Ariz. Admin. Code § R9-10-1903 - Administration
A. A governing
authority shall:
1. Consist of one of more
individuals accountable for the organization, operation, and administration of
a counseling facility;
2.
Establish, in writing:
a. A counseling
facility's scope of services, and
b. Qualifications for an
administrator;
3.
Designate, in writing, an administrator who has the qualifications established
in subsection (A)(2)(b);
4. Adopt a
quality management program according to
R9-10-1904;
5. Review and evaluate the effectiveness of
the quality management program in
R9-10-1904 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 premises
for more than 30 calendar days, or
b. Not present on the 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(1)
when there is a change in an 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 counseling facility and all services
provided by or at the counseling facility;
2. Has the authority and responsibility to
manage the counseling facility; and
3. Except as provided in subsection (A)(6),
designates in writing, an individual who is present on the counseling
facility's premises and accountable for the counseling facility when the
administrator is not available.
C. An administrator or the administrator of
the counseling facility's affiliated outpatient treatment center shall
establish policies and procedures to protect the health and safety of a patient
that:
1. Cover job descriptions, duties, and
qualifications, including required skills, knowledge, education, and
experience, for personnel members, employees, volunteers, and
students;
2. Cover orientation and
in-service education for personnel members, employees, volunteers, and
students;
3. Include how a
personnel member may submit a complaint relating to services provided to a
patient;
4. Cover the requirements
in Title 36, Chapter 4, Article 11;
5. Cover patient screening, admission,
assessment, discharge planning, and discharge;
6. Cover medical records;
7. Cover the provision of counseling and any
services listed in the counseling facility' s scope of services;
8. Include when general consent and informed
consent are required;
9. Cover
telemedicine, if applicable;
10.
Cover specific steps for:
a. A patient or a
patient's representative to file a complaint, and
b. A counseling facility to respond to a
complaint; and
11. 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.
D. An
administrator shall ensure that:
1. Policies
and procedures established according to subsection (C) are documented and
implemented;
2. Counseling facility
policies and procedures are:
a. Reviewed at
least once every three years and updated as needed, and
b. Available to personnel members and
employees;
3. Unless
otherwise stated:
a. Documentation required
by this Article is maintained and provided to the Department within two hours
after a Department request; and
b.
When documentation or information is required by this Chapter to be submitted
on behalf of a counseling facility, the documentation or information is
provided to the unit in the Department that is responsible for licensing and
monitoring the counseling facility;
4. The following are conspicuously posted:
a. The current license for the counseling
facility issued by the Department;
b. The name, address, and telephone number of
the Department;
c. A notice that a
patient may file a complaint with the Department about the counseling
facility;
d. A list of patient
rights;
e. A map for evacuating the
facility; and
f. A notice
identifying the location on the premises where current license inspection
reports required in A.R.S. §
36-425(H),
with patient information redacted, are available;
5. Patient follow-up instructions are:
a. Provided, orally or in written form, to a
patient or the patient's representative before the patient leaves the
counseling facility unless the patient leaves against a personnel member's
advice; and
b. Documented in the
patient's medical record; and
6. Cardiopulmonary resuscitation training
includes a demonstration of the individual's ability to perform cardiopulmonary
resuscitation.
E. If
abuse, neglect, or exploitation of a patient is alleged or suspected to have
occurred before the patient was admitted or while the patient is not on the
premises and not receiving services from a counseling facility's employee or
personnel member, an administrator shall report the alleged or suspected abuse,
neglect, or exploitation of the patient as follows:
1. For apatient 18 years of age or older,
according to A.R.S. §
46-454;
or
2. For a patient under 18 years
of age, according to A.R.S. §
13-3620.
F. If an administrator has a
reasonable basis, according to A.R.S. §§
13-3620
or
46-454,
to believe that abuse, neglect, or exploitation has occurred on the premises or
while a patient is receiving services from a counseling facility's employee or
personnel member, an 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 as follows:
a. For apatient 18 years of age or older,
according to A.R.S. §
46-454;
or
b. For a patient 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 (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
subsection (F)(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 suspected abuse or neglect and any change to the patient's
physical, cognitive, functional, 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 occurring 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.
Notes
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