Section R9-10-1004. Quality Management

An administrator shall ensure that:

1.        A plan is established, documented, and implemented for an ongoing quality management program that, at a mini- mum, includes:

a.         A method to identify, document, and evaluate inci- dents;

b.        A method to collect data to evaluate services pro- vided to patients;

c.         A method to evaluate the data collected to identify a concern about the delivery of services related to patient care;

d.        A method to make changes or take action as a result of the identification of a concern about the delivery of services related to patient care; and

e.         The frequency of submitting a documented report required in subsection (2) to the governing authority;

2.        A documented report is submitted to the governing authority that includes:

a.         An identification of each concern about the delivery of services related to patient care, and

b.        Any change made or action taken as a result of the identification of a concern about the delivery of ser- vices related to patient care; and

3.        The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.

Historical Note

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp.

14-2).