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Arizona Administrative Code (Last Updated: November 17, 2016) |
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Title 9. HEALTH SERVICES |
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Chapter 21. DEPARTMENT OF HEALTH SERVICES |
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Article 2. RIGHTS OF PERSONS WITH SERIOUS MENTAL ILLNESS |
Section R9-21-203. Protection from Abuse, Neglect, Exploitation, and Mistreatment
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A. No mental health agency shall mistreat a client or permit the mistreatment of a client by staff subject to its direction. Mis- treatment includes any intentional, reckless or negligent action or omission which exposes a client to a serious risk of physical or emotional harm. Mistreatment includes but is not limited to:
1. Abuse, neglect, or exploitation;
2. Corporal punishment;
3. Any other unreasonable use or degree of force or threat of force not necessary to protect the client or another person from bodily harm;
4. Infliction of mental or verbal abuse, such as screaming, ridicule, or name calling;
5. Incitement or encouragement of clients or others to mis- treat a client;
6. Transfer or the threat of transfer of a client for punitive reasons;
7. Restraint or seclusion used as a means of coercion, disci- pline, convenience, or retaliation;
8. Any act in retaliation against a client for reporting any violation of the provisions of this Chapter to the Depart- ment; or
9. Commercial exploitation.
B. The following special sanctions shall be available to the Department, in addition to those set forth in 9 A.A.C. 10, Arti- cle 10 of its rules, to protect the interests of the client involved as well as other current and former clients of the mental health agency.
1. Mistreatment of a client by staff or persons subject to the direction of a mental health agency may be grounds for suspension or revocation of the license of the mental health agency or the provision of Departmental financial assistance, and, with respect to employees of the Depart- ment, grounds for disciplinary action, which may include dismissal.
2. Failure of an employee of the Department to report to the Department any instance of mistreatment within any mental health agency subject to this Chapter shall be grounds for disciplinary action, which may include dis- missal.
3. Failure of an agency director to report client deaths and allegations of sexual and physical abuse to the Depart- ment and to comply with the procedures described in Article 4 of this Chapter for the processing and investiga- tion of grievances and reports shall be grounds for sus-
pension of the license of the mental health agency or the provision of Departmental financial assistance, and, with respect to a service provider directly operated by the Department, grounds for disciplinary action, which may include dismissal.
4. The agency director shall report all allegations of mis- treatment and denial of rights to the Office of Human Rights and the regional authority for review and monitor- ing in accordance with R9-21-105.
C. An agency director shall report all incidents of abuse, neglect, or exploitation to the appropriate authorities as required by
A.R.S. § 46-454 and shall document all such reports in the mental health agency’s records.
D. Where an agency director has reasonable cause to believe that a felony relevant to the functioning of the program has been committed by staff persons subject to the agency’s direction, a report shall be filed with the county attorney.
E. The identity of persons making reports of abuse, neglect, exploitation, or mistreatment shall not be disclosed by the agency director or by the Department, except as necessary to investigate the subject matter of the report.
Historical Note
Adopted under an exemption from A.R.S. Title 41, Chap- ter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to
2. Appropriate techniques for placing a client in each type of restraint or seclusion; used at the mental health agency, and
3. Immediate release of a client during an emergency.
F. A mental health agency shall develop and implement a train- ing program on the policies and procedures in subsection (E).
G. A mental health agency shall only use restraint or seclusion according to:
1. A written order given:
a. By a physician providing treatment to a client; or
b. If a physician providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1 psychiatric acute hospital according to R9-20-102, by a physician or a nurse practitioner; or
ii. If the agency is licensed as a level 1 subacute agency or a level 1 RTC according to R9-20- 102, by a medical practitioner;
2. An oral order given to a nurse by:
a. A physician providing treatment to a client, or
b. If a physician providing treatment to a client is not present on the premises or on-call:
i. If the agency is licensed as a level 1 psychiatric acute hospital according to R9-20-102, by a physician or a nurse practitioner; or
ii.
Laws 1992, Ch.
