(1) The program must implement and maintain an active quality assessment program for improving policies, procedures, and services. At a minimum, the quality assessment program must include procedures for:

(a) conducting program participant satisfaction surveys at least annually which are maintained and filed at the program;

(b) maintaining records on the occurrence, duration, and frequency of physical restraints used; and

(c) reviewing, on an ongoing basis, serious incident reports, grievances, complaints, medication errors, and the use of physical restraints with special attention given to identifying patterns and making necessary changes in how services are provided.

(2) The program must prepare and maintain, on file, an annual report including improvements made as a result of the quality assessment activities specified in this rule.

 

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