Minnesota Administrative Rules

9533.0160 QUALITY ASSURANCE AND IMPROVEMENT.

Subpart 1.

System to collect data for commissioner.

The certificate holder must implement and maintain a quality assurance system to evaluate the effectiveness of services being delivered and to capture program results. The certificate holder must:

A.

use procedures and outcome measurement methods approved by the commissioner; and

B.

submit process and outcome data as requested by the commissioner.

Subp. 2.

Quality improvement plan.

The certificate holder must adopt a quality improvement plan that requires the activities in items A to C. The quality improvement plan must include processes to perform these activities and to review the data or information obtained at least quarterly.

A.

The certificate holder must measure client outcomes by:

(1)

obtaining and evaluating feedback from the client, family members, staff, and referring agencies about the services provided; and

(2)

evaluating the outcome data to identify ways to improve the effectiveness of the services and improve client outcomes.

B.

The certificate holder must review significant incidents by:

(1)

determining whether policies and procedures were followed;

(2)

evaluating the staff's response to the critical and other significant incidents;

(3)

assessing what could have prevented the critical and other significant incidents from occurring; and

(4)

modifying policies, procedures, training plans, or recipients' individual treatment plans in response to the findings of the review.

C.

The certificate holder must monitor compliance by:

(1)

developing and maintaining a system for routine self-monitoring for compliance with the requirements of parts 9533.0010 to 9533.0170;

(2)

maintaining documentation of self-monitoring for review by the commissioner upon request; and

(3)

documenting reasonable efforts and action taken to improve the program's compliance with parts 9533.0010 to 9533.0170 based on the results of self-monitoring.

Subp. 3.

Quality improvement plan review.

An integrated treatment team leader must:

A.

annually review, evaluate, and update the quality improvement plan;

B.

document the actions the certificate holder will take as a result of information gained from implementing the plan;

C.

establish goals for improved service delivery for the following year; and

D.

evaluate and document the status of the previous year's goal.

Statutory Authority:

MS s 245.4863

History:

38 SR 523

Published Electronically:

November 12, 2013