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Oklahoma Administrative Code (Last Updated: March 11, 2021) |
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TITLE 450. Department of Mental Health and Substance Abuse Services |
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Chapter 18. Standards and Criteria for Substance Related and Addictive Disorder Treatment Services |
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Subchapter 5. Organizational and Facility Management |
SECTION 450:18-5-2.3. Performance improvement program
Latest version.
- (a) The facility shall have an ongoing performance improvement program designed to objectively and systematically monitor, evaluate and improve the quality of consumer care.(b) The performance improvement program shall also address the fiscal management of the facility.(c) The facility shall have an annual written plan for performance improvement activities. The plan shall include, but not be limited to:(1) Outcomes management specific to each program;(2) A quarterly quality consumer record review to evaluate the quality of service delivery;(3) Staff privileging;(4) Review of critical and unusual incidents and consumer grievances and complaints; and(5) Improvement in the following:(A) Co-occurring capability;(B) Provision of trauma informed services;(C) Provision of culturally competent services; and(D) Provision of consumer driven services.(6) Activities to improve access and retention within the treatment program, including an annual "walk through" of the intake and admission process.(d) The facility shall identify a performance improvement officer.(e) The facility shall monitor the implementation of the performance improvement plan on an annual basis and shall make adjustments as needed.(f) Performance improvement findings shall be communicated and made available to, among others:(1) Governing authority;(2) Facility staff;(3) Consumers;(4) Stakeholders; and(5) ODMHSAS, as requested.(g) Compliance with 450:18-5-2.3 shall be determined by a review of the written program evaluation plan; written program evaluations (annual and/or special or interim; program goals and objectives; and other supporting documentation provided).