Ariz. Admin. Code § 9-10-1003

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-1003 - Administration

A. If an outpatient treatment center is operating under a single group license issued to a hospital according to A.R.S. § 36-422(F) or (G), the hospital's governing authority is the governing authority for the outpatient treatment center.

B. A governing authority shall:

1. Consist of one or more individuals accountable for the organization, operation, and administration of an outpatient treatment center;

2. Establish, in writing:

a. An outpatient treatment center's scope of services, and

b. Qualifications for an administrator;

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

4. Adopt a quality management program according to R9-10-1004;

5. Review and evaluate the effectiveness of the quality management program in R9-10-1004 at least once every 12 months;

6. Designate, in writing, an acting administrator who has the qualifications established in subsection (B)(2)(b) if the administrator is:

a. Expected not to be present on an outpatient treatment center's premises for more than 30 calendar days, or

b. Not present on an outpatient treatment center's premises for more than 30 calendar days; and

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

C. An administrator:

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

2. Has the authority and responsibility to manage the outpatient treatment center; and

3. Except as provided in subsection (B)(6), designates, in writing, an individual who is present on the outpatient treatment center's premises and accountable for the outpatient treatment center when the administrator is not available.

D. 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 services provided to a patient;

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

e. Cover cardiopulmonary resuscitation training including:

i. The method and content of cardiopulmonary resuscitation training which includes a demonstration of the individual's ability to perform cardiopulmonary resuscitation,

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 that an individual has received cardiopulmonary resuscitation training;

f. Cover first aid training;

g. Include a method to identify a patient to ensure the patient receives the services ordered for the patient;

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 health care directives;

j. Cover medical records, including electronic medical records;

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

l. Cover contracted services;

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

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

b. Cover the provision of medical services, nursing services, behavioral health services, health-related services, and ancillary services;

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

d. Cover obtaining, administering, storing, and disposing of medications, including provisions for controlling inventory and preventing diversion of controlled substances;

e. Cover prescribing a controlled substance to minimize substance abuse by a patient;

f. Cover infection control;

g. Cover telemedicine, if applicable;

h. Cover environmental services that affect patient care;

i. Cover specific steps for:

i. A patient to file a complaint, and

ii. An outpatient treatment center to respond to a complaint;

j. Cover smoking tobacco products on an outpatient treatment center's premises; and

k. 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;

3. Outpatient treatment center policies and procedures are:

a. Reviewed at least once every three years and updated as needed, and

b. Available to personnel members and employees;

4. 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 an outpatient treatment center, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the outpatient treatment center;

5. The following are conspicuously posted:

a. The current license for the outpatient treatment center issued by the Department;

b. The name, address, and telephone number of the Department;

c. A notice that a patient may file a complaint with the Department about the outpatient treatment center;

d. One of the following:

i. A schedule of rates according to A.R.S. § 36-436.01(C), or

ii. A notice that the schedule of rates required in A.R.S. § 36-436.01(C) is available for review upon request;

e. A list of patient rights;

f. A map for evacuating the facility; and

g. A notice identifying the location on the premises where current license inspection reports required in A.R.S. § 36-425(D), with patient information redacted, are available; and

6. Patient follow-up instructions are:

a. Provided, orally or in written form, to a patient or the patient's representative before the patient leaves the outpatient treatment center unless the patient leaves against a personnel member's advice; and

b. Documented in the patient's medical record.

E. If abuse, neglect, or exploitation of a patient is alleged or suspected to have occurred before the patient was admitted or while the patient is not on the premises and not receiving services from an outpatient treatment center'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.

F. If an administrator has a reasonable basis, according to A.R.S. § 13-3620 or 46-454, to believe that abuse, neglect, or exploitation has occurred on the premises or while a patient is receiving services from an outpatient treatment center's employee or personnel member, an 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 as follows:

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 (F)(1); and

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

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

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

d. The actions taken by the administrator to prevent the suspected abuse, neglect, or exploitation from occurring in the future; and

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

G. If an outpatient treatment center is an affiliated outpatient treatment center, an administrator shall ensure that the outpatient treatment center complies with the requirements for an affiliated outpatient treatment center in 9 A.A.C. 10, Article 19.

Ariz. Admin. Code § R9-10-1003

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). 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, effective 7/1/2014. Amended by exempt rulemaking at 20 A.A.R. 3535, effective 1/1/2015. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019.