Section R9-10-1402. Administration

A.      A governing authority shall:

1.        Consist of one or more individuals accountable for the organization, operation, and administration of a substance abuse transitional facility;

2.        Establish, in writing:

a.         A substance abuse transitional facility’s scope of services, and

b.        Qualifications for an administrator;

3.        Designate, in writing, an administrator who meets the qualifications established in subsection (A)(2)(b);

4.        Adopt a quality management program according to R9- 10-1403;

5.        Review and evaluate the effectiveness of the quality man- agement program at least once every 12 months;

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

a.         Expected not to be present on a substance abuse transitional facility’s premises for more than 30 cal- endar days, or

b.        Not present on a substance abuse transitional facil- ity’s premises for more than 30 calendar days; and

7.        Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the administrator and identify the name and qualifications of the new administrator.

B.       An administrator:

1.        Is directly accountable to the governing authority for the daily operation of the substance abuse transitional facility and all services provided by or at the substance abuse transitional facility;

2.        Has the authority and responsibility to manage the sub- stance abuse transitional facility; and

3.        Except as provided in subsection (A)(6), designates, in writing, an individual who is present on a  substance abuse transitional facility’s premises and accountable for the substance abuse transitional facility when the admin- istrator is not present on the substance abuse transitional facility’s premises.

C.      An administrator shall ensure that:

1.        Policies and procedures are established, documented, and implemented to protect the health and safety of a partici- pant 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 partici- pant;

d.        Cover the requirements in A.R.S. Title 36, Chapter 4, Article 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 the indi- vidual has received cardiopulmonary resuscita- tion training;

f.         Include a method to identify a participant to ensure the participant receives physical health services and behavioral health services as ordered;

g.        Cover first aid training;

h.        Cover participant rights, including assisting a partic- ipant who does not speak English or who has a phys- ical or other disability to become aware of participant rights;

i.         Cover specific steps for:

i.         A participant to file a complaint, and

ii.        The substance abuse transitional facility to respond to a participant’s complaint;

j.         Cover medical records, including electronic medical records;

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

l.         Cover contracted services; and

m.       Cover when an individual may visit a participant in the substance abuse transitional facility;

2.        Policies and procedures for services are established, doc- umented, and implemented to protect the health and safety of a participant that:

a.         Cover participant screening, admission, assessment, transfer, discharge planning, and discharge;

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

c.         Cover the provision of behavioral health services and physical health services;

d.        Cover medication administration, assistance in the self-administration of medication, and disposing of medication, including provisions for inventory con- trol and preventing diversion of controlled sub- stances;

e.         Cover infection control;

f.         Cover environmental services that affect participant care;

g.        Cover the process for receiving a fee from and refunding a fee to a participant or the participant’s representative;

h.        Cover the security of a participant’s possessions that are allowed on the premises;

i.         Cover smoking tobacco products on the premises;

j.         Cover how the facility will respond to a participant’s sudden, intense, or out-of-control behavior to pre- vent harm to the participant or another individual; and

k.        Cover how often periodic monitoring occurs based on a participant’s condition;

3.        Policies and procedures are reviewed at least once every three years and updated as needed;

4.        Policies and procedures are available to employees; and

5.        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 a substance abuse transitional facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the substance abuse transitional facility.

D.      An administrator shall provide written notification to the Department of a participant’s:

1.        Death, if the participant’s death is required to be reported according to A.R.S. § 11-593, within one working day after the participant’s death; and

2.        Self-injury, within two working days after the participant inflicts a self-injury that requires immediate intervention by an emergency medical services provider.

E.       If abuse, neglect, or exploitation of a participant is alleged or suspected to have occurred before the participant was admitted or while the participant is not on the premises and not receiv- ing services from a substance abuse transitional facility’s employee or personnel member, an administrator shall imme- diately report the alleged or suspected abuse, neglect, or exploitation of the participant according to A.R.S. § 46-454.

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

§ 46-454, to believe that abuse, neglect, or exploitation has occurred on the premises or while a participant is receiving services from a substance abuse transitional facility’s employee or personnel member, 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 participantaccording to A.R.S. § 46-454;

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 participant and any change to the participant’s physical, cognitive, func- tional, or emotional 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.      An administrator shall establish, document, and implement a process for responding to a participant’s need for immediate and unscheduled behavioral health services or physical health services.

H.      An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, an employee, a participant, or a participant’s representative:

1.        The participant rights listed in R9-10-1409,

2.        The facility’s current license,

3.        The location at which inspection reports are available for review or can be made available for review, and

4.        The days and times when a participant may accept visi- tors and make telephone calls.

Historical Note

Adopted effective February 1, 1994 (Supp. 94-1). Section repealed; new Section made by exempt rulemaking at 19

A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Section R9-10-1402 repealed; new Section R9-10-1402 renumbered from Section R9-10-1403 and amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).