Ariz. Admin. Code § R9-10-603 - Administration

A. A governing authority shall:

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

2. Establish, in writing:

a. A hospice's scope of services, and

b. Qualifications for an administrator;

3. Designate, in writing, an administrator who has the qualifications established in subsection (A)(2)(b);

4. Adopt a quality management plan according to R9-10-604 ;

5. Review and evaluate the effectiveness of the quality management 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:

i. At a hospice service agency's administrative office for more than 30 calendar days, or

ii. On a hospice inpatient facility's premises for more than 30 calendar days; or

b. Not present:

i. At a hospice service agency's administrative office for more than 30 calendar days, or

ii. On a hospice inpatient facility'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(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 a hospice for the daily operation of the hospice and all services provided by or through the hospice;

2. Has the authority and responsibility to manage the hospice;

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the hospice's premises and accountable for the:

a. Hospice service agency when the administrator is not present at the hospice service agency's administrative office, or

b. Inpatient hospice facility when the administrator is not on hospice inpatient facility's premises; and

4. Designates a personnel member to provide direction for volunteers.

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, 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. Include methods to prevent abuse or neglect of a patient, including:

i. Training of personnel members, at least annually, on how to recognize the signs and symptoms of abuse or neglect; and

ii. Reporting of abuse or neglect of a patient;

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

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

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

g.h. Cover specific steps for:

i. A patient to file a complaint, and

ii. The hospice service agency or hospice inpatient facility to respond to a patient's complaint;

h.i. Cover health care directives;

i.j. Cover medical records, including electronic medical records;

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

k.l. Cover contracted services; and

m. Cover information and education to a patient or a patient's representative of proper disposal of schedule II controlled substances in compliance with A.R.S. § 36-425.04;

2. Policies and procedures for hospice services are established, documented, and implemented to protect the health and safety of a patient that:

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

b. Cover the provision of hospice 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 dispensing, administering, and disposing of medication;

f. Cover infection control; and

g. Cover telemedicine, if applicable;

h. Cover clergy visitation procedures in compliance with A.R.S. § 36-407.02;

3. For a hospice inpatient facility, policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

a. Cover visitation of a patient, including:

i. Allowing visitation by individuals 24 hours a day, and

ii. Allowing a visitor to bring a pet to visit the patient;

b. Cover the use and display of a patient's personal belongings; and

c. Cover environmental services that affect patient care;

4. Policies and procedures are reviewed and updated at least once every three years;

5. Policies and procedures are available to personnel members, employees, volunteers, and students; and

6. 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 hospice, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the hospice.

D. An administrator shall designate, in writing, a:

1. Physician as the medical director who has the authority and responsibility for providing direction for the medical services provided by the hospice, and

2. Registered nurse as the director of nursing who has the authority and responsibility for managing nursing services provided by the hospice.

E. An administrator shall ensure that the following are conspicuously posted:

1. The current Department-issued license;

2. The current telephone number of the Department; and

3. The location at which the following are available for review:

a. A copy of the most recent Department inspection report;

b. A list of the services provided by the hospice; and

c. A written copy of rates and charges, as required in A.R.S. § 36-436.03.

Notes

Ariz. Admin. Code § R9-10-603

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, effective 7/1/2014. Amended by final expedited rulemaking at 30 A.A.R. 2499, effective 7/8/2024.