10.12.01.16

.16 Quality Assurance Program.

A. The administrator shall ensure that the facility develops and maintains a quality assurance program which includes:

(1) Monitoring and evaluation of the quality of patient care; and

(2) Identification, evaluation, and resolution of care problems.

B. The facility shall conduct ongoing quality assurance activities and document the activities on a continuous basis, but not less than quarterly.

C. The administrator shall ensure that the facility develops a quality control procedure to monitor and document the safety and performance of all biomedical equipment.

D. The facility shall document the following information for all quality assurance activities:

(1) A description of identified problems;

(2) Findings;

(3) Conclusions;

(4) Recommendations;

(5) Actions taken;

(6) Results; and

(7) Follow-up.