Section R9-10-1003. Administration

A.	In addition to the license application requirements in A.R.S. §	A.	If an outpatient treatment center is operating under a single
	36-422 and 9 A.A.C. 10, Article 1, a governing authority		group license issued to a hospital according to A.R.S. § 36-
	applying for an initial license shall submit, in a format pro-		422(F) or (G), the hospital's governing authority is the govern-
	vided by the Department:		ing authority for the outpatient treatment center.
	1.     The days and hours of clinical operation and, if different	B.	A governing authority shall:
	from the days and hours of clinical operation, the days		1.     Consist of one or more individuals accountable for the
	and hours of administrative operation; and		organization, operation, and administration of an outpa-
	2.     A request to provide one or more of the following ser-		tient treatment center;
	vices:		2.     Establish, in writing:
	a.      Behavioral health services and, if applicable;		a.      An outpatient treatment center’s scope of services,
	i.      Behavioral health observation/stabilization ser-		and
	vices,		b.     Qualifications for an administrator;
	ii.     Behavioral health services to individuals under		3.     Designate, in writing, an administrator who has the quali-
	18 years of age,		fications established in subsection (B)(2)(b);
	iii.   Court-ordered evaluation,		4.     Adopt a quality management program according to R9-
	iv.   Court-ordered treatment,		10-1004;
	v.     Counseling,		5.     Review and evaluate the effectiveness of the quality man-
	vi.   Crisis services,		agement program in R9-10-1004 at least once every 12
	vii.  Opioid treatment services,		months;
	viii. Pre-petition screening,		6.     Designate, in writing, an acting administrator who has the
	ix.   Respite services,		qualifications established in subsection (B)(2)(b) if the
	x.     DUI education,		administrator is:
	xi.   DUI screening,		a.      Expected not to be present on an outpatient treat-
	xii.  DUI treatment, or		ment center’s premises for more than 30 calendar
	xiii. Misdemeanor domestic violence offender treat-		days, or
	ment;		b.     Not  present  on   an  outpatient   treatment  center’s
	b.     Diagnostic imaging services;		premises for more than 30 calendar days; and
	c.      Clinical laboratory services;		7.     Except  as  provided  in  subsection  (B)(6),  notify  the
	d.     Dialysis services;		Department according to A.R.S. § 36-425(I) when there

is a change in an administrator and identify the name and qualifications of the new administrator.

C.       An administrator:

1.        Is directly accountable to the governing authority for the daily operation of the outpatient treatment center and all services provided by or at the outpatient treatment center;

2.        Has the authority and responsibility to manage the outpa- tient treatment center; and

3.        Except as provided in subsection (B)(6), designates, in writing, an individual who is present on the outpatient treatment center's premises and accountable for the out- patient treatment center when the administrator is not available.

D.       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, vol- unteers, and students;

b.        Cover orientation and in-service education for per- sonnel members, employees, volunteers, and stu- dents;

c.         Include how a personnel member may submit a complaint relating to services provided to a patient;

d.        Cover the requirements in Title 36, Chapter 4, Arti- cle 11;

e.         Cover cardiopulmonary resuscitation training including:

i.         The method and content of cardiopulmonary resuscitation training which includes a demon- stration of the individual’s ability to perform cardiopulmonary resuscitation,

ii.        The qualifications for an individual to provide cardiopulmonary resuscitation training,

iii.      The time-frame for renewal of cardiopulmo- nary resuscitation training, and

iv.       The documentation that verifies that an individ- ual has received cardiopulmonary resuscitation training;

f.         Cover first aid training;

g.        Include a method to identify a patient to ensure the patient receives the services ordered for the patient;

h.        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;

i.         Cover health care directives;

j.         Cover medical records, including electronic medical records;

k.        Cover quality management, including incident report and supporting documentation; and

l.         Cover contracted services;

2.        Policies and procedures for services provided at or by an outpatient treatment center are established, documented, and implemented to protect the health and safety of a patient that:

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

b.        Cover the provision of medical services, nursing ser- vices, health-related services, and ancillary services;

