Ariz. Admin. Code § 9-10-1909

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

Section R9-10-1909 - Counseling

A. An administrator of a counseling facility shall ensure that:

1. Counseling provided at the counseling facility is provided under the direction of a behavioral health professional;

2. A personnel member who provides counseling is at least 18 years old; and

3. If a counseling facility provides counseling to a patient who is less than 18 years of age, an employee or a volunteer and the owner comply with the fingerprint clearance card requirements in A.R.S. § 36-425.03.

B. An administrator of a counseling facility shall ensure that:

1. Before counseling for a patient is initiated, there is a behavioral health assessment for the patient that complies with the requirements in this Section that is:

a. Available:

i. In the patient's medical record maintained by the counseling facility;

ii. If the counseling facility is an affiliated counseling facility, in the patient's integrated medical record; or

iii. If the counseling facility has an affiliated outpatient treatment center, in the patient's integrated medical record maintained by the counseling facility's affiliated outpatient treatment center; and

b. Either:

i. Completed by a personnel member at the counseling facility; or

ii. Obtained from a behavioral health provider other than the counseling facility;

2. A behavioral health assessment, obtained from a behavioral health provider other than the counseling facility or available in a medical record or integrated medical record, was completed within 12 months before the date of the patient's current admission;

3. If a behavioral health assessment is obtained from a behavioral health provider other than the counseling facility or is available as stated in subsection (B)( 1)(a), the information in the behavioral health assessment is reviewed and updated if additional information that affects the patient's behavioral health assessment is identified;

4. The review and update of the patient's assessment information in subsection (B)(3) is documented in the patient's medical record within 48 hours after the review is completed;

5. If a behavioral health assessment is conducted by a:

a. Behavioral health technician or a registered nurse, within 72 hours after the behavioral health assessment is conducted, a behavioral health professional certified or licensed to provide the counseling needed by the patient reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the counseling needed by the patient; or

b. Behavioral health paraprofessional, a behavioral health professional certified or licensed to provide the counseling needed by the patient supervises the behavioral health paraprofessional during the completion of the behavioral health assessment and signs the behavioral health assessment to ensure that the assessment identifies the counseling needed by the patient;

6. A behavioral health assessment:

a. Documents a patient's:

i. Presenting issue;

ii. Substance use history;

iii. Co-occurring disorder;

iv. Medical condition and history;

v. Legal history, including:

(1) Custody,

(2) Guardianship, and

(3) Pending litigation;

vi. Criminal j ustice record;

vii. Family history;

viii. Behavioral health treatment history; and

ix. Symptoms reported by the patient or the patient's representative and referrals needed by the patient, if any;

b. Includes:

i. Recommendations for further assessment or examination of the patient's needs;

ii. A description of the counseling, including type, frequency, and number of hours, that will be provided to the patient; and

iii. The signature and date signed of the personnel member conducting the behavioral health assessment; and

c. Is documented in patient's medical record;

7. A patient is referred to a medical practitioner if a determination is made that the patient requires immediate physical health services or the patient's behavioral health issue may be related to the patient's medical condition;

8. A request for participation in a patient's behavioral health assessment is made to the patient or the patient's representative;

9. An opportunity for participation in the patient's behavioral health assessment is provided to the patient or the patient's representative;

10. Documentation of the request in subsection (B)(8) and the opportunity in subsection (B)(9) is in the patient's medical record;

11. A patient's behavioral health assessment information is documented in the medical record within 48 hours after completing the assessment;

12. If information in subsection (B)(6)(a) is obtained about a patient after the patient's behavioral health assessment is completed, an interval note, including the information, is documented in the patient's medical record within 48 hours after the information is obtained;

13. Counseling is:

a. Offered as described in the counseling facility's scope of services;

b. Provided according to the type, frequency, and number of hours identified in the patient's assessment; and

c. Provided by a behavioral health professional or a behavioral health technician;

14. A personnel member providing counseling to address a specific type of behavioral health issue has the skills and knowledge necessary to provide the counseling that addresses the specific type of behavioral health issue; and

15. Each counseling session is documented in the patient's medical record to include:

a. The date of the counseling session;

b. The amount of time spent in the counseling session;

c. Whether the counseling was individual counseling, family counseling, or group counseling;

d. The treatment goals addressed in the counseling session; and

e. The signature of the personnel member who provided the counseling and the date signed.

C. An administrator may provide any of the following, according to the applicable requirements in 9 A.A.C. 20, to individuals required to attend by a referring court, if approved by the Department to provide the services:

1. DUI screening,

2. DUI education,

3. DUI treatment, or

4. Misdemeanor domestic violence offender treatment.

D. An administrator of a counseling facility authorized to provide the services in subsection (C):

1. Shall comply with the requirements for the specific service in 9 A.A.C. 20, and

2. May have a behavioral health technician who has the appropriate skills and knowledge established in policies and procedures provide the services.

Ariz. Admin. Code § R9-10-1909

Adopted by exempt rulemaking at 20 A.A.R. 3535, effective 1/1/2015. Amended by final expedited rulemaking at 26 A.A.R. 3041, effective 11/3/2020.