Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 3 - BEHAVIORAL HEALTH INPATIENT FACILITIES
Section R9-10-306 - Personnel

Universal Citation: AZ Admin Code R 9-10-306

Current through Register Vol. 30, No. 38, September 20, 2024

A. An administrator shall ensure that:

1. A personnel member, an employee, or a student is at least 18 years old; and

2. A volunteer is at least 21 years old.

B. An administrator shall ensure that:

1. The qualifications, skills, and knowledge required for each type of personnel member:
a. Are based on:
i. The type of physical health services or behavioral health services expected to be provided by the personnel member according to the established job description, and

ii. The acuity of the patients receiving physical health services or behavioral health services from the personnel member according to the established job description; and

b. Include:
i. The specific skills and knowledge necessary for the personnel member to provide the expected physical health services and behavioral health services listed in the established job description,

ii. The type and duration of education that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description, and

iii. The type and duration of experience that may allow the personnel member to have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description;

2. A personnel member's skills and knowledge are verified and documented:
a. Before the personnel member provides physical health services or behavioral health services, and

b. According to policies and procedures;

C. An administrator shall comply with the requirements for behavioral health technicians and behavioral health paraprofessionals in R9-10-115.

D. An administrator shall ensure that an individual who is licensed under A.R.S. Title 32, Chapter 33 as a baccalaureate social worker, master social worker, associate marriage and family therapist, associate counselor, or associate substance abuse counselor is under direct supervision, as defined in A.A.C. R4-6-101.

E. An administrator shall ensure that a personnel member, or an employee, a volunteer, or a student who has or is expected to have direct interaction with a participant for more than eight hours in a week, provides evidence of freedom from infectious tuberculosis:

1. On or before the date the individual begins providing services at or on behalf of the behavioral health inpatient facility, and

2. As specified in R9-10-113.

F. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:

1. The individual's name, date of birth, and contact telephone number;

2. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and

3. Documentation of:
a. The individual's qualifications including skills and knowledge applicable to the individual's job duties;

b. The individual's education and experience applicable to the employee's job duties;

c. The individual's completed orientation and in-service education as required by policies and procedures;

d. The individual's license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;

e. The individual's qualifications and on-going training for each type of restraint or seclusion used, as required in R9-10-316;

f. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;

g. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-303(C)(l)(e);

h. First aid training, if required for the individual according to this Article or policies and procedures; and

i. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (D).

G. An administrator shall ensure that personnel records are:

1. Maintained:
a. Throughout an individual's period of providing services in or for the behavioral health inpatient facility, and

b. For at least 24 months after the last date the individual provided services in or for the behavioral health inpatient facility; and

2. For a personnel member who has not provided physical health services or behavioral health services at or for the behavioral health inpatient facility during the previous 12 months, provided to the Department within 72 hours after the Department's request.

H. An administrator shall ensure that:

1. A plan to provide orientation specific to the duties of a personnel member, an employee, a volunteer, and a student is developed, documented, and implemented;

2. A personnel member completes orientation before providing behavioral health services or physical health services;

3. An individual's orientation is documented, to include:
a. The individual's name,

b. The date of the orientation, and

c. The subject or topics covered in the orientation;

4. A clinical director develops, documents, and implements a plan to provide in-service education specific to the duties of a personnel member; and

5. A personnel member's in-service education is documented, to include:
a. The personnel member's name,

b. The date of the training, and

c. The subject or topics covered in the training.

I. An administrator shall ensure that a behavioral health inpatient facility has a daily staffing schedule that:

1. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

2. Includes documentation of the employees who work each calendar day and the hours worked by each employee; and

3. Is maintained for at least 12 months after the last date on the daily staffing schedule.

J. An administrator shall ensure that:

1. A physician or registered nurse practitioner is present on the behavioral health inpatient facility's premises or on-call,

2. A registered nurse is present on the behavioral health inpatient facility's premises, and

3. A registered nurse who provides direction for the nursing services provided at the behavioral health inpatient facility is present at the behavioral health inpatient facility at least 40 hours every week.

Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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