The licensee must establish policies and procedures to ensure ongoing maintenance of a coordinated quality improvement program to improve the quality of care provided to residents and to identify and prevent serious or unanticipated resident and facility outcomes. The licensee must:

(1) Establish a written performance improvement plan that is periodically evaluated.

(2) Collect, measure, and assess data on policies and procedures, and outcomes related to resident care and the environment including:

(a) Medication administration errors;

(b) Allegations of abuse;

(c) Death;

(d) Suicide;

(e) Injuries which result in serious or unanticipated outcomes;

(f) Restraint or seclusion use;

(g) Resident grievances;

(h) Security incidents; and

(i) Disruption of services through internal or external emergency or disaster event.

(3) Review serious or unanticipated resident or facility outcomes as specified in subsection (2) of this section, in a timely manner.

(4) Implement and document changes or improvements made to prevent future occurrences of any serious or unanticipated resident outcome specified in subsection (2) of this section.