Ariz. Admin. Code § R9-10-1406 - Admission; Assessment

An administrator shall ensure that:

1. A participant is admitted based upon the participant's presenting behavioral health issue and treatment needs and the substance abuse transitional facility's ability and authority to provide behavioral health services or physical health services consistent with the participant's needs;

2. General consent is obtained from

a. a participant or the participant's representative before or at the time of admission;

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

3. The general consent obtained in subsection (2) is documented in the participant's medical record;

4. An assessment of a participant is completed or updated by an emergency medical care technician or a registered nurse;

5. If an assessment is completed or updated by an emergency medical care technician, a registered nurse reviews the assessment within 24 hours after the completion of the assessment to ensure that the assessment identifies the behavioral health services and physical health services needed by the participant;

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

a. The participant's assessment information is reviewed and updated if additional information that affects the participant's assessment is identified, and

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

7. An assessment:

a. Documents a participant's:

i. Presenting issue;

ii. Substance abuse history;

iii. Co-occurring disorder;

iv. Medical condition and history;

v. Legal history, including:

(1) Custody,

(2) Guardianship, and

(3) Pending litigation;

vi. Criminal justice record;

vii. Family history;

viii. v. Behavioral health treatment history;

ix. vi. Symptoms reported by the participant; and

x. vii. Referrals needed by the participant, if any;

b. Includes:

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

ii. The behavioral health services and physical health services that will be provided to the participant, and

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

c. Is documented in participant's medical record;

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

9. If a participant requires behavioral health services that the substance abuse transitional facility is not authorized or not able to provide, a personnel member arranges for the participant to be provided transportation to transfer to another health care institution where the behavioral health services can be provided;

10. A request for participation in a participant's assessment is made to the participant or the participant's representative;

11. An opportunity for participation in the participant's assessment is provided to the participant or the participant's representative;

12. Documentation of the request in subsection (10) and the opportunity in subsection (11) is in the participant's medical record; and

13. A participant's assessment information is:

a. Documented in the medical record within 48 hours after completing the assessment, and

b. Reviewed and updated when additional information that affects the participant's assessment is identified.

Notes

Ariz. Admin. Code § R9-10-1406

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). Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014.