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

Ariz. Admin. Code § R9-10-1903

Adopted by exempt rulemaking at 20 A.A.R. 3535, effective 1/1/2015. Amended by final expedited rulemaking at 26 A.A.R. 3041, effective 11/3/2020.