1. (1) The administrator shall develop and follow a well-defined quality assurance plan designed to improve resident care that:

   1. (a) implements a system to assess identified problems, concerns, and opportunities for improvement;
   2. (b) implements actions that are designed to eliminate identified problems and improve resident care;
   3. (c) includes a system for the collection of data indicators; and
   4. (d) includes an incident reporting system in accordance with Rule R380-600 to identify problems, concerns, and opportunities for improvement of resident care.

2. (2) The licensee shall ensure the quality assurance plan includes a quality assurance committee that functions as follows:

   1. (a) conducts quarterly meetings and reports findings, concerns and actions to the administrator and governing body;
   2. (b) coordinates input of data indicators from any provided services and other departments as determined by the resident's care plan and facility scope of services; and
   3. (c) documents committee meeting minutes including any corrective actions and results.

3. (3) The licensee shall ensure incident and accident reports:

   1. (a) are available for OL and quality assurance committee review;
   2. (b) are numbered and logged in a manner to account for each filed report; and
   3. (c) have space for written comments by the administrator or medical director.
4. (4) The licensee shall ensure infection reporting is integrated into the quality assurance plan and is reported to the department in accordance with Rule R386-702.

KEY: health care facilities

Date of Last Change: February 18, 2025

Notice of Continuation: January 24, 2022

Authorizing, and Implemented or Interpreted Law: 26B-2-202