Section R9-10-1012. Behavioral Health Observation/Stabilization Ser- vices

A.      An administrator of an outpatient treatment center that is authorized to provide behavioral health observation/stabiliza- tion services shall ensure that:

1.        Behavioral health observation/stabilization services are available 24 hours a day, every calendar day;

2.        Behavioral health observation/stabilization services are provided in a designated area that:

a.         Is used exclusively for behavioral health observa- tion/stabilization services;

b.        Has the space for a patient to receive privacy in treatment and care for personal needs; and

c.         For every 15 observation chairs or less, has at least one bathroom that contains:

i.         A working sink with running water,

ii.        A working toilet that flushes and has a seat,

iii.      Toilet tissue,

iv.       Soap for hand washing,

v.        Paper towels or a mechanical air hand dryer,

vi.       Lighting, and

vii.     A means of ventilation;

3.        If the outpatient treatment center is authorized to provide behavioral health observation/stabilization services to individuals under 18 years of age:

a.         There is a separate designated area for providing behavioral health observation/stabilization services to individuals under 18 years of age that:

i.         Meets the requirements in subsection (B)(2), and

ii.        Has floor to ceiling walls that separate the des- ignated area from other areas of the outpatient treatment center;

b.        A registered nurse is present in the separate desig- nated area; and

c.         A patient under 18 years of age does not share any space, participate in any activity or treatment, or

have verbal or visual interaction with a patient 18 years of age or older;

4.        A medical practitioner is available;

5.        If the medical practitioner present at the outpatient treat- ment center is a registered nurse practitioner or a physi- cian assistant, a physician is on-call;

6.        A registered nurse is present and provides direction for behavioral health observation/stabilization services in the designated area;

7.        A nurse monitors each patient at the intervals determined according to subsection (A)(12) and documents the moni- toring in the patient’s medical record;

8.        An individual who arrives at the designated area for behavioral health observation/stabilization services in the outpatient treatment center is screened within 30 minutes after entering the designated area to determine whether the individual is in need of immediate physical health ser- vices;

9.        If a screening indicates that an individual needs immedi- ate physical health services that the outpatient treatment center is:

a.         Able to provide according to the outpatient treat- ment center’s scope of services, the individual is examined by a medical practitioner within 30 min- utes after being screened; or

b.        Not able to provide, the individual is transferred to a health care institution capable of meeting the indi- vidual’s immediate physical health needs;

10.     If a screening indicates that an individual needs behav- ioral health observation/stabilization services and the out- patient treatment center has the capabilities to provide the behavioral health observation/stabilization services, the individual is admitted to the designated area for behav- ioral health observation/stabilization services and may remain in the designated area and receive observation/sta- bilization services for up to 23 hours and 59 minutes;

11.     Before a patient is discharged from the designated area for behavioral health observation/stabilization services, a medical practitioner determines whether the patient will be:

a.         If the behavioral health observation/stabilization ser- vices are provided in a health care institution that also provides inpatient services and is capable of meeting the patient’s needs, admitted to the health care institution as an inpatient;

b.        Transferred to another health care institution capable of meeting the patient’s needs;

c.         Provided a referral to another entity capable of meet- ing the patient’s needs; or

d.        Discharged and provided patient follow-up instruc- tions;

12.     When a patient is admitted to a designated area for behav- ioral health observation/stabilization services, an assess- ment of the patient includes the interval for monitoring the patient based on the patient’s medical condition, behavior, suspected drug or alcohol abuse, and medica- tion status to ensure the health and safety of the patient;

13.     If a patient is not being admitted as an inpatient to a health care institution, before discharging the patient from a designated area for behavioral health observation/ stabilization services, a personnel member:

a.         Identifies the specific needs of the patient after dis- charge necessary to assist the patient to function independently;

b.        Identifies any resources, including family members, community social services, peer support services,

and Regional Behavioral Health Agency staff, that may be available to assist the patient; and

c.         Documents the information in subsection (A)(13)(a) and the resources in subsection (A)(13)(b) in the patient’s medical record;

14.     When a patient is discharged from a designated area for behavioral health observation/stabilization services, a personnel member:

a.         Provides the patient with discharge information that includes:

i.         The identified specific needs of the patient after discharge, and

ii.        Resources that may be available for the patient; and

b.        Contacts any resources identified as required in sub- section (A)(13)(b);

15.     Except as provided in subsection (A)(16), a patient is not re-admitted to the outpatient treatment center for behav- ioral health observation/stabilization services within two hours after the patient’s discharge from a designated area for behavioral health observation/stabilization services;

16.     A patient may be re-admitted to the outpatient treatment center for behavioral health observation/stabilization ser- vices within two hours after the patient’s discharge if:

a.         It is at least one hour since the time of the patient’s discharge;

b.        A law enforcement officer or the patient’s case man- ager accompanies the patient to the outpatient treat- ment center;

c.         Based on a screening of the patient, it is determined that re-admission for behavioral health observation/ stabilization is necessary for the patient; and

d.        The name of the law enforcement officer or the patient’s case manager and the reasons for the deter- mination in subsection (A)(16)(c) are documented in the patient’s medical record;

