Ariz. Admin. Code § 9-10-1203

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

Section R9-10-1203 - Administration

A. A governing authority shall:

1. Consist of one or more individuals responsible for the organization, operation, and administration of the home health agency;

2. Establish, in writing:

a. A home health agency's scope of services, and

b. Qualifications for an administrator;

3. Designate, in writing, an administrator who has the qualifications established in subsection (A)(2)(b);

4. Adopt a quality management program according to R9-10-1204;

5. Review and evaluate the effectiveness of the quality management program at least once every 12 months;

6. Designate, in writing, an acting administrator who has the qualifications established in subsection (A)(2)(b) if the administrator is:

a. Expected not to be present in a home health agency's administrative office for more than 30 calendar days, or

b. Not present in a home health agency's administrative office for more than 30 calendar days;

7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the administrator and identify the name and qualifications of the new administrator;

8. Appoint, according to A.R.S. § 36-151(5)(b), an advisory group that consists of four or more members that include:

a. A physician;

b. A registered nurse who has at least one year of experience as a registered nurse providing home health services; and

c. Two or more individuals who represent a medical, nursing, or health-related profession; and

9. Ensure that the advisory group appointed according to subsection (A)(8):

a. Meets at least once every 12 months,

b. Documents meetings, and

c. Assists in establishing and evaluating policies and procedures for the home health agency.

B. An administrator:

1. Is directly accountable to the governing authority of a home health agency for all services provided by the home health agency;

2. Has the authority and responsibility to manage the home health agency;

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present at the home health agency's administrative office and accountable for services provided by the home health agency when the administrator is not present at the home health agency's administrative office; and

4. Ensures compliance with A.R.S. § 36-411.

C. An administrator shall:

1. Ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

a. Cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, and volunteers;

b. Cover orientation and in-service education for personnel members, employees, and volunteers;

c. Cover how a personnel member may submit a complaint relating to patient care;

d. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11;

e. Include a method to identify a patient to ensure the patient receives the appropriate services;

f. Cover patient rights, including assisting a patient who does not speak English or who has a disability to become aware of patient rights;

g. Cover specific steps for:

i. A patient to file a complaint, and

ii. The home health agency to respond to a patient complaint;

h. Cover health care directives;

i. Cover medical records, including electronic medical records;

j. Cover a quality management program, including incident reports and supporting documentation;

k. Cover contracted services; and

l. Cover and designate which personnel members or employees are required to have current certification in cardiopulmonary resuscitation and first aid training;

2. Ensure that policies and procedures for services provided by a home health agency are established, documented, and implemented to protect the health and safety of a patient that:

a. Cover patient admission, discharge planning, and discharge;

b. Cover the provision of home health services and, if applicable, specific types of supportive services and medical social services;

c. Include when general consent and informed consent are required;

d. Cover how personnel members will respond to a patient's sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;

e. Cover medication procurement, if applicable, and administration; and

f. Cover infection control;

3. Ensure that policies and procedures are:

a. Available to personnel members, employees, and volunteers, and

b. Reviewed at least once every three years and updated as needed;

4. Ensure that records of advisory group meetings are maintained for at least 24 months after the date of the meeting;

5. Designate, in writing, a home health services director who is:

a. A physician with at least 24 months of experience working for or with a home health agency; or

b. A registered nurse with at least three years of nursing experience, including at least 24 months of experience as a registered nurse providing home health services;

6. Ensure that:

a. Speech therapy or speech-language pathology services are provided by a speech-language pathologist according to A.R.S. § 36-1940.01 or speech-language pathologist assistant licensed according to A.R.S. § 36-1940.04;

b. Nutritional services are provided by a registered dietitian;

c. Occupational therapy services are provided by an occupational therapist or occupational therapy assistant;

d. Physical therapy services are provided by a physical therapist or a physical therapist assistant;

e. Respiratory care services are provided by a respiratory therapist, respiratory therapy technician licensed according to A.R.S. Title 32, Chapter 35, or a practical nurse or registered nurse licensed according to A.R.S. Title 32, Chapter 15;

f. Pharmacy services are provided by a pharmacist; and

g. Medical social services are provided:

i. By a personnel member qualified according to policies and procedures that coordinates medical social services; and

ii. For medical social services, related to the practice of social work in A.R.S. § 32-3251, by a personnel member licensed under A.R.S. Title 32, Chapter 33, Article 5;

7. Ensure that the services specified in subsection (C)(6) are provided to a patient only under an order by the patient's physician, registered nurse practitioner, or podiatrist, as applicable; and

8. Unless otherwise stated, ensure that:

a. Documentation required by this Article is provided to the Department within two hours after a Department request; and

b. When documentation or information is required by this Chapter to be submitted on behalf of a home health agency, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the home health agency.

Ariz. Admin. Code § R9-10-1203

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, effective 7/1/2014. Amended by final expedited rulemaking at 25 A.A.R. 3391, effective 11/6/2019.