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

   1. a. A method to identify, document, and evaluate incidents;
   2. b. A method to collect data to evaluate services provided to patients;
   3. c. A method to evaluate the data collected to identify a concern about the delivery of services related to patient care;
   4. 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
   5. e. The frequency of submitting a documented report required in subsection (2) to the licensee;

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

   1. a. An identification of each concern about the delivery of services related to patient care, and
   2. b. Any changes made or actions taken as a result of the identification of a concern about the delivery of services related to patient care; and
3. 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 licensee.

A medical director shall ensure that:

Historical Note

Adopted effective August 6, 1993, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1993, Ch. 163, § 3(B). Amended effective May 2, 1997, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1996, Ch. 329, § 5 (Supp. 97-2). Repealed effective November 1, 1998, under an exemption from the provisions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). New Section adopted effective April 1, 2000, under an exemption from the provisions of the Arizona Administrative Procedure Act pursuant to Laws 1999, Chapter 311; filed with the Office of the Secretary of State December 23, 1999 at 6 A.A.R. 351 (Supp. 99-4). Amended by exempt rulemaking at 20 A.A.R. 448, effective April 1, 2014 (Supp. 14-1). Section R9-10-1504 renumbered to R9-10-1505; new Section R9-10-1504 made by final rulemaking at 24 A.A.R. 3043, effective October 2, 2018 (Supp. 18-4).