Ariz. Admin. Code § 9-10-2106

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

Section R9-10-2106 - Medical Staff

A. A governing authority shall require that:

1. The organized medical staff is directly accountable to the governing authority for the quality of care provided by a medical staff member to a patient in a recovery care center;

2. The medical staff bylaws and medical staff regulations are approved according to the medical staff bylaws and governing authority requirements;

3. A medical staff member complies with medical staff bylaws and medical staff regulations;

4. The medical staff includes at least two physicians who have clinical privileges to admit patients to the recovery care center;

5. A medical staff member is available to direct patient care;

6. Medical staff bylaws or medical staff regulations are established, documented, and implemented for the process of:

a. Conducting peer review according to A.R.S. Title 36, Chapter 4, Article 5;

b. Appointing members to the medical staff, subject to approval by the governing authority;

c. Establishing committees, including identifying the purpose and organization of each committee;

d. Appointing one or more medical staff members to a committee;

e. Requiring that each patient has a medical staff member who coordinates the patient's care;

f. Defining the responsibilities of a medical staff member to provide medical services to the medical staff member's patient;

g. Defining a medical staff member's responsibilities for the transfer of a patient;

h. Specifying requirements for oral, telephone, and electronic orders, including which orders require identification of the time of the order;

i. Establishing a time-frame for a medical staff member to complete a patient's medical record; and

j. Establishing criteria for granting, denying, revoking, and suspending clinical privileges; and

7. The organized medical staff reviews the medical staff bylaws and the medical staff regulations at least once every three years and updates the bylaws and regulations as needed.

B. An administrator shall ensure that:

1. A medical staff member provides evidence of freedom from infectious tuberculosis as specified in R9-10-113 before providing services at the recovery care center and at least once every 12 months thereafter;

2. A record for each medical staff member is established and maintained that includes:

a. A completed application for clinical privileges,

b. The dates and lengths of appointment and reappointment of clinical privileges,

c. The specific clinical privileges granted to the medical staff member including revision or revocation dates for each clinical privilege, and

d. A verification of current Arizona health care professional active license according to A.R.S. Title 32; and

3. Except for documentation of peer review conducted according to A.R.S. § 36-445, a record under subsection (B)(2) is provided to the Department for review:

a. For a current medical staff member, within 2 hours after the Department's request, or

b. Within 72 hours after the time of the Department's request if the individual is no longer a current medical staff member.

Ariz. Admin. Code § R9-10-2106

Renumbered from R9-10-506 by final rulemaking at 25 A.A.R. 1222, effective 4/25/2019