(a) Established.  Each licensed nursing facility shall develop and implement a quality improvement program and establish a quality improvement committee.

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(b)  Each licensed nursing facility shall designate a qualified individual, who shall be determined by the facility’s administrator, to coordinate and manage the nursing facility’s quality improvement program.

(1)  The nursing facility’s quality improvement committee shall include at least the following members:

(i)  The nursing facility administrator;

(ii)  The director of nursing;

(iii)  The medical director;

(iv)  A social worker; and

(v)  A representative of dietary services.

(2)  The quality improvement committee shall:

(i)  Meet at least quarterly;

(ii)  Maintain records of all quality improvement activities; and

(iii)  Keep records of committee meetings that shall be available to the department during any on-site visit.

(3)  The quality improvement committee for a nursing facility shall annually review and approve the quality improvement plan for the nursing facility. Said plan shall be available to the public upon request.

(c)  Each nursing facility shall establish a written quality improvement plan that shall be reviewed by the department during the facility’s annual survey and that:

(1)  Provides criteria to monitor nursing care, including medication administration, prevention and treatment of decubitus ulcers, dehydration and nutritional status and weight loss or gain, accidents and injuries, unexpected deaths, changes in mental or psychological status, and any other data necessary to monitor quality of care; and

(2)  Includes methods to identify, evaluate and correct problems.

(d)  The nursing facility administrator shall take appropriate remedial actions based on the recommendations of the nursing facility’s quality improvement committee.

(e)  The director may not require the quality improvement committee to disclose the records and the reports prepared by the committee except as necessary to assure compliance with the requirements of this section.

(f)  Good faith attempts by the quality improvement committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

(g)  If the department determines that a nursing facility is not implementing its quality improvement program effectively and that quality improvement activities are inadequate, the department may impose sanctions on the nursing facility to improve quality of resident care including mandated hiring of, directly or by contract, an independent quality consultant.