1. 1. A plan for a quality management program for the home health agency is established, documented, and implemented that includes:

   1. a. A method to identify, document, and evaluate incidents;
   2. b. A method to collect data to evaluate the provision of services, including oversight of personnel members;
   3. c. A method to evaluate the data collected to identify a concern about the provision of services;
   4. d. A method to make changes or take action as a result of the identification of a concern about the provision of services;
   5. e. A method to determine whether actions taken improved the provision of services; and
   6. f. The frequency of submitting the documented report required in subsection (2) to the governing authority;

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

   1. a. Each identified concern about the delivery of services related to patient care, and
   2. b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to patient care; and
3. 3. The report 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 .

An administrator shall ensure that:

Historical Note

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).