(a) Each crisis residence program shall have an organized quality assurance program designed to enhance resident care through the ongoing objective assessment of important aspects of resident care and the correction of identified problems. The quality assurance program shall provide for the following:

1. (1) identification of problems or concerns related to the care of residents including, but not limited to resident engagement in crisis residential services;
2. (2) objective assessment of the cause and scope of the problems or concerns, including the determination of priorities for both investigating and resolving problems and concerns. Priorities shall be related to the degree of adverse impact on the care provided to residents that can be expected if the problems or concerns remain unresolved;
3. (3) recommendations related to implementation of decisions or actions that are designed to eliminate, insofar as possible, identified problems; and
4. (4) monitoring to assess whether or not the desired result has been achieved and sustained.

(b) Each crisis residence program shall prepare a written quality assurance plan designed to ensure that there is an ongoing quality assurance program that includes effective mechanisms for reviewing and evaluating resident care and provides for appropriate response to findings. This quality assurance plan shall be subject to approval by the Office of Mental Health. The quality assurance plan may be program-specific or part of an overall facility quality assurance plan. The written quality assurance plan shall address at a minimum:

1. (1) the individual or group with the overall responsibility to administer or coordinate the quality assurance program;
2. (2) the individuals or organizational entities to whom responsibility will be delegated for specific activities or mechanisms;
3. (3) the activities or mechanisms for reviewing and evaluating resident care;
4. (4) the activities or mechanisms for assuring the accountability of the clinical staff for the care they provide;
5. (5) the individuals or organizational entities to whom responsibility will be delegated for responding to findings or implementing corrective actions designed to eliminate, insofar as possible, identified problems;
6. (6) the activities or mechanisms for monitoring whether or not the corrective actions have been implemented, and whether or not the desired result has been achieved and sustained; and
7. (7) crisis residence programs shall develop and implement an incident management program in accordance with Part 524 of this Title.