(1) Each outpatient crisis response facility shall implement and maintain an active quality assessment program using information collected to make improvements in the facility's policies, procedures and services. At a minimum, the program must include procedures for:

(a) conducting client satisfaction surveys, at least annually;

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

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

(2) Each crisis response facility shall prepare and maintain on file an annual report of improvements made as a result of the quality assessment program.