(1) The governing body of a facility must ensure that there is an effective, ongoing, facility wide, written quality assurance program and implementation plan in effect which ensures and evaluates the quality of the patient care provided there and which includes the following:

(a) Periodic review, not less than semi-annually, of the following, in order to determine whether utilization of services was appropriate, established policies were followed, and any changes are needed:

(i) the utilization of facility services, including at least the number of patients served and the volume of services;

(ii) a representative sample consisting of not less than 10% of both active and closed patient records; and

(iii) the facility's health care policies.

(b) Consideration by the facility's medical staff of the findings of the evaluation and the taking of subsequent remedial action, if necessary.

(c) Evaluation of all services provided by contractors.

(d) Implementation of a discharge planning program that facilitates the provision of post discharge care and:

(i) Ensures that discharge planning for each patient is initiated in a timely manner;

(ii) Ensures that each patient, along with necessary medical information, is transferred or referred to appropriate facilities, agencies, or outpatient services, as needed, for continued, follow up, or ancillary care; and

(iii) Includes a formal referral agreement with one or more hospitals ensuring acceptance by that hospital of the facility's patients needing hospital level care.

(e) The taking and documentation of appropriate remedial action to address deficiencies found through the quality assurance program, as well as documentation of the outcome of the remedial action.