- (1) The board members shall ensure that there is a well-defined quality improvement plan designed to improve patient care.
(2) The plan shall:
- (a) be consistent with the delivery of patient care;
- (b) be implemented and include a system for the collection of indicator data;
- (c) ensure that incident reports are available for department review;
- (d) implement actions designed to eliminate identified problems and improve patient care;
- (e) include a system for assessing identified problems, concerns, and opportunities for improvement of patient care; and
- (f) include an incident reporting system to identify problems, concerns, and opportunities for improvement of patient care.
(3)(a) The licensee shall maintain a quality improvement committee.
- (b) The quality improvement committee shall maintain written minutes documenting any corrective action and result and make these minutes available for department review.
- (4) The quality improvement committee shall report findings and concerns, at least quarterly, to the board, the medical staff, and the administrator.
- (5) The licensee shall ensure that infection reporting is integrated into the quality improvement plan and is reported to the department in accordance with Rule R386-702.
KEY: health care facilities
Date of Last Change: June 5, 2026
Notice of Continuation: August 22, 2025
Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203