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 quali- fications 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 man- agement 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 administra- tive 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 expe- rience 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 ser- vices  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, docu- mented, 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 per- sonnel members, employees, and volunteers;

c.         Cover how a personnel member may submit a com- plaint 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 train- ing;

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, supportive 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 main- tained 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 nurs- ing experience, including at least 24 months of expe-

rience as a registered nurse providing home health services;

6.        Ensure that:

a.         Speech therapy or speech-language pathology ser- vices are provided by a speech-language pathologist 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 assis- tant;

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

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

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 medi- cal social services; and

ii.        For medical social services that require a license under A.R.S. Title 32, Chapter 33, Arti- cle 5, 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 Depart- ment 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 respon- sible for licensing and monitoring the home health agency.

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).