Sec. 10.22.02.14. Quality Assurance

A. The licensee shall submit a quality assurance plan and any subsequent substantive changes to the plan to the Administration for approval.

B. The licensee shall develop and implement a system of internal quality assurance which at a minimum:

(1) Is focused on the individual's choices, preferences, and satisfaction, and includes personal contact with the individuals being served;

(2) Has outcomes and results that are measurable and may be incorporated into future IPs for the individuals being served;

(3) Has outcomes and results that are measurable and may be incorporated into systemic changes in a licensee's operation;

(4) Collects and evaluates data and analyzes trends identified through quality assurance activities including:

(a) The name of the individual with a behavior plan,

(b) The medication or other restrictive technique used,

(c) The date and time the restrictive technique was used,

(d) Whether the medication or other restrictive technique was used as an emergency or as part of a behavior plan, and

(e) Whether the medication or other restrictive technique used is meeting the goals and objectives established in the behavior plan;

(5) Provides for prompt and appropriate response when an individual's health or safety is at risk; and

(6) Includes proactive strategies to improve the quality of services, including health and safety.

C. The licensee shall:

(1) Establish goals and standards to measure the quality of services being delivered and define how the standards are measured;

(2) Maintain records to demonstrate the effectiveness of its quality assurance activities;

(3) Implement changes based on the results of the evaluated data; and

(4) Be held accountable by the Administration for accomplishing the goals and standards that are established as part of the licensee's system of quality assurance.

D. The Administration may request documentation from a licensee to verify that the licensee is accomplishing the goals and standards set forth in the licensee's quality assurance plan.

E. Standing Committees.

(1) The licensee shall establish a committee or committees to perform the following functions:

(a) Perform the quality assurance functions set forth in this regulation;

(b) Review the licensee's protocol for identifying, reporting, documenting, investigating, and reviewing of incidents to ensure compliance with Administration procedures;

(c) Monitor whether the licensee's protocol identified in §E(2) of this regulation is being properly implemented by reviewing all incidents in an effort to identify deficient practices and recommend necessary corrective action;

(d) Approve all behavior plans which use restrictive techniques to ensure that the behavior plan complies with the requirements of COMAR 10.22.04.03A and 10.22.10;

(e) Review, approve, and establish the time frame for the restriction of a right if it is not related to a challenging behavior, in accordance with COMAR 10.22.04.03A; and

(f) Review the licensee's policies and procedures, and implementation of them, to ensure that they adequately protect the legal and human rights of each individual served by the licensee.

(2) The committee or committees may be organized to perform the functions set forth in §A of this regulation for one or more licensees.

(3) The committee or committees shall include an equal number of licensee staff, and individuals, proponents, or members of the community who are not employed by the licensee. For a committee member who is remunerated only to serve as a member of the committee, that member is not counted as staff or as a member of the community.

(4) The committee or committees may consult with a licensed health professional such as a psychologist, physician, physician's assistant, nurse practitioner, or board-certified clinical pharmacist, as needed.

(5) A committee member may not participate in the decision making process of any:

(a) Incident in which the committee member was involved; or

(b) Behavior plan the committee member has developed.

(6) The committee or committees shall meet as needed to perform the functions identified in §E(1) of this regulation, with, at least, a majority of members present.

(7) The committee or committees shall ensure confidentiality for the individual in accordance with Health-General Article, §7-1010, Annotated Code of Maryland.