Section R9-10-703. Administration

A.      A governing authority shall:

1.        Consist of one or more individuals responsible for the organization, operation, and administration of a behav- ioral health residential facility;

2.        Establish, in writing:

a.         A behavioral health residential facility’s scope of services, and

b.        Qualifications for an administrator;

3.        Designate, in writing, an administrator who has the quali- fications established in subsection (A)(2)(b);

4.        Adopt a quality management program according to R9- 10-704;

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 the behavioral health residential facility’s premises for more than 30 cal- endar days, or

b.        Not present on the behavioral health residential facility’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 of a behavioral health residential facility for the daily opera- tion of the behavioral health residential facility and all services provided by or at the behavioral health residen- tial facility;

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

3.        Except as provided in subsection (A)(6), designates, in writing, an individual who is present on the behavioral health residential facility’s premises and accountable for the behavioral health residential facility when the admin-

istrator is not present on the behavioral health residential 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 resident 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 resident;

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.         Cover first aid training;

g.        Include a method to identify a resident to ensure the resident receives physical health services and behav- ioral health services as ordered;

h.        Cover resident rights, including assisting a resident who does not speak English or who has a physical or other disability to become aware of resident rights;

i.         Cover specific steps for:

i.         A resident to file a complaint, and

ii.        The behavioral health residential facility to respond to a resident complaint;

j.         Cover health care directives;

k.        Cover medical records, including electronic medical records;

l.         Cover a quality management program, including incident reports and supporting documentation;

m.       Cover contracted services; and

n.        Cover when an individual may visit a resident in a behavioral health residential facility;

2.        Policies and procedures for behavioral health services and physical health services are established, documented, and implemented to protect the health and safety of a res- ident that:

a.         Cover resident screening, admission, assessment, treatment plan, transport, transfer, discharge plan- ning, and discharge;

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

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

d.        Cover emergency safety responses;

e.         Cover a resident’s personal funds account;

f.         Cover dispensing medication, administering medi- cation, assistance in the self-administration of medi- cation,  and  disposing   of  medication,  including

provisions  for  inventory  control  and  preventing diversion of controlled substances;

g.        Cover prescribing a controlled substance to mini- mize substance abuse by a resident;

h.        Cover respite services;

i.         Cover services provided by an outdoor behavioral health care program, if applicable;

j.         Cover infection control;

k.        Cover resident time out;

l.         Cover resident outings;

m.       Cover environmental services that affect resident care;

n.        Cover whether pets and other animals are allowed on the premises, including procedures to ensure that any pets or other animals allowed on the premises do not endanger the health or safety of residents or the public;

o.        If animals are used as part of a therapeutic program, cover:

i.         Inoculation/vaccination requirements, and

ii.        Methods to minimize risks to resident’s health and safety;

p.        Cover the process for receiving a fee from a resident and refunding a fee to a resident;

q.        Cover the process for obtaining resident preferences for social, recreational, or rehabilitative activities and meals and snacks;

r.         Cover the security of a resident’s possessions that are allowed on the premises;

s.         Cover smoking and the use of tobacco products on the premises; and

t.         Cover how the behavioral health residential facility will respond to a resident’s sudden, intense, or out- of-control behavior to prevent harm to the resident or another individual;

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

4.        Policies and procedures are available to personnel mem- bers, employees, volunteers, and students; 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 behav- ioral health residential facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the behavioral health residential facility.

D.      If an applicant requests or a behavioral health residential facil- ity has a licensed capacity of 10 or more residents, an adminis- trator shall designate a clinical director who:

1.        Provides direction for the behavioral health services pro- vided by or at the behavioral health residential facility;

2.        Is a behavioral health professional; and

3.        May be the same individual as the administrator, if the individual meets the qualifications in subsections (A)(2)(b) and (D)(1) and (2).

E.       Except for respite services, an administrator shall ensure that medical services, nursing services, health-related services, or ancillary services provided by a behavioral health residential facility are only provided to a resident who is expected to be present in the behavioral health residential facility for more than 24 hours.

F.       An administrator shall provide written notification to the Department of a resident’s:

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

2.        Self-injury, within two working days after the resident inflicts a self-injury or has an accident that requires immediate intervention by an emergency medical ser- vices provider.

G.      If abuse, neglect, or exploitation of a resident is alleged or sus- pected to have occurred before the resident was admitted or while the resident is not on the premises and not receiving ser- vices from a behavioral health residential facility’s employee or personnel member, an administrator shall report the alleged or suspected abuse, neglect, or exploitation of the resident as follows:

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

A.R.S. § 46-454; or

2.        For a resident under 18 years of age, according to A.R.S.

§ 13-3620.

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

§§ 13-3620 or 46-454, to believe abuse, neglect, or exploita- tion has occurred on the premises or while a resident is receiv- ing services from a behavioral health residential 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 resident:

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

A.R.S. § 46-454; or

b.        For a resident 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 (H)(1); and

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

4.        Maintain the documentation in subsection (H)(3) for at least 12 months after the date of the report in subsection (H)(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 (H)(2):

a.         The dates, times, and description of the suspected abuse, neglect, or exploitation;

b.        A description of any injury to the resident related to the suspected abuse or neglect and any change to the resident’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 (H)(5) and any other information obtained during the investigation for at least 12 months after the date the investigation was initiated.

