1. A. A governing authority shall:

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

   2. 2. Establish, in writing:

      1. a. A hospital’s scope of services,
      2. b. Qualifications for an administrator,
      3. c. Which organized services are to be provided in the hospital, and
      4. d. The organized services that are to be provided in a multi-organized service unit according to R9-10-228(A);
   3. 3. Designate, in writing, an administrator who has the qualifications established in subsection (A)(2)(b);
   4. 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. 5. Adopt a quality management program according to R9-10-204;
   6. 6. Review and evaluate the effectiveness of the quality management program at least once every 12 months;

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

      1. a. Expected not to be present on a hospital’s premises for more than 30 calendar days, or
      2. b. Not present on a hospital’s premises for more than 30 calendar days;
   8. 8. Except as provided in subsection (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. 9. For a health care institution under a single group license, except for outpatient treatment centers, that are exempt pursuant to A.R.S. § 36-402, ensure that the health care institution complies with the applicable requirements in this Chapter for the class or subclass of the health care institution.

2. B. An administrator:

   1. 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. 2. Has the authority and responsibility to manage the hospital; and
   3. 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.

3. C. An administrator shall ensure that:

   1. 1. Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

      1. a. Cover job descriptions, duties, and qualifications, including required skills and knowledge for personnel members, employees, volunteers, and students;
      2. b. Cover orientation and in-service education for personnel members, employees, volunteers, and students;
      3. c. Include how a personnel member may submit a complaint relating to patient care;

      4. d. Cover the prevention and reporting of abuse, neglect, and exploitation of minors and vulnerable adults in compliance with A.R.S. §§ 13-3620 and 46-454 including:

         1. i. Annual training for personnel members who have patient interaction, prescribed in the hospital’s policies and procedures on how to recognize the signs and symptoms of minor or vulnerable adult abuse, neglect, and exploitation;
         2. ii. Reporting suspected abuse, neglect or exploitation of a minor or vulnerable adult;
         3. iii. Submitting to the Department reports of suspected abuse, neglect or exploitation that are filed with law enforcement or the Department of Economic Security; and
         4. iv. Maintaining documentation relating to an abuse, neglect, or exploitation investigation for at least 12 months after an initial allegation, including any steps taken to stop or deter substantiated abuse, neglect, or exploitation;
      5. e. Cover the requirements in A.R.S. Title 36, Chapter 4, Article 11;

      6. f. Cover cardiopulmonary resuscitation training required in R9-10-206(5) including:

         1. i. The method and content of cardiopulmonary resuscitation training,
         2. ii. The qualifications for an individual to provide cardiopulmonary resuscitation training,
         3. iii. The time-frame for renewal of cardiopulmonary resuscitation training, and
         4. iv. The documentation that verifies an individual has received cardiopulmonary resuscitation training;
      7. g. Cover use of private duty staff, if applicable;
      8. h. Cover diversion, including:

      9. i. The criteria for initiating diversion;

         1. ii. The categories or levels of personnel or medical staff that may authorize or terminate diversion;
         2. iii. The method for notifying emergency medical services providers of initiation of diversion, the type of diversion, and termination of diversion; and
         3. iv. When the need for diversion will be reevaluated;
         4. i. Include a method to identify a patient to ensure the patient receives hospital services as ordered;
      10. j. Cover patient rights, including assisting a patient who does not speak English or who has a disability to become aware of patient rights;
      11. k. Cover health care directives;
      12. l. Cover medical records, including electronic medical records;
      13. m. Cover quality management, including incident reports and supporting documentation;
      14. n. Cover contracted services;
      15. o. Cover tissue and organ procurement and transplant;
      16. p. Cover when an individual may visit a patient in a hospital, including visiting a neonate in a nursery, if applicable, that comply with A.R.S. § 36-407.03; and
      17. q. Cover a workplace violence prevention plan according to A.R.S. § 36-420.03;

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

      1. a. Cover patient screening, admission, transport, and transfer;
      2. 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;
      3. c. Cover the provision of hospital services;
      4. d. Cover acuity, including a process for obtaining sufficient nursing personnel to meet the needs of patients;
      5. e. Include when general consent and informed consent are required;
      6. f. Include the age criteria for providing hospital services to pediatric patients;
      7. g. Cover dispensing, administering, and disposing of medication;
      8. h. Cover prescribing a controlled substance to minimize substance abuse by a patient;
      9. i. Cover infection control;

      10. j. Cover restraints that:

          1. i. Require an order, including the frequency of monitoring and assessing the restraint; or
          2. 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;

      11. k. Cover seclusion of a patient including:

          1. i. The requirements for an order, and
          2. ii. The frequency of monitoring and assessing a patient in seclusion;
      12. l. Cover communicating with a midwife when the midwife’s client begins labor and ends labor;
      13. m. Cover telehealth, if applicable; and
      14. n. Cover environmental services that affect patient care;
   3. 3. Policies and procedures are reviewed at least once every three years and updated as needed;
   4. 4. Policies and procedures are available to personnel members;
   5. 5. The licensed capacity in an organized service is not exceeded, except for an emergency admission of a patient;
   6. 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. 7. Unless otherwise stated:

      1. a. Documentation required by this Article is provided to the Department within two hours after a Department request; and
      2. 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.

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

   1. 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. 2. A physician or nurse, qualified in cardiopulmonary resuscitation, is on the hospital premises.

5. E. An administrator shall provide written notification to the Department of a patient’s:

   1. 1. Death associated with the use of restraints or seclusion by the hospital, within one working day after the patient’s death;
   2. 2. Death caused by suicide occurring within the hospital, within one working day after the patient’s death; and
   3. 3. Self-injury, within two working days after the patient inflicts a self-injury on the premises that requires medical treatment by a physician.

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, effective 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, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2). Amended by final rulemaking at 25 A.A.R. 1583, effective October 1, 2019 (Supp. 19-3). Amended by exempt rulemaking at 27 A.A.R. 661, effective May 1, 2021 (Supp. 21-2). Amended by final rulemaking at 31 A.A.R. 2457 (July 25, 2025), effective August 30, 2025 (Supp. 25-3).