Sec. 10.34.35.08. Performance Improvement Program

A. The performance improvement program shall consist of:

(1) A committee which:

(a) Consists of representation of personnel and varied areas of job responsibility; and

(b) Is responsible for analysis of data, reporting trends and corrective actions; and

(c) Meets at least quarterly;

(2) Quality assurance and performance improvement monitoring parameters;

(3) Documentation requirements for:

(a) Established monitoring parameters;

(b) Trend analyses; and

(c) Retention of committee meeting minutes for 3 years;

(5) Documentation of tracking, trending, analyzing, resolving, and developing corrective action plans as appropriate for:

(a) Medication errors;

(b) Adverse drug reactions; and

(c) Equipment malfunctions;

(6) Reporting of adverse events to regulatory and standard-setting bodies as applicable to State and federal regulations;

(7) Documentation and resolution of patient care issues involving:

(a) Incorrect equipment, supplies, or medications;

(b) Delays in delivery of care;

(c) Missed doses;

(d) Patient infections;

(e) Failures in after-hours care; and

(f) Patient, caregiver, or health care provider complaints;

(8) Documentation of patient outcomes;

(9) Recall management;

(10) Patient compliance monitoring; and

(11) Staff training and competency compliance.

B. The permit holder shall review the performance improvement program at a minimum of every 3 years.