I.        An administrator shall:

1.        Establish and document requirements regarding resi- dents, personnel members, employees, and other individ- uals entering and exiting the premises;

2.        Establish and document guidelines for meeting the needs of an individual residing at a behavioral health residential facility with a resident, such as a child accompanying a parent in treatment, if applicable;

3.        If children under the age of 12, who are not admitted to a behavioral health residential facility, are residing at the behavioral health residential facility and being cared for by employees or personnel members, ensure that:

a.         An employee or personnel member caring for chil- dren has current cardiopulmonary resuscitation and first aid training specific to the ages of children being cared for; and

b.        The staff-to-children ratios in A.A.C. R9-5-404(A) are maintained, based on the age of the youngest child in the group;

4.        Establish and document the process for responding to a resident’s need for immediate and unscheduled behav- ioral health services or physical health services;

5.        Establish and document the criteria for determining when a resident’s absence is unauthorized, including criteria for a resident who:

a.         Was admitted under A.R.S. Title 36, Chapter 5, Arti- cles 1, 2, or 3;

b.        Is absent against medical advice; or

c.         Is under the age of 18;

6.        If a resident’s absence is unauthorized as determined according to the criteria in subsection (I)(5), within an hour after determining that the resident’s absence is unau- thorized, notify:

a.         For a resident who is under 18 years of age, the resi- dent’s parent or legal guardian; and

b.        For a resident who is under a court’s jurisdiction, the appropriate court;

7.        Maintain a written log of unauthorized absences for at least 12 months after the date of a resident’s absence that includes the:

a.         Name of a resident absent without authorization,

b.        Name of the individual to whom the report required in subsection (I)(6) was submitted, and

c.         Date of the report;

8.        Document the notification in subsection (I)(6) and the written log required in subsection (I)(7); and

9.        Evaluate and take action related to unauthorized absences under the quality management program in R9-10-704.

J.        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, employee, resi- dent, or a resident’s representative:

1.        The behavioral health residential facility’s current license,

2.        The location at which inspection reports required in R9- 10-720(C) are available for review or can be made avail- able for review, and

3.        The calendar days and times when a resident may accept visitors or make telephone calls.

K.      An administrator shall ensure that:

1.        Labor performed by a resident for the behavioral health residential facility is consistent with A.R.S. § 36-510;

2.        A resident who is a child is only released to the child’s custodial parent, guardian, or custodian or as authorized in writing by the child’s custodial parent, guardian, or custodian;

3.        The administrator obtains documentation of the identity of the parent, guardian, custodian, or family  member authorized to act on behalf of a resident who is a child; and

4.        A resident, who is an incapacitated person according to

A.R.S. § 14-5101 or who is gravely disabled, is assisted in obtaining a resident’s representative to act on the resi- dent’s behalf.

L.       If an administrator determines that a resident is incapable of handling the resident’s financial affairs, the administrator shall:

1.        Notify the resident’s representative or contact a public fiduciary or a trust officer to take responsibility of the res- ident’s financial affairs, and

2.        Maintain documentation of the notification required in subsection (L)(1)(a) in the resident’s medical record for at least 12 months after the date of the notification.

M.     If an administrator manages a resident’s money through a per- sonal funds account, the administrator shall ensure that:

1.        Policies and procedure are established, developed, and implemented for:

a.         Using resident’s funds in a personal funds account,

b.        Protecting  resident’s  funds  in  a  personal  funds account,

c.         Investigating a complaint about the use of resident’s funds in a personal funds account and ensuring that the complaint is investigated by an individual who does not manage the personal funds account,

d.        Processing each deposit into and withdrawal from a personal funds account, and

e.         Maintaining a record for each deposit into and with- drawal from a personal funds account; and

2.        The personal funds account is only initiated after receiv- ing a written request that:

a.         Is provided:

i.         Voluntarily by the resident,

ii.        By the resident’s representative, or

iii.      By a court of competent jurisdiction;

b.        May be withdrawn at any time; and

c.         Is maintained in the resident’s record.

Historical Note

Adopted as an emergency effective October 26, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-4). Emergency expired. Readopted without change as an emergency effective January 27, 1989, pur- suant to A.R.S. § 41-1026, valid for only 90 days (Supp.

89-1). Emergency expired. Readopted without change as an emergency effective April 27, 1989, pursuant to

A.R.S. § 41-1026, valid for only 90 days (Supp. 89-2).

Emergency expired. Readopted without change as an emergency effective July 31, 1989, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 89-3). Permanent rules adopted with changes effective October 30, 1989 (Supp. 89-4). Section R9-10-703 repealed, new Section R9-10-703 adopted effective November 1, 1998, under an exemption from the provisions of the Administrative Pro- cedure Act pursuant to Laws 1998, Ch. 178, § 17; filed with the Office of the Secretary of State October 2, 1998 (Supp. 98-4). Amended 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, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).