Every hospice licensee must establish and implement a quality improvement program to ensure the quality of care and services provided throughout all approved service areas or within a hospice care center that includes, at a minimum:

(1) A complaint process that includes a procedure for the receipt, investigation, and disposition of complaints regarding services provided;

(2) A method to identify, monitor, evaluate, and correct problems identified by patients, families, personnel, contractors, or volunteers; and

(3) A system to assess patient satisfaction with the overall services provided by the agency.