Section R9-10-1302. Administration

A.      The governing authority for a behavioral health specialized transitional facility:

1.        Is the superintendent of the state hospital; and

2.        Shall:

a.         Establish, in writing:

i.         A behavioral health specialized transitional facility’s scope of services, and

ii.        Qualifications for an administrator;

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

c.         Adopt a quality management program according to R9-10-1303;

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

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

i.         Expected not to be present on the behavioral health specialized transitional facility’s prem- ises for more than 30 calendar days, or

ii.        Not present on the behavioral health special- ized transitional facility’s premises for more than 30 calendar days; and

f.         Except as provided in subsection (A)(2)(e), notify the Department according to A.R.S. § 36-425(I) when there is a change in the administrator and iden- tify the name and qualifications of the new adminis- trator.

B.       An administrator:

1.        Is directly accountable to the superintendent of the state hospital for the daily operation of the behavioral health specialized transitional facility and for all services pro- vided by or at the behavioral health specialized transi- tional facility;

2.        Has the authority and responsibility to manage the behav- ioral health specialized transitional facility; and

3.        Except as provided in subsection (A)(2)(e), designates, in writing, an individual who is present on the behavioral health specialized transitional facility’s premises and accountable for the behavioral health specialized transi-

tional facility when the administrator is not present on the behavioral health specialized transitional facility’s prem- ises.

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, vol- unteers, and students;

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

c.         Cover patient admission, assessment, treatment plan, transfer, discharge planning, discharge, and recordkeeping;

d.        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;

e.         Cover the requirements in A.R.S. §§ 36-3708, 36- 3709, and 36-3714;

f.         Establish the process for warning an identified or identifiable individual, as described in A.R.S. § 36-

517.02 (B) through (C), if a patient communicates to a personnel member a threat of imminent serious physical harm or death to the identified or identifi- able individual and the patient has the apparent intent and ability to carry out the threat;

g.        Cover when informed consent is required and how informed consent is obtained;

h.        Cover the criteria and process for conducting research using patients or patients’ medical records;

i.         Include the establishment of, disbursing from, and recordkeeping for a patient personal funds account;

j.         Include a method of patient identification to ensure a patient receives the services ordered for the patient;

k.        Cover contracted services;

l.         Cover health care directives;

m.       Cover medical records, including electronic medical records;

n.        Cover medication procurement, storage, inventory monitoring and control, and disposal;

o.        Cover infection control;

p.        Cover and designate which personnel members or employees are required to have current certification in cardiopulmonary resuscitation and first aid train- ing;

q.        Cover environmental services that affect patient care;

r.         Cover reporting suspected or alleged abuse, neglect, exploitation, or other criminal activity;

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

t.         Cover emergency treatment and disaster plan;

u.        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;

v.        Include security of the facility, patients and their possessions, personnel members, and visitors at the behavioral health specialized transitional facility;

w.       Include preventing unauthorized patient absences;

x.        Cover transportation of patients, including the crite- ria for using a locking mechanism to restrict a patient's movement during transportation;

y.        Cover specific steps for:

i.         A patient to file a complaint, and

ii.        The behavioral health specialized transitional facility to respond to a patient’s complaint;

z.         Cover visitation, telephone usage, sending or receiv- ing mail, computer usage, and  other recreational activities; and

aa.   Include equipment inspection and maintenance;

2.        Policies and procedures are available to each personnel member;

3.        Laboratory services are provided by a laboratory that holds a certificate of accreditation or certificate of com- pliance issued by the U.S. Department of Health and Human Services under the 1988 amendments to the Clin- ical Laboratories Improvement Act of 1967;

4.        Food services are provided as specified in R9-10-1314;

5.        The following individuals have access to a patient:

a.         The patient’s representative,

b.        An individual assigned by a court of law to provide services to the patient, and

c.         An attorney hired by the patient or patient’s family;

6.        Labor performed by a patient for the behavioral health specialized transitional facility is consistent with A.R.S. § 36-510 and applicable state and federal law; and

7.        The following information is posted in an area easily viewed by a patient or an individual entering or leaving the behavioral health specialized transitional facility:

a.         Patient rights,

b.        Telephone number for the Department and the Office of Human Rights,

c.         Location of inspection reports,

d.        Complaint procedures, and

e.         Visitation hours and procedures;

