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 quali- fications 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 individ-

ual to grant or suspend a clinical privilege for a limited time, according to medical staff by-laws;

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

6.        Review and evaluate the effectiveness of the quality man- agement 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 hospi- tal services and environmental services provided by or at the hospital;

2.        Has the authority and responsibility to manage the hospi- tal; 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 ser- vices 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 person- nel members, employees, volunteers, 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 patient care;

d.        Cover the requirements in Title 36, Chapter 4, Arti- cle 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 cardiopulmo- nary 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 medi- cal staff that may authorize or terminate diver- sion;

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 reevalu- ated;

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 report 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 estab- lished, documented, and implemented to protect the health and safety of a patient that:

a.         Cover patient screening, admission, transport, trans- fer, discharge planning, and discharge;

b.        Cover the provision of hospital services;

c.         Cover acuity, including a process for obtaining suffi- cient nursing personnel to meet the needs of patients;

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

e.         Include the age criteria for providing hospital ser- vices to pediatric patients;

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

g.        Cover prescribing a controlled substance to mini- mize substance abuse by a patient;

h.        Cover infection control;

i.         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;

j.         Cover seclusion of a patient including:

i.         The requirements for an order, and

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

k.        Cover communicating with a midwife when the midwife’s client begins labor and ends labor;

l.         Cover telemedicine, if applicable; and

m.       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 mem- bers;

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 Depart- ment 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 licens- ing and monitoring the hospital.

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

1.        Medical services are available to an inpatient in an emer- gency 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 resus- citation, is on the hospital premises.

Historical Note

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, effec- tive 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, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).