Commenter:
Henrico Area Mental Health & Developmental Services - Yvonne Russell
Guidance document for Quality Improvement Program
Additional direction is needed regarding the use of the guidance document by the department. Can a provider be cited because they have not developed and implemented their quality improvement plan as outlined in the guidance document? If their plan has all of the components listed in the regulations but do not have all of the key components listed in the guidance document could they receive a citation? The guidance document should not add additional components that are not identified in the regulation 12VAC35-105620.
105.60 - The guidance document states the provider’s policies and procedures should include directions to the quality improvement plan. The regulations do not require written policies and procedures. The guidance documents should not be more prescriptive than the regulations and should be deleted.
105-620 – The regulations identify what should be in the quality improvement program (I – vi). The guidance document exceeds these requirements and adds; quality statement, infrastructure, participation of stakeholders, culture of safety and quality, data collections methods , sources of data all exceed what is stated in the regulation. The guidance documents should not be more prescriptive than the regulations and should be deleted or reworded as suggestions.
