(1) To ensure the proper delivery of services and the maintenance and improvement in quality of care through self-review, any enhanced services facility licensed under this chapter must maintain an active quality improvement committee.

(2) The quality improvement committee will include a multi-disciplinary team.

(3) The quality improvement committee will maintain an ongoing plan that includes areas the facility is working on improving and one continuous quality improvement project annually, beginning in the second contract year for completion by the end of the second calendar year.

(4) To promote quality of care through self-review without the fear of reprisal, and to enhance the objectivity of the review process, the department shall not require disclosure of any quality assurance committee records or reports, unless the disclosure is related to the committee's compliance with this section, if:

(a) The records or reports are not maintained pursuant to statutory or regulatory mandate; and

(b) The records or reports are created for and collected and maintained by the committee.

(5) If the enhanced services facility refuses to release records or reports that would otherwise be protected under this section, the department may then request only that information that is necessary to determine whether the enhanced services facility has a quality assurance committee and to determine that it is operating in compliance with this section. However, if the enhanced services facility offers the department documents generated by, or for, the quality assurance committee as evidence of compliance with enhanced services facility requirements, the documents are not protected as quality assurance committee documents when in the possession of the department.

(6) Good faith attempts by the committee to identify and correct quality deficiencies shall not be used as a basis for sanctions.

(7) Any records that are created for and collected and maintained by the quality assurance committee shall not be discoverable or admitted into evidence in a civil action brought against an enhanced services facility.

(8) Notwithstanding any records created for the quality assurance committee, the facility shall fully set forth in the resident's records, available to the resident, the department, and others as permitted by law, the facts concerning any incident of injury or loss to the resident, the steps taken by the facility to address the resident's needs, and the resident outcome.