D.      An administrator shall:

1.        Provide written notification to the Department of a patient’s:

a.         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;

b.        Self-injury, within two working days after the patient inflicts a self-injury that requires immediate intervention by an emergency medical service pro- vider; and

c.         Absence, within one working day after an unautho- rized patient absence from the behavioral health spe- cialized transitional facility is discovered;

2.        Maintain the documentation required in subsection (D)(1) for at least 12 months after the date of the notification; and

3.        Ensure that sufficient personnel are present at the behav- ioral health specialized transitional facility at all times to maintain safe and secure conditions.

E.       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 the patient is receiving ser- vices from an employee or personnel member of the behav- ioral health specialized transitional facility, 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 of the patient;

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

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

4.        Maintain the documentation required in subsections (E)(1) and (E)(2) for at least 12 months after the date of the report;

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 (E)(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 abuse or neglect and any change to the patient's physical, cognitive, functional, or emotional condi- tion;

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 (C)(10)(e) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

F.       An administrator shall:

1.        Unless otherwise stated, ensure that:

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 a behav- ioral health specialized transitional facility, the doc- umentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the behavioral health specialized transi- tional facility;

2.        Appoint a medical director, to direct the medical and nursing services provided by or at the behavioral health specialized transitional facility, who:

a.         Is a medical staff member, and

b.        Has at least two years of experience providing ser- vices in an organized psychiatric services unit of a hospital or in a behavioral health facility; and

3.        Appoint a clinical director, to provide direction for the behavioral health services provided by or at the behav- ioral health specialized transitional facility, who:

a.         Is a psychiatrist or a psychologist;

b.        Has at least two years of experience providing ser- vices in an organized psychiatric services unit of a hospital or in a behavioral health facility; and

c.         May, if qualified, also serve as the medical director.

G.      A medical director:

1.        Is responsible for the medical services, nursing services, and physical health-related services provided to patients consistent with the patients behavioral treatment plan; and

2.        Shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a patient that cover:

a.         Restraint, according to R9-10-224;

b.        The process for patient assessments, including the identification of and criteria for the on-going moni- toring of a patient’s physical health conditions;

c.         Dispensing and administration of medications, including the process and criteria for determining whether a patient is capable of and eligible to self- administer medication;

d.        The process by which emergency medical treatment will be provided to a patient; and

e.         The requirements for completion of medication records and recording of adverse events.

H.      A clinical director:

1.        Is responsible for the behavioral health services provided to patients;

2.        Shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a patient that cover:

a.         Assessing the competency and proficiency of a behavioral health personnel member for each type of service the personnel member provides and each type of patient to which the personnel member is assigned;

b.        Providing:

i.         Supervision  to  behavioral   health  paraprofes- sionals, according to R9-10-115(1); and

ii.        Clinical oversight to behavioral health techni- cians, according to R9-10-115(2);

c.         The qualifications for personnel members who pro- vide clinical oversight;

d.        The process for patient assessments, including the identification of and criteria for the on-going moni- toring of a patient’s behavioral health issues;

e.         The process for developing and implementing a patient's treatment plan;

f.         The frequency of and process for reviewing and modifying a patient’s treatment plan, based on the ongoing monitoring of the patient’s response to treatment; and

g.        The process for determining whether a patient is eli- gible for discharge or conditional release to a less restrictive alternative;

3.        Shall ensure that patient services are provided by person- nel competent and proficient in providing the services; and

4.        Shall ensure that clinical oversight of personnel members is provided according to the policies and procedures.

Historical Note

Emergency rule adopted effective November 29, 1991, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 91-4). Emergency rule adopted again effective February 28, 1992, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 92-1). Emergency rule adopted again effective May 28, 1992, pursuant to A.R.S. § 41- 1026, valid for only 90 days (Supp. 92-2). Emergency rule adopted again effective August 27, 1992, pursuant to

A.R.S. § 41-1026, valid for only 90 days (Supp. 92-3). Adopted with changes effective November 25, 1992 (Supp. 92-4). Section R9-10-1302 repealed effective

November 1, 1998, under an exemption from the provi- sions of the Administrative Procedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). New Section 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, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).