Ariz. Admin. Code § 9-10-203

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

Section R9-10-203 - Administration

A. A governing authority shall:

1. Consist of one or more individuals responsible for the organization, operation, and administration of a hospital;

2. Establish, in writing:

a. A hospital's scope of services,

b. Qualifications for an administrator,

c. Which organized services are to be provided in the hospital, and

d. The organized services that are to be provided in a multi-organized service unit according to R9-10-228(A);

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

4. Grant, deny, suspend, or revoke a clinical privilege of a medical staff member or delegate authority to an individual to grant or suspend a clinical privilege for a limited time, according to medical staff bylaws;

5. Adopt a quality management program according to R9-10-204;

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

7. 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 on a hospital's premises for more than 30 calendar days, or

b. Not present on a hospital's premises for more than 30 calendar days;

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

9. For a health care institution under a single group license, ensure that the health care institution complies with the applicable requirements in this Chapter for the class or subclass of the health care institution.

B. An administrator:

1. Is directly accountable to the governing authority of a hospital for the daily operation of the hospital and hospital services and environmental services provided by or at the hospital;

2. Has the authority and responsibility to manage the hospital; and

3. Except as provided in subsection (A)(7), shall designate, in writing, an individual who is present on a hospital's premises and available and accountable for hospital services and environmental services when the administrator is not present on the hospital's premises.

C. An administrator shall ensure that:

1. 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 and knowledge for personnel members, employees, volunteers, and students;

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

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

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

e. Cover cardiopulmonary resuscitation training required in R9-10-206(5) including:

i. The method and content of cardiopulmonary resuscitation training,

ii. The qualifications for an individual to provide cardiopulmonary resuscitation training,

iii. The time-frame for renewal of cardiopulmonary resuscitation training, and

iv. The documentation that verifies an individual has received cardiopulmonary resuscitation training;

f. Cover use of private duty staff, if applicable;

g. Cover diversion, including:

i. The criteria for initiating diversion;

ii. The categories or levels of personnel or medical staff that may authorize or terminate diversion;

iii. The method for notifying emergency medical services providers of initiation of diversion, the type of diversion, and termination of diversion; and

iv. When the need for diversion will be reevaluated;

h. Include a method to identify a patient to ensure the patient receives hospital services as ordered;

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

j. Cover health care directives;

k. Cover medical records, including electronic medical records;

l. Cover quality management, including incident reports and supporting documentation;

m. Cover contracted services;

n. Cover tissue and organ procurement and transplant; and

o. Cover when an individual may visit a patient in a hospital, including visiting a neonate in a nursery, if applicable;

2. Policies and procedures for hospital services are established, documented, and implemented to protect the health and safety of a patient that:

a. Cover patient screening, admission, transport, and transfer;

b. Cover discharge planning and discharge, including the requirements in R9-10-225(B) for an inpatient who was admitted after a suicide attempt or who exhibits suicidal ideation;

c. Cover the provision of hospital services;

d. Cover acuity, including a process for obtaining sufficient nursing personnel to meet the needs of patients;

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

f. Include the age criteria for providing hospital services to pediatric patients;

g. Cover dispensing, administering, and disposing of medication;

h. Cover prescribing a controlled substance to minimize substance abuse by a patient;

i. Cover infection control;

j. Cover restraints that:

i. Require an order, including the frequency of monitoring and assessing the restraint; or

ii. Are necessary to prevent imminent harm to self or others, including how personnel members will respond to a patient's sudden, intense, or out-of-control behavior;

k. Cover seclusion of a patient including:

i. The requirements for an order, and

ii. The frequency of monitoring and assessing a patient in seclusion;

l. Cover communicating with a midwife when the midwife's client begins labor and ends labor;

m. Cover telemedicine, if applicable; and

n. Cover environmental services that affect patient care;

3. Policies and procedures are reviewed at least once every three years and updated as needed;

4. Policies and procedures are available to personnel members;

5. The licensed capacity in an organized service is not exceeded, except for an emergency admission of a patient;

6. A patient is only admitted to an organized service that has exceeded the organized service's licensed capacity after a medical staff member reviews the medical history of the patient and determines that the patient's admission is an emergency; and

7. Unless otherwise stated:

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 hospital, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the hospital.

D. An administrator of a special hospital shall ensure that:

1. Medical services are available to an inpatient in an emergency based on the inpatient's medical conditions and the scope of services provided by the special hospital; and

2. A physician or nurse, qualified in cardiopulmonary resuscitation, is on the hospital premises.

Ariz. Admin. Code § R9-10-203

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 final rulemaking at 12 A.A.R. 4004, effective December 5, 2006 (Supp. 06-4). Amended by final rulemaking at 14 A.A.R. 4646, effective December 2, 2008 (Supp. 08-4). Amended by final rulemaking at 16 A.A.R. 688, effective November 1, 2010 (Supp. 10-2). 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. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by exempt rulemaking at 27 A.A.R. 661, effective 5/1/2021.