55 Pa. Code § 52.24 – Quality management.

(a) The provider shall create and implement a QMP to ensure the provider meets the requirements of this chapter and Chapter 1101 (relating to general provisions).
(b) The QMP must contain at least the following:
1. (1) Measureable goals to ensure compliance with this chapter, Chapter 1101 and other chapters in this title under which the provider is licensed.
2. (2) Data-driven outcomes to achieve compliance with this chapter, Chapter 1101 and other chapters in this title which the provider is licensed.
3. (3) The current Department-approved CAP, if the provider has a CAP.
(c) The provider may add additional items to the QMP to address self-identified areas of quality improvement.
(d) The QMP must be updated at least annually by the provider.
(e) The Department may request a provider to update the provider’s QMP if the provider receives a CAP.
(f) The provider shall submit a copy of the QMP to the Department upon request.