(a) Quality assurance program. The center shall adopt, implement, and enforce a written quality assurance (QA) program that includes all health and safety aspects of client care for both mother and newborn.      
        (1) The quality assurance program shall include, but not be limited to:                  (A) a review of the clinical record(s);                   (B) incidences of morbidity and mortality of mother and newborn;                   (C) postpartum infections;                   (D) all cases transferred to a hospital for delivery, care of newborn, or postpartum care of mother;                   (E) incidents, problems and potential problems identified by staff of the center, including infection control;                   (F) address issues of unprofessional conduct by any member of the center's staff (including contract staff);                   (G) address the integrity of surgical instruments, medical equipment, and patient supplies;                   (H) address client referrals and consultations;                   (I) address medication therapy practices, if applicable; and                   (J) problems with compliance with any federal and state laws and rules.         
        (2) This program must be reviewed and updated or revised at least annually.       
        (3) The results of the quality assurance program must be reviewed and documented at least quarterly.       
      (b) Quality assurance issues. The center shall identify and address quality assurance issues and implement corrective action plans as necessary. The outcome of any corrective action plans shall be documented. The outcome of the remedial action shall be documented.     
      (c) Departmental review.      
        (1) A representative(s) of the department shall verify that the center has a quality assurance program which addresses quality concerns and that center staff know how to access that process.       
        (2) Attempts by the center to identify and correct deficiencies will not be used by the department as a basis for adverse action against the center.       
     Source Note:        The provisions of this §137.52 adopted to be effective December 2, 2007, 32 TexReg 8507