SECTION 450:17-5-192. Data reporting, performance measurement and quality improvement

(a)   Facility shall annually submit a cost report containing data elements as specified by ODMHSAS with supporting data within six months after the end of each calendar year.

(b)   There shall be an ongoing performance improvement program designed to objectively and systematically monitor, evaluate and improve the quality of consumer care related to facility operations.

(c)   The performance improvement activities must:

(1)   Focus on high risk, high volume, or problem-prone areas.

(2)   Consider incidence, prevalence, and severity of problems.

(3)   Give priority to improvements that affect behavioral outcomes, client safety, and person-centered quality of care.

(d)   Performance improvement activities must also track adverse client events, analyze their causes, and implement preventive actions and mechanisms.

(e)   The program must use quality indicator data, including client care, and other relevant data in the design of its program.

(f)   The facility must use the data collected to monitor the effectiveness and safety of services and quality of care and identify opportunities and priorities for improvement.

(g)   The functions and processes outlined in (a) through (e) shall be evidenced in an annual written plan for performance improvement activities. The plan shall include but not be limited to:

(1)   Outcomes management processes which include measures required by CMS and the State and may also include measures from the SAMHSA National Outcomes Measures, NCQA, and HEDIS as required to document improvement in population health.

(2)   Quarterly record review to minimally assess:

(A)   Quality of services delivered;

(B)   Appropriateness of services;

(C)   Patterns of service utilization;

(D)   Treatment goals and objectives based on assessment findings and consumer input;

(E)   Services provided which were related to the goals and objectives;

(F)   Patterns of access to and utilization of specialty care; and

(G)   The care plan is reviewed and updated as prescribed by policy.

(3)   Review of critical incident reports and consumer grievances or complaints.

(h)   Compliance with this Section will be determined by a review of the written program evaluation plan, program goals and objectives and other supporting documentation provided as well as policy, cost report and annual written plan.

[Source: Added at 33 Ok Reg 964, eff 9-1-16]