Section 29-2319. ADMINISTRATIVE STANDARDS -- QUALITY IMPROVEMENT STANDARDS

 

2319.1 A substance abuse treatment facility or program shall develop and implement a Continuous Quality Improvement (CQI) plan that integrates the process improvement into the agencies’ organizational structure and ongoing service delivery as follows:

 

(a) The facility or program shall establish a written quality improvement plan, approved by the governing board and executive director. The plan shall mandate that all organizational members participate in a quality improvement process;

 

(b) The quality improvement plan shall identify the committee, group, or person responsible for the coordination and implementation of the quality improvement process; and

 

(c) The staff and the governing body shall review the plan annually and revise it as appropriate.

 

2319.2 A substance abuse treatment facility or program shall establish support for, and maintain the quality improvement process through the facility’s or program’s professional and administrative staff by requiring:

 

(a) The active involvement of interdisciplinary teams of service delivery staff and management in improving the treatment process;

 

(b) Interdisciplinary teams to gather data on treatment outcomes before and after changing the process of care; and

 

(c) The establishment of procedures to ensure that the findings of the quality improvement process, recommendations for addressing problem areas, and results of corrective action efforts are reviewed and written evidence of utilization by staff to enhance service delivery.

 

2319.3 The following functions and programmatic indicators shall be included in the comprehensive quality improvement process:

 

(a) Verification of necessary experience, education and ongoing competence of staff for the delivery of substance abuse treatment services;

 

(b) Supervision and training of all personnel;

 

(c) Auditing of administrative and patient records to determine accuracy, completeness, quality, and timeliness of entries in the record in accordance with certification standards and program policy;

 

(d) Monitoring of key quality indicators of service delivery and outcomes including:

 

(1) Recovery and recidivism rates;

 

(2) Cost of services;

 

(3) Appropriateness of services; and

 

(4) Access to services.

 

(e) Identifying and monitoring of unusual occurrences and the related problems/issues;

 

(f) Reviewing the appropriateness of the level of service on an ongoing basis;

 

(g) Reviewing the utilization of services beyond the usual and customary length of stay consistent with an objective review by unbiased participants; and

 

(h) Obtaining recommendations and feedback from patients, staff and other individuals, patients’ family members, and community agencies regarding the appropriateness and effectiveness of the facility’s or program’s services.

 

2319.4 A substance abuse treatment facility or program shall monitor any other programmatic indicators identified by the facility, program or the Department.

 

2319.5 A substance abuse treatment facility or program shall collect data for each indicator on an ongoing basis using a standardized format as required by the Department.

 

2319.6 A substance abuse treatment facility or program shall have computer hardware, software and network capability compatible with the Department’s management information system for the electronic transmission of required uniform data and information which will be used to determine appropriateness of admissions and service plans, measure outcomes and recovery rates, and determine compliance with other requirements of this chapter.

 

2319.7 The substance abuse treatment facility or program shall collect quarterly random samplings of patient outcomes, including but not limited to biological markers such as drug/alcohol screening results, on a form provided by the Department.

 

2319.8 When a significant problem or quality of service issue is identified, the substance abuse treatment facility or program shall act to correct the problem or improve the effectiveness of service delivery, or both, and shall assess corrective or supportive actions through continued monitoring.

 

2319.9 A substance abuse treatment facility or program shall maintain a quality improvement record system, compatible with the Department’s data requirements.

 

2319.10 The record system shall contain documentation, including peer and other monitoring reviews, reports, recommendations, corrective actions and the status of previously identified problems, outcomes related to certification standards, or both.

 

2319.11 The record system shall be available to the Department for review.

 

2319.12 The record system shall include minutes of all quality improvement meetings, with attendance, time, place, date, actions or recommendations for actions noted, achievement of outcomes, and information disseminated to patients and staff concerning improvement.

 

2319.13 The Department shall maintain a record of the outcomes of treatment for each substance abuse facility or program. The Department shall treat the record as a public document and shall periodically publish and/or distribute findings to providers, patients, and the general public.

 

 

source

Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7725 (September 22, 2000).