Sec. 10.21.17.12. Quality Management (QM)

A. A program shall establish and maintain a QM process in accordance with the requirements of this regulation.

B. QM Plan. The program director shall develop and, at least every 3 years, review a written QM plan that:

(1) Provides for an internal, ongoing quality performance evaluation process that describes the:

(a) Program goals; and

(b) Mechanisms, including staff responsible and resources available, for implementing the QM process;

(2) Is oriented to the individuals served and emphasizes recovery, collaboration, continuity of care, accessibility, accountability, and efficiency;

(3) Includes a system to evaluate:

(a) Quality of care and services rendered to individuals;

(b) Staff performance in the provision of the services;

(c) Staff competencies; and

(d) Appropriateness of the program's:

(i) Services, including accessibility and hours of operation;

(ii) Staff; and

(iii) If the program provides services in a facility, physical plant, and environment;

(4) Includes a process for the adequate collection of data in order to identify problems; and

(5) In order for staff to implement actions to correct deviations from the program's established standards, identifies a plan that:

(a) Is based on:

(i) The data collected under §B(4) of this regulation;

(ii) Input from staff and individuals served;

(iii) A review of the program's outcomes; and

(iv) Current trends in efficient and effective treatment and services;

(b) Is consistent with the program model and the specialized needs of those served; and

(c) Provides for ongoing internal review of the program, including monitoring for effectiveness of changes incorporated.

C. Risk Management (RM). The program director shall develop and, at least every 3 years, review a written RM plan, which may be a component of the QM plan, that:

(1) Includes policies and procedures for critical incidents, including:

(a) Suicides; and

(b) Unfavorable service-related outcomes, including discharges that are not mutually agreed upon;

(2) Includes a mechanism by which the program director reports:

(a) An allegation of mental, physical, or sexual abuse or neglect of an individual, as provided under Health-General Article, §10-705, and Family Law Article, Title 5, Subtitle 7, and Title 14, Annotated Code of Maryland; and

(b) The death of an individual, as outlined in Regulation .13 of this chapter; and

(3) Tracks and evaluates incidents reported under §C(1) and (2) of this regulation and complaints filed under Regulation .16 of this chapter to determine trends.

D. Program Service Outcomes. The program director shall:

(1) Comply with the outcome reporting requirements as determined by the Administration;

(2) Report data when required and as specified by the Administration;

(3) Conduct and analyze the results of an annual satisfaction survey of the program's consumers;

(4) Develop a process to inform the individuals served of the program's service outcomes; and

(5) Make programmatic changes as appropriate.