(1) The substance use disorder facility (SUDF) must have a quality management committee that is representative of the SUDF's administration and staff members.

(2) The quality management committee must meet on a quarterly basis and is responsible for:

(a) developing a written plan for a continuous quality improvement program that is applicable to the entire organization;

(b) implementing the quality improvement plan and monitoring the quality and appropriateness of services;

(c) identifying problems, taking corrective action as indicated, and monitoring results of those actions; and

(d) at least annually, reviewing and updating the quality improvement plan.

(3) The quality improvement program must include at a minimum:

(a) administrative processes;

(b) fiscal processes;

(c) clinical services;

(d) client outcomes; and

(e) a process for reviewing serious incidents, grievances and complaints, and medication errors.

(4) The SUDF must prepare and maintain on file an annual report including improvements made as a result of the quality management plan.