Section R9-10-1702. Administration

A.      A governing authority for a health care institution not other- wise classified or subclassified in A.R.S. Title 36, Chapter 4 or 9 A.A.C. 10 shall:

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

2.        Establish, in writing:

a.         A health care institution’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- 10-1703;

5.        Review and evaluate the effectiveness of the quality man- agement program in R9-10-1703 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 on a health care institu- tion’s premises for more than 30 calendar days, or

b.        Not present on a health care institution’s premises for more than 30 calendar days; and

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

B.       An administrator:

1.        Is directly accountable to the governing authority of a health care institution for the daily operation of the health care institution and all services provided by or at the health care institution;

2.        Has the authority and responsibility to manage the health care institution; and

3.        Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the health care institution’s premises and accountable for the health care institution when the administrator is not present on the health care institution’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, knowledge, education, and experience for personnel members, employees, vol- unteers and students;

b.        Cover orientation and in-service education for per- sonnel members, employees, volunteers and stu- dents;

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

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

e.         Cover cardiopulmonary resuscitation training, including:

i.         The method and content of cardiopulmonary resuscitation training,

ii.        The qualifications for an individual providing cardiopulmonary resuscitation training,

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

iv.       The documentation that verifies that the indi- vidual has received cardiopulmonary resuscita- tion training;

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

g.        Cover first aid training;

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

i.         Cover specific steps for:

i.         A patient to file a complaint, and

ii.        The health care institution to respond to and resolve a patient complaint;

j.         Cover medical records, including electronic medical records;

k.        Cover a quality management program, including incident report and supporting documentation;

l.         Cover contracted services;

m.       Cover health care directives; and

n.        Cover when an individual may visit a patient in a health care institution;

2.        Policies and procedures for health care institution ser- vices are established, documented, and implemented to protect the health and safety of a patient that:

a.         Cover patient screening, admission, assessment, treatment plan, transport, transfer, and discharge, if applicable;

b.        Cover patient outings, if applicable;

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

d.        Cover the provision of services listed in the health care institution's scope of services;

e.         Cover administering medication, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory con- trol and preventing diversion of controlled sub- stances, if applicable;

f.         Cover infection control;

g.        Cover telemedicine, if applicable;

h.        Cover environmental services that affect patient care;

i.         Cover smoking and the use of tobacco products on the health care institution’s premises;

j.         Cover how the health care institution will respond to a patient's sudden, intense, or out-of-control behav- ior to prevent harm to the patient or another individ- ual;

k.        Cover how incidents are reported and investigated; and

l.         Designate which employees or personnel members are required to have current certification in cardio- pulmonary resuscitation and first aid training;

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

4.        Policies and procedures are available to personnel mem- bers, employees, volunteers, and students; and

5.        Unless otherwise stated:

a.         Documentation required by this Article is provided to the Department within two hours after the Depart- ment’s request; and

b.        When documentation or information is required by this Chapter to be submitted on behalf of a health care institution, the documentation or information is provided to the unit in the Department that is respon-

sible for licensing and monitoring the health care institution.

D.      If applicable, an administrator shall designate a clinical direc- tor who:

1.        Provides direction for behavioral health services provided at the health care institution, and

2.        Is a behavioral health professional.

E.       An administrator shall provide written notification to the Department of a patient’s:

1.        Death, if the patient’s death is required to be reported according to A.R.S. § 11-593, within one working day after the patient’s death; and

2.        Self-injury, within two working days after the patient inflicts a self-injury that requires immediate intervention by an emergency medical services provider.

F.       If abuse, neglect, or exploitation of a patient is alleged or sus- pected to have occurred before the patient was admitted or while the patient is not on the premises and not receiving ser- vices from a health care institution’s employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the patient as follows:

1.        For a patient 18 years of age or older, according to A.R.S.

§ 46-454; or

2.        For a patient under 18 years of age, according to A.R.S. § 13-3620.

G.      If an administrator has a reasonable basis, according to A.R.S.

§ 13-3620 or 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while the patient is receiving unclassified healthcare services, the administrator shall:

1.        If applicable, take immediate action to stop the suspected abuse, neglect, or exploitation;

2.        Report the suspected abuse, neglect, or exploitation of the patient:

a.         For a patient 18 years of age or older, according to

A.R.S. § 46-454; or

b.        For a patient under 18 years of age, according to

A.R.S. § 13-3620;

3.        Document:

a.         The suspected abuse, neglect, or exploitation;

b.        Any action taken according to subsection (G)(1); and

c.         The report in subsection (G)(2);

4.        Maintain the documentation in subsection (G)(3) for at least 12 months after the date of the report in subsection (G)(2);

5.        Initiate an investigation of the suspected abuse, neglect, or exploitation and document the following information within five working days after the report required in (G)(2):

a.         The dates, times, and description of the suspected abuse, neglect, or exploitation;

b.        A description of any injury to the patient related to the suspected abuse or neglect and any change to the patient’s physical, cognitive, functional, or emo- tional condition;

c.         The names of witnesses to the suspected abuse, neglect, or exploitation; and

d.        The action taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occur- ring in the future; and

6.        Maintain a copy of the documented information required in subsection (G)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

H.      An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are

available upon request to a personnel member, an employee, a patient, or a patient’s representative:

1.        The health care institution’s current license,

2.        The evacuation plan listed in R9-10-1711, and

3.        The location at which inspection reports required in R9- 10-1712(B) are available for review or can be made avail- able for review.

Historical Note

Adopted effective July 6, 1994 (Supp. 94-3). Amended by final rulemaking at 16 A.A.R. 688, effective Novem- ber 1, 2010 (Supp. 10-2). Section 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, pursuant to Laws 2013, Ch. 10, § 13; effec- tive July 1, 2014 (Supp. 14-2).