(1) Each 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 patient satisfaction surveys, at least annually, for all facility programs. The survey must address:

(i) whether the patient, parent, or guardian is adequately involved in the development and review of the patient's treatment plan;

(ii) whether the patient, parent, or guardian was informed of patient's rights and the facility's grievance procedure;

(iii) the patient's, parent's, or guardian's satisfaction with all facility programs in which the patient participated; and

(iv) the patient's, parent's, or guardian's recommendations for improving facility's services.

(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 facility shall prepare and maintain on file an annual report of improvements made resulting from the quality assessment program.