55 Pa. Code § 2800.26 – Quality management.

(a) The residence shall establish and implement a quality management plan.
(b) The quality management plan must address the periodic review and evaluation of the following, to assure compliance with law and with the relevant standard of care:
1. (1) The reportable incident and condition reporting procedures.
2. (2) Complaint procedures.
3. (3) Staff person training.
4. (4) Licensing violations and plans of correction, if applicable.
5. (5) Resident or family councils, or both, if applicable.
(c) The quality management plan must include the development and implementation of measures to address the areas needing improvement that are identified during the periodic review and evaluation.