La. Admin. Code tit. 48 § I-5639

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-5639 - Quality Improvement Plan

A. A BHS provider shall develop, implement and maintain a quality improvement (QI) plan that:

1. assures that the provider is in compliance with federal, state, and local laws;

2. meets the needs of the providers clients;

3. is attaining the goals and objectives established by the provider;

4. maintains systems to effectively identify issues that require quality monitoring, remediation and improvement activities;

5. improves individual outcomes and individual satisfaction;

6. includes plans of action to correct identified issues that:

a. monitor the effects of implemented changes; and

b. result in revisions to the action plan;

7. is updated on an ongoing basis to reflect changes, corrections and other modifications.

B. The QI plan shall include:

1. a process for obtaining input from the client, or clients parents or legal guardian, as applicable, at least once a year that may include, but not be limited to:

a. satisfaction surveys conducted by a secure method that maintains the clients privacy;

b. focus groups; and

c. other processes for receiving input regarding the quality of services received;

2. a sample review of client case records on a quarterly basis to ensure that:

a. individual treatment plans are up to date;

b. records are accurate, complete and current;

c. the treatment plans have been developed and implemented as ordered; and

d. the program involves all services and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors;

3. a process for identifying on a quarterly basis the risk factors that affect or may affect the health, safety and/or welfare of the clients of the BHS provider receiving services, that includes, but is not limited to:

a. review and resolution of complaints;

b. review and resolution of incidents; and

c. incidents of abuse, neglect and exploitation;

4. a process to review and resolve individual client issues that are identified;

5. a process to review and develop action plans to resolve all system wide issues identified as a result of the processes above;

6. a process to correct problems that are identified through the program that actually or potentially affect the health and safety of the clients;

7. a process of evaluation to identify or trigger further opportunities for improvement, such as:

a. identification of individual care and service components;

b. application of performance measures; and

c. continuous use of a method of data collection and evaluation;

8. a methodology for determining the amount of client case records in the quarterly sample review that will involve all services and produce accurate data to guide the provider toward performance improvement.

C. The QI program shall establish and implement an internal evaluation procedure to:

1. collect necessary data to formulate a plan; and

2. hold quarterly committee meetings comprised of at least three individuals who:

a. assess and choose which QI plan activities are necessary and set goals for the quarter;

b. evaluate the activities of the previous quarter; and

c. implement any changes that protect the clients from potential harm or injury.

D. The QI plan committee shall:

1. be comprised of at least three persons, one of whom is a LMHP and the others are staff with the qualifying experience to contribute to the committees purpose; and

2. develop and implement the QI plan.

E. The QI program outcomes shall be documented and reported to the administrator, clinical director and/or medical director for action, as necessary, for any identified systemic problems.

F. The BHS provider shall maintain documentation of the most recent 12 months of the QI plan.

La. Admin. Code tit. 48, § I-5639

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 411698 (9/1/2015), Amended by the Department of Health, Bureau of Health Services Financing, LR 431383 (7/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2151-2161.