Ariz. Admin. Code § 9-10-204

Current through Register Vol. 30, No. 44, November 1, 2024

Section R9-10-204 - Quality Management

A. A governing authority shall ensure that an ongoing quality management program is established that:

1. Complies with the requirements in A.R.S. § 36-445; and

2. Evaluates the quality of hospital services and environmental services related to patient care.

B. An administrator shall ensure that:

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

a. A method to identify, document, and evaluate incidents;

b. A method to collect data to evaluate hospital services and environmental services related to patient care;

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

e. A method to identify and document each occurrence of exceeding licensed capacity, as described in R9-10-203(C)(5), and to evaluate the occurrences of exceeding licensed capacity, including the actions taken for resolving occurrences of exceeding licensed capacity; and

f. The frequency of submitting a documented report required in subsection (B)(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 hospital services or environmental services related to patient care, and

b. Any changes made or actions taken as a result of the identification of a concern about the delivery of hospital services or environmental services related to patient care;

3. The acuity plan required in R9-10-214(C)(2) is reviewed and evaluated at least once every 12 months and the results are documented and reported to the governing authority;

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

5. Except for information or documentation that is confidential under federal or state law, a report or documentation required in this Section is provided to the Department for review within two hours after the Department's request.

Ariz. Admin. Code § R9-10-204

New Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Amended 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, effective 7/1/2014.