301, § 61, effective September 30,
1993 (Supp. 93-3). Amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30,
2003 (Supp. 03-2). H. If a restraint or seclusion is used
according to
subsection (G)(2), the
individual giving the
order shall, at the time of the oral order in consultation with the nurse, determine whether, R9-21-204. Restraint and Seclusion based upon the client’s current and
past medical, physical and A. A mental health agency shall only
use restraint or seclusion to psychiatric condition, it is clinically necessary for: the extent permitted by
and in compliance with this Chapter, 9 1. If
the agency is licensed as a
level 1 psychiatric acute A.A.C. 20, and other applicable federal or
state law. hospital according to R9-20-102, a physician to examine B. A mental health agency shall only use restraint or seclusion: the client as
soon as
possible and, if applicable, the physi- 1. To ensure the
safety of
the client or another individual in cian shall examine the client
as soon as possible; or an emergency safety situation; 2. If
the agency is licensed as a
level 1
sub-acute agency or a 2. After other available less restrictive methods to
control level 1 RTC according to R9-20-102, a
medical practitio- the client’s behavior have been tried and were unsuccess- ner to examine the
client as
soon as possible and, if
appli- ful; cable, the
medical practitioner shall examine the client as 3. Until the emergency safety situation ceases and the
cli- soon as possible. ent’s safety and
the safety of others can be ensured, even I. An individual who gives an order for restraint or seclusion if the restraint or seclusion order has not expired; and shall: 4. In a manner that: 1. Order the
least restrictive restraint or seclusion that may a. Prevents physical injury to
the client, resolve the
client’s behavior that is creating the emer- b. Minimizes the client’s physical discomfort and
men- gency safety situation, based upon consultation with a tal distress, and staff member at the agency; c. Complies with the mental health agency’s policies 2. Be available to the agency for consultation, at least by and procedures required in
subsection (E)
and with telephone, throughout the period of
the restraint or seclu- this Section. sion; C. A mental health agency shall not use restraint or seclusion as a 3. Include the following information on the
order: means of coercion, discipline, convenience, or retaliation. a. The
name of the
individual ordering the
restraint or D. A service
provider shall at all times have staff qualified seclusion, according to 9
A.A.C. 20
on duty to provide: b. The
date and
time that the
restraint or seclusion was 1. Restraint and seclusion according to this Section, and ordered, 2. The behavioral health services the
mental health agency c. The
restraint or
seclusion ordered, is authorized to provide according to
9 A.A.C. 20. d. The
criteria for release from restraint or seclusion E. A mental health agency shall develop and
implement written without an additional order, and policies and procedures for the
use of restraint and seclusion e. The
maximum duration for the restraint or seclusion that are
consistent with this Section and other applicable fed- 4. If the
order is
for mechanical restraint or seclusion, limit eral or state law and include: the order to
a period of time not to exceed three hours. 1. Methods of controlling behavior that may prevent the 5. If
the order is for a
drug used as a
restraint, limit the: need for
restraint or
seclusion, a. The
dosage to
that necessary to achieve the desired
If the agency is licensed as a level 1 sub-acute agency
or a level 1 RTC according to R9-20- 102, by a medical
practitioner;
b. Drug ordered to a drug other than a time-released drug designed to be effective for more than three hours; and
6. If the individual ordering the use of restraint or seclusion is not a physician providing treatment to the client:
a. After ordering the restraint or seclusion, consult with the physician providing treatment as soon as possible, and
b. Inform the physician providing treatment of the cli- ent’s behavior that created the emergency safety sit- uation and required the client to be restrained or placed in seclusion.
J. PRN orders shall not be used for any form of restraint or seclu- sion.
K. If an individual has not examined the client according to sub- section (H), the following individual shall conduct a face-to- face assessment of a client’s physical and psychological well- being within one hour after the initiation of restraint or seclu- sion:
1. For a behavioral health agency licensed according to R9- 20-102 as a level 1 psychiatric acute hospital, a physician or nurse practitioner who is either on-site or on-call at the time the mental health agency initiates the restraint or seclusion; or
2. For a behavioral health agency licensed according to R9- 20-102 as a level 1 RTC or a level 1 sub-acute agency a medical practitioner or a registered nurse with at least one year of full time behavioral health work experience, who is either on-site or on-call at the time the mental health agency initiates the restraint or seclusion.
L. A face-to-face assessment of a client according to subsection
(K) shall include a determination of:
1. The client’s physical and psychological status,
2. The client’s behavior,
3. The appropriateness of the restraint or seclusion used,
4. Whether the emergency safety situation has passed, and
5. Any complication resulting from the restraint or seclusion used.
M. For each restraint or seclusion of a client, a mental health agency shall include in the client’s record the order and any renewal order for the restraint or seclusion, and shall docu- ment in the client’s record:
1. The nature of the restraint or seclusion;
2. The reason for the restraint or seclusion, including the facts and behaviors justifying it;
3. The types of less restrictive alternatives that were attempted and the reasons for the failure of the less restrictive alternatives;
4. The name of each individual authorizing the use of restraint or seclusion and each individual restraining or secluding a client or monitoring a client who is in restraint or seclusion;
5. The evaluation and assessment of the need for seclusion or restraint conducted by the individual who ordered the restraint or seclusion;
6. The determination and the reasons for the determination made according to subsection (H) above;
7. The specific and measurable criteria for client release from mechanical restraint or seclusion with documenta- tion to support that the client was notified of the release criteria and the client’s response;
8. The date and times the restraint or seclusion actually began and ended;
9. The time and results of the face-to-face assessment required in subsection (L);
10. For the monitoring of a client in restraint or seclusion required by subsection (P):
a. The time of the monitoring,
b. The name of the staff member who conducted the monitoring, and
c. The observations made by the staff member during the monitoring; and
11. The outcome of the restraint or seclusion.
N. If, at any time during a seclusion or restraint, a medical practi- tioner or registered nurse determines that the emergency which justified the seclusion or restraint has subsided, or if the required documentation reflects that the criteria for release have been met, the client shall be released and the order termi- nated. The client shall be released no later than the end of the period of time ordered for the restraint or seclusion, unless a the order for restraint or seclusion is renewed according to subsection (Q).
