Section 146.270  Quality Assurance Plan

Each SLF shall be responsible for establishing an effective, internal quality assurance plan that encompasses oversight and monitoring, peer review, utilization review, resident satisfaction and ongoing quality improvement and implementation of any corrective action plans that address improved quality services.  The quality assurance plan shall include:

a)         Documentation of results of, and SLF responses to, the annual resident satisfaction survey that shall include, but not be limited to, whether the:

1)         Residents have the opportunity to provide input into development and implementation of existing SLF policies and procedures;

2)         Existing SLF policies and procedures are clear to residents;

3)         Residents have access to existing SLF policies and procedures;

4)         Residents have a degree of control over personal lifestyle preferences;

5)         Residents have access to common areas;

6)         Residents are satisfied with surroundings as "home-like"; and

7)         Residents have the opportunity to exercise personal lifestyle preferences and direct services according to personal preferences (for example, meal choices and refusal of services).

b)         Evaluation of care and services pursuant to accepted standards and practices and the service needs of the resident population.

c)         Tracking of improvements based on care outcomes such as changes in activities of daily living, resident response to services and other indicators of service quality listed in subsection (d) of this Section.

d)         A system of indicators of service quality that measure:

1)         Quality of services provided;

2)         Resident rating of the services, including food service;

3)         Cleanliness and furnishings of the common area;

4)         Service availability;

5)         Adequacy of service provision and coordination;

6)         Provision of safe environment, including emergency contingency plans that are in accordance with Section 146.295;

7)         Socialization activities; and

8)         Resident autonomy, which includes, but is not limited to:

A)        Protection of resident rights;

B)        Provision of appropriate oversight for vulnerable residents; and

C)        Resident exercise of personal autonomy and choice.

e)         Procedures for preventing, detecting and reporting resident neglect and abuse.

f)         Objectives for improving service quality, including the service quality indicators and measures to determine when objectives have been met.

g)         Ongoing quality improvements resulting from the quality review data.

h)         A committee formed to organize and proceed with the required reviews for both the health care professionals and social service providers of the SLF staff or to serve in a contractual relationship with the SLF. Committee duties shall include:

1)         A regular schedule for review, and

2)         A system to evaluate the process and methods by which care is given by specific providers in accordance with the service plan developed by the SLF licensed nursing staff and approved by the resident.

i)          The Department shall review the SLF's plan initially and annually thereafter.

(Source:  Amended at 33 Ill. Reg. 11803, effective August 1, 2009)