Section R6-6-806. Health

A.      At least annually and on forms prescribed by the Division, the licensee shall obtain written informed consent of the guardian, if applicable, for the provision of emergency medical care, routine medical care, and special procedures.

B.       Within 30 calendar days of a client’s initial admission to a community residential setting, the licensee shall obtain docu- mentation of the following:

1.        A physical examination by a medical practitioner;

2.        A tuberculosis screening and results;

3.        A hepatitis B screening and results;

4.        Type of developmental disability;

5.        Medication history;

6.        Immunization history;

7.        History of significant injuries, illnesses, surgeries, and hospitalizations;

8.        History of allergies;

9.        Dental history;

10.     Seizure history;

11.     Developmental history; and

12.     Family medical history.

C.      The licensee shall maintain records in the place of residence sufficient to document the current health status of the resident. These records shall include, at a minimum:

1.        The name, address, and telephone numbers of the health care provider for each resident;

2.        The name and telephone numbers of the health plan and insurance carrier for each resident and the process for authorization of health care for each resident;

3.        Guardianship status for each resident;

4.        The name and telephone number of the responsible party and the person to be contacted in case of emergency for each resident;

5.        Reports of accidents, illness, current treatments, and fol- low-up for at least one year for each resident;

6.        A description of the client’s individualized health care and safety needs, including, at a minimum:

a.         Allergies;

b.        Nutritional needs, whether a regular or special diet;

c.         Special fluid intake needs;

d.        Seizure activity and recommended response;

e.         Adaptive equipment, protective devices, and facility adaptations;

f.         Required medical monitoring;

g.        References to the behavior treatment plan or the ISPP if there are health care-related issues contained therein;

h.        Special instructions for carrying, lifting, positioning, bathing, feeding, or other aspects of personal health care; and

i.         Other individualized health care routines.

7.        The client’s medical history, which includes updated information on all components identified in subsection (B);

8.        Current medication log for each client;

9.        Current health care consents for each client, including:

a.         Consent for the use of sedation, mechanical restraint, or protective devices in the course of planned medical or dental procedures or for follow- up;

b.        Consent for the ongoing or recurring use of a protec- tive device in response to a medical condition; and

c.         Consent for emergency medical care, routine medi- cal care, and special procedures, if applicable;

10.     A copy of “do not resuscitate” orders, for each client, signed by the responsible person, if such an order has been effected.

D.      The licensee shall maintain medical records in their entirety.

E.       The licensee shall maintain documentation of medical consul- tations which include, at a minimum:

1.        The date of the medical consultation;

2.        The name and title of the medical professional consulted;

3.        The purpose of the consultation;

4.        A description of the service or treatment provided; and

5.        Instructions for follow-up, if applicable.

F.       For medications administered by or under the supervision of the direct care staff, the licensee shall ensure that any prescrip- tion or nonprescription medications are administered:

1.        To a client only with the written or verbal orders of a medical practitioner; and

2.        Only to the person for whom it is prescribed or indicated.

G.      The licensee shall maintain a log of all prescribed and nonpre- scribed medications administered to a client by or under the supervision of direct care staff. The medication log shall con- tain, at a minimum:

1.        The name of the client who received the medication;

2.        The name of the medication;

3.        The medication dosage;

4.        The date and time of administration;

5.        The route of administration;

6.        Special instructions for administration of the medication; and

7.        Signature and initials of the direct care staff who adminis- tered or supervised the administration of the medication.

H.      The licensee shall maintain, in a location which is readily accessible to direct care staff who are responsible for medica- tion administration, resource information regarding all medi- cations prescribed for clients living in the setting. The resource information shall include, at a minimum:

1.        Name of the medication;

2.        Common side effects and adverse reactions;

3.        Indications for use;

4.        Medication interactions; and

5.        Recommended monitoring.

I.        The licensee shall store medications in the following manner:

1.        Under sanitary conditions;

2.        Consistent with label instructions;

3.        In containers with legible and accurate labels which spec- ify the name of the client for whom the medication is pre- scribed and the current dosage; and

4.        In locked storage, unless otherwise specified in the cli- ent’s ISPP.

J.        The licensee shall remove or dispose of medications which are expired or for which the prescription has been discontinued.

K.      When a medication error or reaction is detected, the licensee shall ensure that staff:

1.        Immediately consult medical personnel,

2.        Notify appropriate persons, and

3.        Document the error or reaction and the action taken in response.

L.       The licensee shall monitor on an ongoing basis the condition for which any medications have been prescribed and the response to the medications, in accordance with any recom- mendations of the medical practitioner. The licensee shall report the client’s response to the medical practitioner based on the monitoring. The licensee shall document any medica- tion change made by the medical practitioner and share results with agency staff.

M.     When a medication is prescribed for the purpose of behavior modification, the licensee shall:

1.        Document the behavior for which the medication is pre- scribed;

2.        Monitor the client’s response to the medication on an ongoing basis consistent with the client’s needs and the recommendations of the ISPP team;

3.        Document the client’s response to the medication, includ- ing the frequency and intensity of target behaviors and the occurrence of side effects;

4.        Report to the client’s physician regarding the client’s response to the medication; and

5.        Document the results of any change made by the physi- cian and share that information with direct care staff.

N.      Except for treatment of medical emergencies, the licensee shall obtain written informed consent from the responsible person and authorization by a medical practitioner for the use of sedation, mechanical restraint, or protective devices in the

course of planned medical or  dental procedures or in the course of follow-up to such procedures. The licensee shall not use physical restraints, including mechanical restraints as a negative consequence to a behavior, for the convenience of the licensee, or in lieu of a behavior management plan.

O.      The licensee shall ensure that the following conditions are met prior to ongoing or recurring use of a protective device in response to a medical condition:

1.        Authorization for use of the protective device is obtained from a medical practitioner;

2.        Written informed consent is obtained from the responsi- ble person; and

3.        The plan for use of the protective device is reviewed by the ISPP team and reassessed at least annually.

P.       The licensee shall ensure that individualized health care instructions for the client are followed.

Q.      The licensee shall plan for and prepare nutritional meals in accordance with the client’s needs and consistent with the cli- ent’s preferences. If the client is responsible for planning and preparing meals, the licensee shall assist, monitor, and educate the person regarding preparation of nutritionally adequate meals.

R.      The licensee shall keep insecticides, poisonous materials, cor- rosives, and other hazardous substances in locked storage, unless otherwise specified in the client’s ISPP, and in areas away from food and areas where medications are stored or administered.

S.       The licensee shall ensure that bodies of water are fenced. Unsupervised access to bodies of water by the client is prohib- ited unless specifically allowed by the client’s ISPP. The ISPP cannot supersede any local ordinance or state law pertaining to the safety of bodies of water or swimming pools.

Historical Note

Adopted effective August 30, 1994, under an exemption from the provisions of A.R.S. Title 41, Chapter 6

(Supp. 94-3).