff 1-29-20; ss by #14206, eff 2-28-25 (formerly He-P 811.20)