The performance improvement program shall consist of: A committee which: Consists of representation of personnel and varied areas of job responsibility; and Is responsible for analysis of data, reporting trends and corrective actions; and Meets at least quarterly; Quality assurance and performance improvement monitoring parameters; Documentation requirements for: Established monitoring parameters; Trend analyses; and Retention of committee meeting minutes for 3 years; Documentation of tracking, trending, analyzing, resolving, and developing corrective action plans as appropriate for: Medication errors; Adverse drug reactions; and Equipment malfunctions; Reporting of adverse events to regulatory and standard-setting bodies as applicable to State and federal regulations; Documentation and resolution of patient care issues involving: Incorrect equipment, supplies, or medications; Delays in delivery of care; Missed doses; Patient infections; Failures in after-hours care; and Patient, caregiver, or health care provider complaints; Documentation of patient outcomes; Recall management; Patient compliance monitoring; and Staff training and competency compliance. The permit holder shall review the performance improvement program at a minimum of every 3 years.