Ariz. Admin. Code § 9-10-1315

Current through Register Vol. 31, No. 1, January 3, 2025

Section R9-10-1315 - Emergency and Safety Standards

A. A medical director shall ensure that policies and procedures for providing medical emergency treatment to a patient are established, documented, and implemented and include:

1. The medications, supplies, and equipment required on the premises for the medical emergency treatment provided by the behavioral health specialized transitional facility;

2. A system to ensure all medications, supplies, and equipment are available, have not been tampered with, and, if applicable, have not expired;

3. A requirement that a cart or container is available for medical emergency treatment that contains all of the medication, supplies, and equipment specified in the behavioral health specialized transitional facility's policies and procedures;

4. A method to verify and document that the contents of the cart or container in subsection (A)(3) are available for medical emergency treatment; and

5. A method for ensuring a patient may be transported to a hospital or other health care institution to receive treatment for a medical emergency that the behavioral health specialized transitional facility is not able or not authorized to provide.

B. An administrator shall ensure that medical emergency treatment is provided to a patient admitted to the behavioral health specialized transitional facility according to the behavioral health specialized transitional facility's policies and procedures.

C. An administrator shall ensure that the behavioral health specialized transitional facility has:

1. A fire alarm system installed according to the National Fire Protection Association 72: National Fire Alarm and Signaling Code, incorporated by reference in R9-10-104.01, that is in working order; and a sprinkler system installed according to the National Fire Protection Association 13 Standard for the Installation of Sprinkler Systems, incorporated by reference in R9-10-104.01, that is in working order; or

2. An alternative method to ensure a patient's safety, documented and approved by the local jurisdiction.

D. An administrator shall ensure that:

1. A disaster plan is developed, documented, maintained in a location accessible to personnel members and other employees, and, if necessary, implemented that includes:

a. Procedures for protecting the health and safety of patients and other individuals at the behavioral health specialized transitional facility;

b. When, how, and where patients will be relocated;

c. How each patient's medical record will be available to personnel providing services to the patient during a disaster;

d. A plan to ensure each patient's medication will be available to administer to the patient during a disaster; and

e. A plan for obtaining food and water for individuals present in the behavioral health specialized transitional facility or the behavioral health specialized transitional facility's relocation site during a disaster;

2. The disaster plan required in subsection (D)(1) is reviewed at least once every 12 months;

3. A disaster drill is performed on each shift at least once every 12 months;

4. Documentation of a disaster plan review required in subsection (D)(2) and a disaster drill required in subsection (D)(3) is created, is maintained for at least 12 months after the date of the disaster plan review or disaster drill, and includes:

a. The date and time of the disaster plan review or disaster drill;

b. The name of each personnel member, employee, or volunteer participating in the disaster plan review or disaster drill;

c. A critique of the disaster plan review or disaster drill; and

d. If applicable, recommendations for improvement;

5. An evacuation drill is conducted on each shift at least once every three months;

6. Documentation of an evacuation drill is created, is maintained for at least 12 months after the date of the evacuation drill, and includes:

a. The date and time of the evacuation drill;

b. The amount of time taken for all employees and patients to evacuate the behavioral health specialized transitional facility;

c. If applicable, an identification of patients needing assistance for evacuation;

d. Any problems encountered in conducting the evacuation drill; and

e. Recommendations for improvement, if applicable; and

7. An evacuation path is conspicuously posted on each hallway of each floor of the behavioral health specialized transitional facility.

E. An administrator shall:

1. Obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal,

2. Make any repairs or corrections stated on the fire inspection report, and

3. Maintain documentation of a current fire inspection.

Ariz. Admin. Code § R9-10-1315

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 25 A.A.R. 3481, effective 11/5/2019.