Ariz. Admin. Code § 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 qualifications 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 individual to grant or suspend a clinical privilege for a limited time,
according to medical staff bylaws;
5. Adopt a quality management program
according to
R9-10-204 ;
6. Review and evaluate the effectiveness of
the quality management 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 hospital
services and environmental services provided by or at the hospital;
2. Has the authority and responsibility to
manage the hospital; 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 services 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 personnel members,
employees, volunteers, and students;
b. Cover orientation and in-service education
for personnel members, employees, volunteers, and students;
c. Include how a personnel member may submit
a complaint relating to patient care;
d. Cover the requirements in Title 36,
Chapter 4, Article 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
cardiopulmonary 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 medical staff that may authorize or
terminate diversion;
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
reevaluated;
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 reports 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 established, documented, and implemented to protect the health and
safety of a patient that:b.
c. Cover the provision of hospital services;
c.
d.
Cover acuity, including a process for obtaining sufficient nursing personnel to
meet the needs of patients;
d.
e. Include when general
consent and informed consent are required;
e.
f. Include the age
criteria for providing hospital services to pediatric patients;
f.
g.
Cover dispensing, administering, and disposing of medication;
g.
h.
Cover prescribing a controlled substance to minimize substance abuse by a
patient;
h.
i. Cover infection control;
i.
j. Cover restraints
that:
j.
k.
Cover seclusion of a patient including:
k.
l. Cover communicating with a midwife when the
midwife's client begins labor and ends labor;
l.
m. Cover telemedicine,
if applicable; and
m.
n. Cover environmental services that affect patient
care;
a. Cover patient
screening, admission, transport, and transfer;
b. Cover discharge planning and discharge,
including the requirements in
R9-10-225(B) for
an inpatient who was admitted after a suicide attempt or who exhibits suicidal
ideation;
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;
i. The
requirements for an order, and
ii.
The frequency of monitoring and assessing a patient in seclusion;
3. Policies and
procedures are reviewed at least once every three years and updated as
needed;
4. Policies and procedures
are available to personnel members;
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 Department 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 licensing and monitoring the
hospital.
D.
An administrator of a special hospital shall ensure that:
1. Medical services are available to an
inpatient in an emergency 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 resuscitation, is on the hospital premises.
Notes
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No prior version found.