Section R9-10-902. Administration

A.      A governing authority shall:

1.        Consist of one or more individuals responsible for the organization, operation, and administration of an outpa- tient surgical center;

2.        Establish, in writing:

a.         An outpatient surgical center’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.        Grant, deny, suspend, or revoke clinical privileges of a physician and other members of the medical staff and delineate, in writing, the clinical privileges of each medi- cal staff member, according to the medical staff by-laws;

5.        Adopt a quality management plan according to R9-10- 903;

6.        Review and evaluate the effectiveness of the quality man- agement plan 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 an outpatient surgical center’s premises for more than 30 calendar days, or

b.        Not present on an outpatient surgical center’s prem- ises for more than 30 calendar days; and

8.        Except as provided in subsection (A)(7), 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.

B.       An administrator:

1.        Is directly accountable to the governing authority of an outpatient surgical center for the daily operation of the outpatient surgical center and for all services provided by or at the outpatient surgical center;

2.        Has the authority and responsibility to manage the outpa- tient surgical center; and

3.        Except as provided in subsection (A)(7), designates, in writing, an individual who is present on an outpatient sur- gical center’s premises and accountable for the outpatient surgical center when the administrator is not present on the outpatient surgical center’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 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 that the patient receives services as ordered;

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 outpatient surgical center 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; and

k.        Cover contracted services;

2.        Policies and procedures for medical services and nursing services provided by an outpatient surgical center are established, documented, and implemented to protect the health and safety of a patient that:

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

b.        Cover the provision of medical services, nursing ser- vices, and health-related services in the outpatient surgical center’s scope of services;

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

d.        Cover dispensing, administering, and disposing of medications;

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

f.         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;

g.        Cover infection control; and

h.        Cover environmental services that affect patient care;

3.        Policies and procedures are:

a.         Available to personnel members, employees, volun- teers, and students of the outpatient surgical center; and

b.        Reviewed at least once every three years and updated as needed;

4.        A pharmacy maintained by the outpatient surgical center is licensed according to A.R.S. Title 32, Chapter 18;

5.        Pathology services are provided by a laboratory that holds a certificate of accreditation, certificate of compli-

ance, or certificate of waiver issued by the U.S. Depart- ment of Health and Human Services under the 1988 amendments to the Clinical Laboratories Act of 1967;

6.        If the outpatient surgical center meets the definition of “abortion clinic” in A.R.S. § 36-449.01, abortions and related services are provided in compliance with the requirements in Article 15 of this Chapter; 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 an outpa- tient surgical center, the documentation or informa- tion is provided to the unit in the Department that is responsible for licensing and monitoring the outpa- tient surgical center.

Historical Note

Adopted effective February 17, 1995 (Supp. 95-1). Sec- tion repealed; new Section made by final rulemaking at 9

A.A.R. 338, effective March 16, 2003 (Supp. 03-1). Sec- tion repealed; new 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).