Ariz. Admin. Code § 9-10-303

Current through Register Vol. 30, No. 18, May 3, 2024

Section R9-10-303 - Administration

A. A governing authority shall:

1. Consist of one or more individuals responsible for the organization, operation, and administration of a behavioral health inpatient facility;

2. Establish, in writing:

a. A behavioral health inpatient facility's scope of services, and

b. Qualifications for an administrator;

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

4. Adopt a quality management program according to R9-10-304;

5. Review and evaluate the effectiveness of the quality management program at least once every 12 months;

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

a. Expected not to be present on the behavioral health inpatient facility's premises for more than 30 calendar days, or

b. Not present on the behavioral health inpatient facility's premises for more than 30 calendar days; and

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

B. An administrator:

1. Is directly accountable to the governing authority of a behavioral health inpatient facility for the daily operation of the behavioral health inpatient facility and for all services provided by or at the behavioral health inpatient facility;

2. Has the authority and responsibility to manage the behavioral health inpatient facility; and

3. Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health inpatient facility's premises and accountable for the behavioral health inpatient facility when the administrator is not present on the behavioral health inpatient facility's premises.

C. 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 A.R.S. Title 36, Chapter 4, Article 11;

e. Cover cardiopulmonary resuscitation training including:

i. The method and content of cardiopulmonary resuscitation training,

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 the individual has received cardiopulmonary resuscitation training;

f. Cover first aid training;

g. Cover the requirements in subsection (J), if applicable;

h. Include a method to identify a patient to ensure the patient receives physical health and behavioral health services as ordered;

i. 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;

j. Cover specific steps for:

i. A patient to file a complaint, and

ii. The behavioral health inpatient facility to respond to a patient's complaint;

k. Cover health care directives;

l. Cover medical records, including electronic medical records;

m. Cover quality management, including incident reports and supporting documentation;

n. Cover contracted services; and

o. Cover when an individual may visit a patient in the behavioral health inpatient facility;

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

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

b. Cover discharge planning and discharge, including the requirements in R9-10-309(B) for a patient who was admitted after a suicide attempt or who exhibits suicidal ideation;

c. Cover the provision of behavioral health services and physical health services;

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

e. Cover restraint and, if applicable, seclusion;

f. Cover dispensing, administering, and disposing of medication, including provisions for inventory control and preventing diversion of controlled substances;

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

h. Cover infection control;

i. Cover telemedicine, if applicable;

j. Cover environmental services that affect patient care;

k. Cover patient outings;

l. Cover whether pets and animals are allowed on the premises, including procedures to ensure that any pets or animals allowed on the premises do not endanger the health or safety of patients or the public;

m. If the behavioral health inpatient facility is involved in research, cover the establishment or use of a Human Subject Review Committee;

n. Cover the process for receiving a fee from a patient and refunding a fee to a patient;

o. Cover the process for obtaining patient preferences for social, recreational, or rehabilitative activities and meals and snacks;

p. Cover the security of a patient's possessions that are allowed on the premises; and

q. Cover smoking and the use of tobacco products on the premises;

3. Policies and procedures are reviewed at least once every three years and updated as needed;

4. Policies and procedures are available to personnel members, employees, volunteers and students; and

5. 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 a behavioral health inpatient facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the behavioral health inpatient facility.

D. An administrator shall designate a:

1. Medical director who:

a. Provides direction for physical health services provided by or at the behavioral health inpatient facility;

b. Is a physician or registered nurse practitioner; and

c. May be the same individual as the administrator, if the individual meets the qualifications in subsections (A)(2)(b) and (D)(1)(a) and (b);

2. Clinical director who:

a. Provides direction for the behavioral health services provided by or at the behavioral health inpatient facility;

b. Is a behavioral health professional; and

c. May be the same individual as the administrator, if the individual meets the qualifications in subsections (A)(2)(b) and (D)(2)(a) and (b); and

3. Registered nurse to provide direction for nursing services provided by or at the behavioral health inpatient facility.

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

1. Death, if the patient's death is required to be reported according to A.R.S. § 11-593, within one working day after the patient's death; and

2. Self-injury, within two working days after the patient inflicts a self-injury that requires immediate intervention by an emergency medical services provider.

F. Except as specified in R9-10-318(A)(1), 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 a behavioral health inpatient facility's employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the patient according to A.R.S. § 46-454.

G. If an administrator has a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation has occurred on the premises or while a patient is receiving services from a behavioral health inpatient facility's employee or personnel member, the 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 according to A.R.S. § 46-454;

3. Document:

a. The suspected abuse, neglect, or exploitation;

b. Any action taken according to subsection (G)(1); and

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

4. Maintain the documentation in subsection (G)(3) for at least 12 months after the date of the report in subsection (G)(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 (G)(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 (G)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

H. An administrator shall establish and document the criteria for determining when a patient's absence is unauthorized, including the criteria for a patient who:

1. Was admitted under A.R.S. Title 36, Chapter 5, Articles 1, 2, or 3;

2. Is absent against medical advice; or

3. Is under the age of 18.

I. An administrator shall:

1. For a patient who is under a court's jurisdiction, within an hour after determining that the patient's absence is unauthorized according to the criteria in subsection (H), notify the appropriate court or a person designated by the appropriate court;

2. Document the notification in subsection (I)(1) and the written log required in subsection (I)(3);

3. Maintain a written log of unauthorized absences for at least 12 months after the date of a patient's absence that includes the:

a. Name of a patient absent without authorization;

b. If applicable, name of the person notified as required in subsection (I)(1); and

c. Date of the notification; and

4. Evaluate and take action related to unauthorized absences under the quality management program in R9-10-304.

J. If a behavioral health inpatient facility has a physician or registered nurse practitioner on-call to comply with R9-10-306(J)(1), an administrator shall ensure that:

1. The on-call schedule is documented;

2. Personnel members are aware of:

a. The location at which the on-call schedule is available to personnel members of the behavioral health inpatient facility,

b. The process through which the on-call physician or registered nurse practitioner is contacted,

c. The circumstances that would require the on-call physician or registered nurse practitioner to come to the behavioral health inpatient facility, and

d. The process through which a request is made for the on-call physician or registered nurse practitioner to come to the behavioral health inpatient facility;

3. A request for the on-call physician or registered nurse practitioner to come to the behavioral health inpatient facility is documented, including:

a. The time that a request for the on-call physician or registered nurse practitioner to come to the behavioral health inpatient facility is made,

b. The name of the individual making the request,

c. The reason for the request,

d. The name of the physician or registered nurse practitioner contacted and requested to come to the behavioral health inpatient facility, and

e. The time the on-call physician or registered nurse practitioner arrives at the behavioral health inpatient facility in response to a request;

4. The documentation in subsections (J)(1) and (3) is maintained for at least 12 months after the last date on the documentation; and

5. Documentation related to the request is included in the medical record of the applicable patient.

Ariz. Admin. Code § R9-10-303

New Section R9-10-303 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 rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by exempt rulemaking at 27 A.A.R. 661, effective 5/1/2021.