Sec. 10.07.02.64. Quality Assurance Program

A. A nursing home shall establish an effective quality assurance program that includes components described in this regulation and Regulation .65 of this chapter.

B. The nursing home shall appoint a qualified individual to manage quality assurance activities within the nursing facility.

C. The nursing home shall establish a quality assurance committee that includes at least:

(1) The nursing home director of nursing;

(2) The nursing home administrator;

(3) A social worker;

(4) The nursing home medical director;

(5) A dietitian-nutritionist; and

(6) A geriatric nursing assistant at the nursing home.

D. The Quality Assurance Committee. The quality assurance committee shall:

(1) Designate an individual to oversee committee activities;

(2) Meet monthly to carry out quality assurance activities;

(3) Help develop and approve the nursing home’s quality assurance plan;

(4) Submit the quality assurance plan to the Department’s Office of Health Care Quality at the time of initial application for licensure;

(5) Submit any changes to the quality assurance plan to the Office of Health Care Quality within 30 days of the changes;

(6) Review and approve the facility's quality assurance plan at least yearly; and

(7) Prepare monthly reports for the ombudsman, family council, and residents' council.

E. Quality Assurance Records. For the purposes of ensuring implementation and effectiveness of the quality assurance program, the facility shall make quality assurance records and documents available to the Office of Health Care Quality.

F. Quality Assurance Committee - Non-members. Anyone not on the committee shall be informed of how to present and submit concerns to:

(1) The committee;

(2) A member of the resident council; or

(3) A member of the family council if one exists.