Ariz. Admin. Code § R9-10-707 - Admission; Assessment

A. An administrator shall ensure that:

1. A resident is admitted based upon:

a. The resident's primary condition for which the resident is admitted to the behavioral health residential facility being a behavioral health issue, and

b. The resident's behavioral health issue and treatment needs are within the behavioral health residential facility's scope of services;

2. A behavioral health professional, authorized by policies and procedures to admit a resident, is available;

3. Except as provided in subsection (A)(4), general consent is obtained from:

a. An adult resident or the resident's representative before or at the time of admission, or

b. A resident's representative, if the resident is not an adult;

4. General consent is not required from a patient receiving a court-ordered evaluation or court-ordered treatment;

4.5. The general consent obtained in subsection (A)(3) is documented in the resident's medical record;

5.6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

6.7. If a medical practitioner performs a medical history and physical examination or a nurse performs a nursing assessment on a resident before admission, the medical practitioner enters an interval note or the nurse enters a progress note in the resident's medical record within seven calendar days after admission;

7.8. If a behavioral health assessment is conducted by a:

a. Behavioral health technician or registered nurse, within 24 hours a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, reviews and signs the behavioral health assessment to ensure that the behavioral health assessment identifies the behavioral health services needed by the resident; or

b. Behavioral health paraprofessional, a behavioral health professional, certified or licensed to provide the behavioral health services needed by the resident, supervises the behavioral health paraprofessional during the completion of the assessment and signs the assessment to ensure that the assessment identifies the behavioral health services needed by the resident;

8.9. Except as provided in subsection (A)(10), a behavioral health assessment for a resident is completed before treatment for the resident is initiated;

9.10. If a behavioral health assessment that complies with the requirements in this Section is received from a behavioral health provider other than the behavioral health residential facility or if the behavioral health residential facility has a medical record for the resident that contains a behavioral health assessment that was completed within 12 months before the date of the resident's current admission:

a. The resident's assessment information is reviewed before treatment for the resident is initiated and updated if additional information that affects the resident's assessment is identified, and

b. The review and update of the resident's assessment information is documented in the resident's medical record within 48 hours after the review is completed;

10.11. A behavioral health assessment:

a. Documents a resident's:

i. Presenting issue;

ii. Substance abuse history;

iii. Co-occurring disorder;

iv. Legal history, including:

(1) Custody,

(2) Guardianship, and

(3) Pending litigation;

v. Criminal justice record;

vi. Family history;

vii. Behavioral health treatment history;

viii. Symptoms reported by the resident; and

ix. Referrals needed by the resident, if any;

b. Includes:

i. Recommendations for further assessment or examination of the resident's needs,

ii. The physical health services or ancillary services that will be provided to the resident until the resident's treatment plan is completed, and

iii. The signature and date signed of the personnel member conducting the behavioral health assessment; and

c. Is documented in resident's medical record;

11.12. A resident is referred to a medical practitioner if a determination is made that the resident requires immediate physical health services or the resident's behavioral health issue may be related to the resident's medical condition; and

12.13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis:

a. Before or within seven calendar days after the resident's admission, and

b. As specified in R9-10-113.

B. An administrator shall ensure that:

1. A request for participation in a resident's behavioral health assessment is made to the resident or the resident's representative,

2. An opportunity for participation in the resident's behavioral health assessment is provided to the resident or the resident's representative, and

3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the resident's medical record.

C. An administrator shall ensure that a resident's behavioral health assessment information is documented in the medical record within 48 hours after completing the behavioral health assessment.

D. If information in subsection (A)(10) is obtained about a resident after the resident's behavioral health assessment is completed, an administrator shall ensure that an interval note, including the information, is documented in the resident's medical record within 24 hours after the information is obtained.

E. If a behavioral health residential facility is authorized to provide respite services, an administrator shall ensure that:

1. Upon admission of a resident for respite services:

a. Except as provided in subsection (F), a medical history and physical examination of the resident:

i. Is performed; or

ii. If dated within the previous 12 months, is available in the resident's medical record from a previous admission to the behavioral health residential facility;

b. A treatment plan that meets the requirements in R9-10-708:

i. Is developed; or

ii. If dated within the previous 12 months, is available in the resident's medical record from a previous admission to the behavioral health residential facility;

c. If a treatment plan, dated within the previous 12 months, is available, the treatment plan is reviewed, updated, and documented in the resident's medical record; and

d. The resident is not required to comply with the requirements in subsection (A)(13) if the resident is not expected to be present in the behavioral health residential facility:

i. For more than seven consecutive days, or

ii. For 10 days or more days in a 90-consecutive-day period;

2. The common area required in R9-10-722(B)(1)(b) provides at least 25 square feet for each resident, including residents who do not stay overnight; and

3. In addition to the requirements in R9-10-722(B)(3), toilets and hand-washing sinks are available to residents, including residents who do not stay overnight, as follows:

a. There is at least one working toilet that flushes and has a seat and one sink with running water for every 10 residents,

b. There are at least two working toilets that flush and have seats and two sinks with running water if there are 11 to 25 residents, and

c. There is at least one additional working toilet that flushes and has a seat and one additional sink with running water for each additional 20 residents.

F. A medical history and physical examination is not required for a child who is admitted or expected to be admitted to a residential behavioral health facility for less than 10 days in a 90-consecutive-day period.

Notes

Ariz. Admin. Code § R9-10-707

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, pursuant 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 R9-10-707 repealed, new Section R9-10-707 adopted effective November 1, 1998, under an exemption from the provisions 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). Section repealed; 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, effective 7/1/2014. Amended by exempt rulemaking at 22 A.A.R. 1035, effective 5/1/2016. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by final expedited rulemaking at 26 A.A.R. 551, effective 3/3/2020.

The following Section was repealed and a new Article adopted under an exemption from the provisions of the Administrative Procedure Act which means these rules were not reviewed by the Governor's Regulatory Review Council; the Department did not submit notice of proposed rulemaking to the Secretary of State for publication in the Arizona Administrative Register; and the Department was not required to hold public hearings on these rules (Supp. 98-4).