SECTION 450:24-15-1. Performance improvement program

(a)   The CCARC 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 organization.

(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 component which minimally measures:

(A)   efficiency;

(B)   effectiveness; and

(C)   consumer satisfaction.

(2)   A quarterly quality consumer record review to evaluate and ensure, among others:

(A)   the quality of services delivered;

(B)   the appropriateness of services;

(C)   patterns of service utilization;

(D)   consumers are provided an orientation to services, and actively involved in making informed choices regarding the services they receive;

(E)   assessments are thorough, timely and complete;

(F)   treatment goals and objectives are based on, at a minimum,

(i)   assessment findings, and

(ii)   consumer input;

(G)   services provided are related to the treatment plan goals and objectives;

(H)   services are documented as prescribed by policy; and

(I)   the service plan is reviewed and updated as prescribed by policy.

(3)   Clinical privileging;

(4)   Review of critical and unusual incidents and consumer grievances and complaints; and

(5)   Improvement in the following:

(A)   co-occurring capability, including the utilization of self-assessment tools as determined or recommended by ODMHSAS;

(B)   provision of trauma informed services;

(C)   provision of culturally competent services; and

(D)   provision of consumer driven services; and

(6)   Activities to improve access and retention within the treatment program, including an annual "walk through" of the intake and admission process.

(d)   The CCARC will identify a performance improvement officer.

(e)   The CCARC shall monitor the implementation of the performance improvement plan on an ongoing basis and makes adjustments as needed.

(f)   Performance improvement findings shall be communicated and made available to, among others:

(1)   the governing authority;

(2)   facility staff;

(3)   consumers;

(4)   stakeholders; and

(5)   ODMHSAS, as requested.

(g)   Compliance with 450:24-15-1 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).

[Source: Added at 28 Ok Reg 2025, eff 10-1-11]