A. The facility shall plan and implement a quality assurance program which includes:
(1) Monitoring and evaluation of the quality of patient care;
(2) Identification, evaluation, and resolution of care problems; and
(3) A peer review process.
B. The facility shall conduct ongoing quality assurance activities and document the activities on a continuous basis, but not less than quarterly.
C. Peer Review. The facility shall establish a peer review process that includes:
(1) A mechanism to evaluate the clinical performance of each health care practitioner on a continuous basis, but not less than annually;
(2) Procedures, approved by a supervising physician, to identify and minimize risks to the patient; and
(3) Documentation of each health care practitioner's annual evaluation.
D. Equipment Quality Control.
(1) The facility shall develop and implement a quality control procedure to monitor the safety and performance of all biomedical equipment.
(2) In developing its procedures, the facility shall consider:
(a) FDA recommendations; and
(b) The equipment manufacturer's recommendations.
E. Quality Assurance Records. The facility shall document the following information for all quality assurance activities:
(1) A description of identified problems;
(5) Actions taken;
(6) Results; and