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

d.        Cover obtaining, administering, storing, and dispos- ing of medications, including provisions for con-

trolling   inventory   and    preventing   diversion   of controlled substances;

e.         Cover prescribing a controlled substance to mini- mize substance abuse by a patient;

f.         Cover infection control;

g.        Cover telemedicine, if applicable;

h.        Cover environmental services that affect patient care;

i.         Cover specific steps for:

i.         A patient to file a complaint, and

ii.        An outpatient treatment center to respond to a complaint;

j.         Cover smoking tobacco products on an outpatient treatment center’s premises; and

k.        Cover how personnel members will respond to a patient’s sudden, intense, or out-of-control behavior to prevent harm to the patient or another individual;

3.        Outpatient treatment center policies and procedures are:

a.         Reviewed at least once every three years and updated as needed, and

b.        Available to personnel members and employees;

4.        Unless otherwise stated:

a.         Documentation required by this Article is provided to the Department within two hours after a Depart- ment request; and

b.        When documentation or information is required by this Chapter to be submitted on behalf of an outpa- tient treatment center, the documentation or infor- mation is provided to the unit in the Department that is responsible for licensing and monitoring the out- patient treatment center;

5.        The following are conspicuously posted:

a.         The current license for the outpatient treatment cen- ter issued by the Department;

b.        The name, address, and telephone number of the Department;

c.         A notice that a patient may file a complaint with the Department about the outpatient treatment center;

d.        One of the following:

i.         A schedule of rates according to A.R.S. § 36- 436.01(C), or

ii.        A notice that the schedule of rates required in

A.R.S. § 36-436.01(C) is available for review upon request;

e.         A list of patient rights;

f.         A map for evacuating the facility; and

g.        A notice identifying the location on the premises where current license inspection reports required in

A.R.S.   §    36-425(D),   with   patient   information redacted, are available; and

6.        Patient follow-up instructions are:

a.         Provided, orally or in written form, to a patient or the patient’s representative before the patient leaves the outpatient treatment center unless the patient leaves against a personnel member’s advice; and

b.        Documented in the patient’s medical record.

E.       If abuse, neglect, or exploitation of a patient is alleged or sus- pected to have occurred before the patient was admitted or while the patient is not on the premises and not receiving ser- vices from an outpatient treatment center’s employee or per- sonnel member, an administrator shall y report the alleged or suspected abuse, neglect, or exploitation of the patient as fol- lows:

1.        For a patient 18 years of age or older, according to A.R.S.

§ 46-454; or

2.        For a patient under 18 years of age, according to A.R.S. § 13-3620.

F.        If an administrator has a reasonable basis, according to A.R.S.

§ 13-3620 or 46-454, to believe that abuse, neglect, or exploitation has occurred on the premises or while a patient is receiving services from an outpatient treatment center’s employee or personnel member, an 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 as follows:

a.         For a patient 18 years of age or older, according to

A.R.S. § 46-454; or

b.        For a patient under 18 years of age, according to

A.R.S. § 13-3620;

3.        Document:

a.         The suspected abuse, neglect, or exploitation;

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

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

4.        Maintain the documentation in subsection (F)(3) for at least 12 months after the date of the report in subsection (F)(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 sub- section (F)(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 emo- tional 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 occur- ring in the future; and

6.        Maintain a copy of the documented information required in subsection (F)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

G.       If an outpatient treatment center is an affiliated outpatient treatment center as defined in R9-10-1901, an administrator shall ensure that the outpatient treatment center complies with the requirements for an affiliated outpatient treatment center in 9 A.A.C. 10, Article 19.

Historical Note

New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section amended by exempt rulemaking at 19 A.A.R. 2015, effective Octo- ber 1, 2013 (Supp. 13-2). Amended by exempt rulemak-

ing at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, §

13; effective July 1, 2014 (Supp. 14-2). Amended by exempt rulemaking at 20 A.A.R. 3535, pursuant to Laws 2014, Ch. 233, § 5; effective January 1, 2015 (Supp. 14-

4).