Ariz. Admin. Code § 9-10-307

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-307 - Admission; Assessment

A. Except as provided in R9-10-315(E) or (F), an administrator shall ensure that:

1. A patient is admitted based upon the patient's presenting behavioral health issue and treatment needs and the behavioral health inpatient facility's ability and authority to provide physical health services, behavioral health services, and ancillary services consistent with the patient's treatment needs;

2. A patient is admitted on the order of a medical practitioner or clinical director;

3. A medical practitioner or clinical director, authorized by policies and procedures to accept a patient for admission, is available;

4. Except in an emergency or as provided in subsections (A)(6) and (7), general consent is obtained from a patient or, if applicable, the patient's representative before or at the time of admission;

5. The general consent obtained in subsection (A)(4) or the lack of consent in an emergency is documented in the patient's medical record;

6. General consent is not required from a patient receiving a court-ordered evaluation or court-ordered treatment;

7. General consent is not required from a patient receiving treatment according to A.R.S. § 36-512;

8. A medical practitioner performs a medical history and physical examination on a patient within 30 calendar days before admission or within 24 hours after admission and documents the medical history and physical examination in the patient's medical record within 24 hours after admission;

9. If a medical practitioner performs a medical history and physical examination on a patient before admission, the medical practitioner enters an interval note into the patient's medical record within seven calendar days after admission;

10. Except when a patient needs crisis services, a behavioral health assessment of a patient is completed to determine the acuity of the patient's behavioral health issue and to identify the behavioral health services needed by the patient before treatment for the patient is initiated and whenever the patient has a significant change in condition or experiences an event that affects treatment;

11. If the patient was admitted after a suicide attempt or exhibits suicidal ideation, the behavioral health assessment in subsection (A)(10) includes a suicide assessment;

12. If a behavioral health assessment in subsection (A)(10), including a suicide assessment in subsection (A)(11) if applicable, is conducted by a:

a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed under A.R.S. Title 32 to provide the behavioral health services needed by the patient, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by and the acuity of the patient; or

b. Behavioral health paraprofessional, a behavioral health professional, certified or licensed under A.R.S. Title 32 to provide the behavioral health services 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 behavioral health assessment identifies the behavioral health services needed by and the acuity of the patient;

13. When a patient is admitted, a registered nurse:

a. Conducts a nursing assessment of a patient's medical condition and history;

b. Determines whether the:

i. Patient requires immediate physical health services, and

ii. Patient's behavioral health issue may be related to the patient's medical condition and history;

c. Determines the acuity of the patient's medical condition;

d. Documents the patient's nursing assessment and the determinations required in subsection (A)(13)(b) and (c) in the patient's medical record; and

e. Signs the patient's medical record;

14. A behavioral health assessment:

a. Documents the patient's:

i. Presenting issue, including the acuity of the patient's presenting issue;

ii. Substance abuse history;

iii. Co-occurring disorder;

iv. Legal history, including:

(1) Custody,

(2) Guardianship, and

(3) Pending litigation;

v. Court-ordered evaluation;

vi. Court-ordered treatment;

vii. Criminal justice record;

viii. Family history;

ix. Behavioral health treatment history;

x. Symptoms reported by the patient; and

xi. Referrals needed by the patient, if any; and

b. Includes:

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

ii. Recommendations for staffing levels or personnel member qualifications related to the patient's treatment to ensure patient health and safety;

iii. For a patient who:

(1) Is admitted to receive crisis services, the behavioral health services and physical health services that will be provided to the patient; or

(2) Does not need crisis services, the behavioral health services or physical health services that will be provided to the patient until the patient's treatment plan is completed; and

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

15. 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;

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

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

18. The request in subsection (A)(16) and the opportunity in subsection (A)(17) are documented in the patient's medical record;

19. For a patient who is admitted to receive crisis services, the patient's behavioral health assessment is documented in the patient's medical record within eight hours after admission;

20. Except as provided in subsection (A)(19), a patient's behavioral health assessment is documented in the patient's medical record within 24 hours after completing the assessment; and

21. If the information listed in subsection (A)(14) 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.

B. If the results of a suicide assessment required in subsection (A)(11) indicate that the patient could be a danger to self upon discharge, an administrator shall ensure that the information in R9-10-309(B)(2) is made available to the patient or the patient's representative as part of the opportunity for participation in the patient's behavioral health assessment required in subsection (A)(17).

Ariz. Admin. Code § R9-10-307

New Section R9-10-307 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.