O. For any client in restraint, the individual ordering the restraint shall determine whether one-to-one supervision is clinically necessary and shall document the determination and the rea- sons for the determination in the client’s record.
P. A mental health agency shall monitor a client in restraint or seclusion as follows:
1. The client shall be personally examined at least every 15 minutes for the purpose of ensuring the client’s general comfort and safety and determining the client’s need for food, fluid, bathing, and access to the toilet. Personal examinations shall be conducted by staff members with documented training in the appropriate use of restraint and seclusion and who are working under the supervision of a licensed physician, nurse practitioner or registered nurse.
2. A registered nurse shall personally examine the client every hour to assess the status of the client’s mental and physical condition and to ensure the client’s continued well-being.
3. If the client has any medical condition that may be adversely affected by the restraint or seclusion, the client shall be monitored every five minutes, until the medical condition resolves, if applicable.
4. If other clients have access to a client being restrained or secluded or, if the individual ordering the restraint or seclusion determines that one-to-one supervision is clini- cally necessary according to subsection (O), a staff mem- ber shall continuously supervise the client on a one-to- one basis.
5. If a mental health agency maintains a client in a mechani- cal restraint, a staff member shall loosen the mechanical restraints every 15 minutes.
6. Nutritious meals shall not be withheld from a client who is restrained or secluded, if mealtimes fall during the period of restraint. Staff shall supervise all meals pro- vided to the client while in restraint or seclusion.
7. At least once every two hours, a client who is restrained or secluded shall be given the opportunity to use a toilet.
Q. An order for restraint or seclusion may be renewed as follows:
1. For the first renewal order, the order shall meet the requirements of subsection (G)(1) or (G)(2); and
2. For a renewal order subsequent to the first renewal order:
a. The individual in (G)(1) or (G)(2) shall personally examine the client before giving the renewal order, and
b. The order shall not permit the continuation of the restraint or seclusion for more than 12 consecutive hours unless the requirements of subsection (P) are met.
R. No restraint or seclusion shall continue for more than 12 con- secutive hours without the review and approval by the medical director or designee of the mental health agency in consulta- tion with the client and relevant staff to discuss and evaluate the needs of the client. The review and approval, if any, and the reasons justifying any continued restraint or seclusion shall be documented in the client’s record.
S. If a client requires the repeated or continuous use of restraint or seclusion during a 24-hour period, a review process shall be initiated immediately and shall include the client and all rele- vant staff persons and clinical consultants who are available to evaluate the need for an alternative treatment setting and the needs of the client. The review and its findings and recommen- dations shall be documented in the client’s record.
T. Whenever a client is subjected to extended or repeated orders for restraint or seclusion during a 30-day period, the medical director shall require a special meeting of the client’s clinical team according to R9-21-314 to determine whether other treat- ment interventions would be useful and whether modifications of the ISP or ITDP are required.
U. As part of a mental health agency’s quality assurance program, an audit will be conducted and a report filed with the agency’s medical director within 24 hours, or the first working day, for every episode of the use of restraint or seclusion to ensure that the agency’s use of seclusion or restraint is in full compliance with the rules set forth in this Article.
V. Not later than the tenth day of every month, the program direc- tor shall prepare and file with the Division and the Office of Human Rights a written report describing the use of any form of restraint or seclusion during the preceding month in the mental health agency or by any employees of the agency. In the case of an inpatient facility, the report shall also be filed with any patient or human rights committee for that facility.
W. The Department’s human rights committee, the Office of Human Rights, and any applicable regional human rights com- mittee shall review such reports to determine if there has been any inappropriate or unlawful use of restraint or seclusion and to determine if restraint or seclusion may be used in a more effective or appropriate fashion.
X. If any human rights committee or the Office of Human Rights determines that restraint or seclusion has been used in viola- tion of any applicable law or rule, the committee or Office may take whatever action is appropriate, including investigat- ing the matter itself or referring the matter to the Division for remedial action.
Historical Note
Adopted under an exemption from A.R.S. Title 41, Chap- ter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Amended by exempt rulemaking at 9
A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).