17.     A patient admitted for behavioral health observation/sta- bilization services is provided:

a.         An observation chair; or

b.        A separate piece of equipment for the patient to use to sit or recline that:

i.         Is at least 12 inches from the floor; and

ii.        Has sufficient space around the piece of equip- ment to allow a personnel member to provide behavioral health services and physical health services, including emergency services, to the patient;

18.     If an individual is not admitted for behavioral health observation/stabilization services because there is not an observation chair available for the individual’s use, a per- sonnel member provides support to the individual to access the services or resources necessary for the individ- ual's health and safety, which may include:

a.         Admitting the individual to the outpatient treatment center to provide behavioral health services other than behavioral health observation/stabilization ser- vices;

b.        Establishing a method to notify the individual when there is an observation chair available;

c.         Referring or providing transportation to the individ- ual to another health care institution;

d.        Assisting the individual to contact the individual's support system; and

e.         If the individual is enrolled with a Regional Behav- ioral Health Authority, contacting the appropriate person to request assistance for the individual;

19.     Personnel members establish a log of individuals who were not admitted because there was not an observation chair available and document the individual’s name, actions taken to provide support to the individual to access the services or resources necessary for the individ- ual’s health and safety, and date and time the actions were taken;

20.     The log required in subsection (A)(19) is maintained for at least 12 months after the date of documentation in the log;

21.     An observation chair or, as provided in subsection (A)(17)(b), a piece of equipment used by a patient to sit or recline is visible to a personnel member;

22.     Except as provided in subsection (A)(23), a patient admitted to receive behavioral health observation/stabili- zation services is visible to a personnel member;

23.     A patient admitted to receive behavioral health observa- tion/stabilization services may use the bathroom and not be visible to a personnel member, if the personnel mem- ber:

a.         Determines that the patient is capable of using the bathroom unsupervised,

b.        Is aware of the patient’s location, and

c.         Is able to intervene in the patient’s actions to ensure the patient’s health and safety; and

24.     An observation chair:

a.         Effective until July 1, 2015, has space around the observation chair that allows a personnel member to provide behavioral health services and physical health services, including emergency services, to a patient in the observation chair; and

b.        Effective on July 1, 2015, has at least three feet of clear floor space:

i.         On at least two sides of the observation chair, and

ii.        Between the observation chair and any other observation chair.

B.       An administrator of an outpatient treatment center that is authorized to provide behavioral health observation/stabiliza- tion services shall:

1.        Have a room used for seclusion that complies with requirements for seclusion rooms in R9-10-316, and

2.        Comply with the requirements for restraint and seclusion in R9-10-316.

C.      An administrator of an outpatient treatment center that is authorized to provide behavioral health observation/stabiliza- tion services shall ensure that:

1.        Policies and procedures are established, documented, and implemented to protect the health and safety of a patient that:

a.  Cover the process for:

i.         Evaluating a patient previously admitted to the designated area to determine whether the patient is ready for admission to an inpatient setting or discharge, including when to imple- ment the process;

ii.        Contacting other health care institutions that provide behavioral health observation/stabiliza- tion services to determine if the patient could be admitted for behavioral health observation/ stabilization services in another health care institution, including when to implement the process; and

iii.      Ensuring that sufficient personnel members, space, and equipment are available to provide behavioral health observation/stabilization ser-

vices to patients admitted to receive behavioral health observation/stabilization services; and

b.        Establish a maximum capacity of the number of patients for whom the outpatient treatment center is capable of providing behavioral health observation/ stabilization services;

2.        The outpatient treatment center does not:

a.         Exceed the maximum capacity established by the outpatient treatment center in subsection (C)(1)(b); or

b.        Admit an individual if the outpatient treatment cen- ter does not have personnel members, space, and equipment available to provide behavioral health observation/stabilization services to the individual; and

3.        Effective on July 1, 2015:

a.         If an admission of an individual causes the outpa- tient treatment center to exceed the outpatient treat- ment center’s licensed occupancy, the individual is only admitted for behavioral health observation/sta- bilization services after:

(i.) A behavioral health professional reviews the individual’s screening and determines the admission is an emergency; and

(ii.) Documents the determination in the individ- ual’s medical record; and

b.        The outpatient treatment center’s quality manage- ment program’s plan, required in R9-10-1004(1), includes a method to identify and document each occurrence of exceeding licensed occupancy, to evaluate the occurrences of exceeding licensed occupancy, and to review the actions taken to reduce future occurrences of exceeding licensed occupancy.

Historical Note

Adopted as an emergency effective November 17, 1983, pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 83-6). Former Section R9-10-1012 adopted as an emergency now adopted and amended as a permanent rule effective February 15, 1984 (Supp. 84-1). Repealed by summary action, interim effective date July 21, 1995 (Supp. 95-3). The proposed summary action repealing R9-10-1012 was remanded by the Governor’s Regulatory Review Council which revoked the interim effectiveness of the summary rule. The Section in effect before the pro- posed summary action has been restored (Supp. 97-1).

Section repealed by final rulemaking at 5 A.A.R. 1222, effective April 5, 1999 (Supp. 99-2). New Section made by final rulemaking at 14 A.A.R. 294, effective March 8, 2008 (Supp. 08-1). Section repealed; new Section made 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).