The nursing home’s quality assurance committee shall develop and implement a quality assurance plan that includes procedures for: Concurrent review; Ongoing monitoring; Resident complaints; Accidents and incidents; and Abuse and neglect. Concurrent Review. The quality assurance plan shall include: The procedures for conducting concurrent review of each resident including: Criteria to determine any change in a resident's condition; A method to document the concurrent review; and Identification of the licensed nurse or nurses conducting the concurrent review; The procedures to evaluate clinical data for any resident with a change in condition including at least: Medications; Laboratory values; Intake and output; Skin breakdown; Noted weights; Appetite; Injuries resulting from accidents or incidents; and Any other relevant parameters that may affect the resident's physical or mental status; Procedures to take action when there is a change in the resident’s condition, including: Communicating changes to the director of nursing or the resident’s attending physician; and Changing the resident’s plan of care as necessary; and Procedure for referring data to the quality assurance committee, when appropriate. Ongoing Monitoring. The quality assurance plan shall include: A description of the measurable criteria for ongoing monitoring of all aspects of resident care including: Medication administration; Prevention of pressure ulcers, dehydration, and malnutrition; Nutritional status and weight loss or weight gain; Accidents and injuries; Unexpected death; and Changes in physical or mental status; The methodology for collecting data; The methodology for evaluating and analyzing data to determine trends and patterns; A description of the thresholds and performance parameters that represent acceptable care for the measured criteria; Time frames for referral to the quality assurance committee; A description of the plan for follow-up to determine effectiveness of the recommendations; and A description of how the quality assurance activities will be documented. Resident Complaints. The quality assurance plan shall include: A description of a complaint process that effectively addresses resident and family concerns including: The designated person or persons and their phone numbers to receive complaints and concerns; The method to be used to acknowledge complaints received; and The time frames for investigating complaints, depending on the nature or seriousness of the complaint; A description of a logging system that will be used including the: Name of the complainant; Date the complaint was received; Nature of the complaint; and Date that the complainant was notified of the disposition or resolution of the complaint; and The procedures for: Notifying residents of their right to file a complaint with the Office of Health Care Quality; Informing residents, families, or guardians of the complaint process upon admission; and Posting the complaint process or making it available without the need to request it. Accidents and Injuries. The quality assurance plan shall include: A definition of accident and injury that is appropriate to the type of resident served by the nursing home; A description of the process for reporting accidents and injuries including: Who shall report incidents; The time frame for reporting incidents; and The procedure for reporting incidents; A policy statement that ensures that incidents can be reported without fear of reprisal; A description of how internal investigations of accidents and injuries will be handled including: Assessment of any injury; Interview of the resident, staff, and any witnesses; Review of any relevant records including the resident's medical records, discharge summary, hospital records, etc.; and Time frames for conducting the investigation; A description of the process for notifying a family or guardian about the incident; A description of the process for the ongoing evaluation of patterns and trends in accidents and injuries; and A description of how relevant information will be referred to the quality assurance committee. Abuse and Neglect. The quality assurance plan shall include: The process for implementing COMAR 10.07.09.15 concerning abuse of residents; A description of the process for providing immediate notification to the family, guardian, or responsible party about the incident; A description of the process for the ongoing evaluation of validated incidents of abuse and neglect to determine patterns and trends; and A description of how relevant information will be referred to the quality assurance committee.