(a) A center must develop, implement, and maintain a written quality assessment and performance improvement (QAPI) program.
(b) A center must designate in writing the group or individuals, by title, responsible for ensuring that a center's written QAPI program is developed, implemented, and maintained in accordance with this section.
(c) The center must implement the QAPI program using a QAPI Committee. The QAPI committee must be composed of the following persons based on the services provided at the center during the time period under review by the QAPI:
  (1) the administrator;
  (2) the medical director;
  (3) the nursing director;
  (4) a therapist from each therapy that provided services during the review period (i.e., if physical therapy was provided during the quarter being reviewed, a PT must be on the QAPI committee);
  (5) a social worker that provided services during the review period; and
  (6) a supervisor of the direct care staff.
(d) The QAPI program must evaluate all services including:
  (1) monitoring activities that have an impact on health and safety of minors;
  (2) monitoring and evaluating the quality of services;
  (3) improving measurable outcomes for minors, if applicable;
  (4) resolving problems identified by a center and raised by parents and adult minors; and
  (5) ensuring a center's compliance with THSC Chapter 248A and this chapter.
(e) The QAPI program must be ongoing. Ongoing means there is a continuous and periodic collection and assessment of measurable care provided to minors and administrative quality data.
(f) The written QAPI program must include the frequency and detail of data collection.
(g) A center must collect quality data at least quarterly for all services provided to a minor.
(h) The QAPI program must include a system that measures the quality, effectiveness, and safety of services provided to minors and identifies opportunities and priorities for performance improvement.
(i) The system of measures must allow the QAPI Committee to collect and analyze services provided to minors and administrative quality data. The measures must include a review and analysis of the following, as applicable to the services provided at the center and the problems a center identifies:
  (1) a representative sample of active and closed medical records;
  (2) negative care outcomes to minors or adverse events;
  (3) complaints and grievances;
  (4) self-reported incidents alleging abuse, neglect, or exploitation by the center employees, volunteers, or contractors;
  (5) minor's parent satisfaction surveys;
  (6) infection control activities;
  (7) incident reports, including reports of medication errors and unprofessional conduct by licensed staff;
  (8) the accuracy and completeness of center personnel records;
  (9) the implementation and effectiveness of center policies;
  (10) the effectiveness and safety of all services provided, including:
    (A) competency and qualifications of staff;
    (B) the promptness, safety, and quality of services provided to minors;
    (C) the center's response to complaints and reports of abuse, neglect, or exploitation; and
    (D) a determination that services are provided as outlined in each minor's plan of care; and
  (11) an annual review and evaluation of a center's total operation.
(j) The QAPI Committee must meet quarterly or more often if needed to analyze the data collected and to use the data to improve services. A center must immediately correct identified problems that directly or potentially threaten health and safety of minors. The QAPI Committee must:
  (1) plan and document actions taken to correct identified problems, and if necessary, to revise center policies;
  (2) measure and document the outcome of the corrective action taken; and
  (3) monitor and document the level of improvement over time to ensure sustained improvements.
(k) The QAPI Committee must review and update or revise the written QAPI program at least annually, or more often if needed.
(l) The center must document the ongoing implementation and annual review of the written QAPI program.
(m) The center must keep QAPI documents confidential and make the documents readily available to DADS upon request.

Source Note: The provisions of this §550.1002 adopted to be effective September 1, 2014, 39 TexReg 6569; transferred effective May 1, 2019, as published in the Texas Register April 12, 2019, 44 TexReg 1875