| (a) A center must develop, implement, and maintain
a written quality assessment and performance improvement (QAPI) program.
(b) A center must designate in writing the group or
individuals, by title, responsible for ensuring that a center's written
QAPI program is developed, implemented, and maintained in accordance
with this section.
(c) The center must implement the QAPI program using
a QAPI Committee. The QAPI committee must be composed of the following
persons based on the services provided at the center during the time
period under review by the QAPI:
(1) the administrator;
(2) the medical director;
(3) the nursing director;
(4) a therapist from each therapy that provided services
during the review period (i.e., if physical therapy was provided during
the quarter being reviewed, a PT must be on the QAPI committee);
(5) a social worker that provided services during the
review period; and
(6) a supervisor of the direct care staff.
(d) The QAPI program must evaluate all services including:
(1) monitoring activities that have an impact on health
and safety of minors;
(2) monitoring and evaluating the quality of services;
(3) improving measurable outcomes for minors, if applicable;
(4) resolving problems identified by a center and raised
by parents and adult minors; and
(5) ensuring a center's compliance with THSC Chapter
248A and this chapter.
(e) The QAPI program must be ongoing. Ongoing means
there is a continuous and periodic collection and assessment of measurable
care provided to minors and administrative quality data.
(f) The written QAPI program must include the frequency
and detail of data collection.
(g) A center must collect quality data at least quarterly
for all services provided to a minor.
(h) The QAPI program must include a system that measures
the quality, effectiveness, and safety of services provided to minors
and identifies opportunities and priorities for performance improvement.
(i) The system of measures must allow the QAPI Committee
to collect and analyze services provided to minors and administrative
quality data. The measures must include a review and analysis of the
following, as applicable to the services provided at the center and
the problems a center identifies:
(1) a representative sample of active and closed medical
records;
(2) negative care outcomes to minors or adverse events;
(3) complaints and grievances;
(4) self-reported incidents alleging abuse, neglect,
or exploitation by the center employees, volunteers, or contractors;
(5) minor's parent satisfaction surveys;
(6) infection control activities;
(7) incident reports, including reports of medication
errors and unprofessional conduct by licensed staff;
(8) the accuracy and completeness of center personnel
records;
(9) the implementation and effectiveness of center
policies;
(10) the effectiveness and safety of all services provided,
including:
(A) competency and qualifications of staff;
(B) the promptness, safety, and quality of services
provided to minors;
(C) the center's response to complaints and reports
of abuse, neglect, or exploitation; and
(D) a determination that services are provided as outlined
in each minor's plan of care; and
(11) an annual review and evaluation of a center's
total operation.
(j) The QAPI Committee must meet quarterly or more
often if needed to analyze the data collected and to use the data
to improve services. A center must immediately correct identified
problems that directly or potentially threaten health and safety of
minors. The QAPI Committee must:
(1) plan and document actions taken to correct identified
problems, and if necessary, to revise center policies;
(2) measure and document the outcome of the corrective
action taken; and
(3) monitor and document the level of improvement over
time to ensure sustained improvements.
(k) The QAPI Committee must review and update or revise
the written QAPI program at least annually, or more often if needed.
(l) The center must document the ongoing implementation
and annual review of the written QAPI program.
(m) The center must keep QAPI documents confidential
and make the documents readily available to DADS upon request.
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| Source Note: The provisions of this §550.1002 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875 |
