Section 270.2300  Quality Assessment and Improvement

a)         The licensee shall develop and implement a quality assessment and improvement program designed to meet at least the following goals:

1)         Ongoing monitoring and evaluation of the quality and accessibility of care and services provided at the facility or under contract, including but not limited to:

A)        Admission of patients appropriate to the capabilities of the facility;

B)        Patient assessment;

C)        Development and implementation of appropriate comprehensive care plans;

D)        Patient satisfaction;

E)        Costs for delivery of services; and

F)         Infection control.

2)         Identification and analysis of problems.

3)         Identification and implementation of corrective action or changes in response to problems.

b)         The program shall operate pursuant to a written plan, which shall include, but not be limited to:

1)         A detailed statement of its goals;

2)         The methodology and criteria that will be used to meet each stated goal;

3)         The action plans for addressing problems;

4)         Procedures for evaluating the effectiveness of action plans and revising action plans to prevent reoccurrence of problems;

5)         Procedures for documenting the activities of the program; and

6)         Identifying the persons responsible for administering the program.

c)         The licensee shall afford the Department and the Board access to any materials or documents generated pursuant to the facility's quality assessment and improvement program or that otherwise relate to patient demand, utilization and satisfaction; healthcare costs; healthcare cost effectiveness; financial viability of the facility; and access to healthcare services.  Such information shall be used by the Department and the Board to evaluate and assess the facility in relation to the Demonstration Program, and shall be afforded the same confidential status as is provided information concerning medical studies in Article VIII, Part 21 of the Code of Civil Procedure (Ill. Rev. Stat. 1991, ch. 110, pars 1-101 et seq.) [735 ILCS 5/1-101 - 1-109].