Ariz. Admin. Code § 6-6-809

Current through Register Vol. 30, No. 50, December 13, 2024

Section R6-6-809 - Policies and Procedures

A. The licensee shall develop and implement policies and procedures which address incidents which occur in the operation of the setting. These policies and procedures shall include, at a minimum:

1. Definitions of events and circumstances which constitute incidents;

2. Procedures for verbally reporting and documenting incidents, consistent with the Division's incident reporting procedures; and

3. Procedures for the review of incidents by the licensee and procedures for the development of corrective action to occur in response to incidents.

B. The licensee shall develop and implement policies and procedures on behavior management which are consistent with the requirements of Article 9. These policies and procedures shall include, at a minimum:

1. Descriptions of positive approaches to behavior management;

2. Procedures for the documentation of maladaptive behaviors not included in the definition of incidents, if applicable;

3. Procedures for the development of behavior treatment plans; and

4. Procedures for the licensee to monitor the effectiveness of behavior treatment plans.

C. The licensee shall develop and implement written policies and procedures for residents for:

1. The following health-related issues:

a. Detection of signs of injury, illness, and changes in health status;

b. Detection of infectious diseases and notification to the Division and other appropriate persons;

c. Response to non-emergency conditions requiring prompt medical attention; and

d. Procedures to be followed in medical emergencies and in rendering emergency medical care.

2. Medications, including nonprescription medications, used by residents which shall include, at a minimum:

a. The training to administer medications;

b. The specific, step-by-step procedures staff are to use in the administration of medications. These procedures shall include:

i. Prevention of contamination;

ii. Instructions for handling various types of medication, including oral, topical, or rectal;

iii. Instructions for verifying that the right medication is given to the right person, at the right time, in the proper dosage, and via the proper route; and

iv. Instructions for documenting the administration of medication on a log or chart.

c. Procedures for recording and reporting medication errors and reactions for residents;

d. Procedures for the agency review and corrective action to occur in response to medication errors;

e. Procedures for having prescriptions filled and maintenance of an adequate supply of medications;

f. Procedures for the safe disposal of expired or discontinued medications;

g. Procedures for the storage and inventory of medications;

h. Provision for self-administration of medications by a client, with the written approval of the ISPP team, if applicable, including criteria for self-administration and requirements for documentation of administration; and

i. Procedures for authenticating, within 72 hours, a medical practitioner's verbal orders for medication.

D. The licensee shall develop and implement policies and procedures which address alleged neglect and abuse of residents. These policies and procedures shall include, at a minimum:

1. Definitions and prohibitions in accordance with A.R.S. § 36-569;

2. Detection of neglect and abuse, including cases occurring outside the agency;

3. Immediate intervention to prevent further neglect and abuse;

4. Reporting in accordance with A.R.S. §§ 13-3620 and 46-454 and R6-6-1601 et seq.;

5. Investigation of alleged neglect and abuse; and

6. Community residential setting review and corrective action to occur in response.

E. The licensee shall develop and implement policies and procedures which address smoking in the community residential setting and which take into account the rights of all residents living in the setting.

F. The licensee shall develop policies and procedures which address the storage and use of alcoholic beverages in the community residential setting and which take into account the rights of all residents living in the setting.

G. The licensee shall develop and implement policies and procedures regarding the internal communication among agency personnel of events affecting clients living in the community residential setting.

H. The licensee shall develop and implement policies and procedures regarding the communication to responsible persons of significant events affecting clients living in the community residential setting.

I. The licensee shall develop and implement policies and procedures which address safeguarding, accounting for, and replacing client property and funds.

J. The licensee shall develop and implement policies and procedures which ensure adequate staffing, consistent with rules related to staff training as specified in R6-6-808 and staff-to-client ratios as specified in R6-6-803. The policies and procedures shall address, at a minimum, planned and unexpected absenteeism, emergencies, and community activities.

K. The licensee shall submit all new or modified policies and procedures required by this Article to the Division for approval.

L. The licensee shall incorporate into policies and procedures any revisions required by the Division.

M. The licensee shall develop and implement policies and procedures which address the role of the community residential setting in the ISPP process, consistent with the requirements of this Article.

N. The licensee shall develop and implement policies and procedures for the maintenance and use of all personally identifiable client information. These policies and procedures shall be consistent with A.R.S. § 36-568.01 and shall address storage, disclosure, retention, and destruction of this information and actions to be taken in the event of violations of these policies and procedures by agency personnel.

Ariz. Admin. Code § R6-6-809

Adopted effective August 30, 1994, under an exemption from the provisions of A.R.S. Title 41, Chapter 6 (Supp. 94-3).