TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER c: LONG-TERM CARE FACILITIES
PART 380 SPECIALIZED MENTAL HEALTH REHABILITATION FACILITIES CODE
SECTION 380.515 REPORTABLE PERFORMANCE INDICATORS


 

Section 380.515  Reportable Performance Indicators

 

a)         The following information shall be made available to the Department upon entry to the facility by a Department survey team:

 

1)         Census information;

 

2)         Key personnel of the facility and the facility's governing body;

 

3)         A roster of the facility's residents with room numbers;

 

4)         Program discharge summaries;

 

5)         Accrediting benchmark achievements;

 

6)         Accrediting performance improvement reports and compliance.

 

7)         The facility's staffing plan;

 

8)         Staff turnover rate;

 

9)         The facility's floor design;

 

10)         The facility's admissions and discharges;

 

11)         Incident reports prepared pursuant to Section 380.530;

 

12)         The facility's performance improvement project or projects;

 

13)         Written records on the facility's use of restraints;

 

14)         Pharmacy reports of adverse outcomes;

 

15)         Medication error reports;

 

16)         The facility's written policies and procedures; and

 

17)         The facility's identified offender list.

 

b)         The facility shall provide to the Department upon request all data elements that a facility is required to submit to any State agency, managed care organization, accrediting body, or any other third party.

 

c)         The facility shall submit the following information concerning each level of service to the Department, DHS-DMH and the Department of Healthcare and Family Services (HFS) at least monthly. This information shall include, but not be limited to:

 

1)         Admissions, including referral sources and consumer living arrangements prior to admission;

 

2)         Transfers to other facilities, to facilities licensed under the Nursing Home Care Act, to private hospitals for both medical and psychiatric treatment, and between levels of service;

 

3)         Discharges, including the frequency of discharges to community-based behavioral health providers, other community-based providers, private hospitals for both medical and psychiatric treatment, State hospitals, detox centers, and involuntary discharges;

 

4)         All emergency department visits for both medical and  psychiatric treatment;

 

5)         Re-admissions to a facility within 30 days after discharge;

 

6)         Suicides and suicide attempts;

 

7)         Deaths of consumers, including deaths of consumers during hospital visits;

 

8)         Incidents of abuse, neglect and maltreatment, including sexual assault; and

 

9)         The number of times restraints were used.

 

d)         The facility shall submit the results of consumer perception of care or quality of life surveys to the Department, DHS-DMH and HFS at least biannually.