Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING
Article 3 - BEHAVIORAL HEALTH INPATIENT FACILITIES
Section R9-10-307 - Admission; Assessment
Universal Citation: AZ Admin Code R 9-10-307
Current through Register Vol. 30, No. 38, September 20, 2024
A. Except as provided in R9-10-315(E) or (F), an administrator shall ensure that:
1. A patient is admitted based upon the
patient's presenting behavioral health issue and treatment needs and the
behavioral health inpatient facility's ability and authority to provide
physical health services, behavioral health services, and ancillary services
consistent with the patient's treatment needs;
2. A patient is admitted on the order of a
medical practitioner or clinical director;
3. A medical practitioner or clinical
director, authorized by policies and procedures to accept a patient for
admission, is available;
4. Except
in an emergency or as provided in subsections (A)(6) and (7), general consent
is obtained from a patient or, if applicable, the patient's representative
before or at the time of admission;
5. The general consent obtained in subsection
(A)(4) or the lack of consent in an emergency is documented in the patient's
medical record;
6. General consent
is not required from a patient receiving a court-ordered evaluation or
court-ordered treatment;
7. General
consent is not required from a patient receiving treatment according to A.R.S.
§
36-512;
8. A medical practitioner performs a medical
history and physical examination on a patient within 30 calendar days before
admission or within 24 hours after admission and documents the medical history
and physical examination in the patient's medical record within 24 hours after
admission;
9. If a medical
practitioner performs a medical history and physical examination on a patient
before admission, the medical practitioner enters an interval note into the
patient's medical record within seven calendar days after admission;
10. Except when a patient needs crisis
services, a behavioral health assessment of a patient is completed to determine
the acuity of the patient's behavioral health issue and to identify the
behavioral health services needed by the patient before treatment for the
patient is initiated and whenever the patient has a significant change in
condition or experiences an event that affects treatment;
11. If the patient was admitted after a
suicide attempt or exhibits suicidal ideation, the behavioral health assessment
in subsection (A)(10) includes a suicide assessment;
12. If a behavioral
health assessment in subsection (A)(10), including a suicide assessment in
subsection (A)(11) if applicable, is conducted by a:
a. Behavioral health technician or registered
nurse, within 24 hours a behavioral health professional, certified or licensed
under A.R.S. Title 32 to provide the behavioral health services needed by the
patient, reviews and signs the behavioral health assessment to ensure that the
behavioral health assessment identifies the behavioral health services needed
by and the acuity of the patient; or
b. Behavioral health paraprofessional, a
behavioral health professional, certified or licensed under A.R.S. Title 32 to
provide the behavioral health services needed by the patient, supervises the
behavioral health paraprofessional during the completion of the behavioral
health assessment and signs the behavioral health assessment to ensure that the
behavioral health assessment identifies the behavioral health services needed
by and the acuity of the patient;
13. When a patient is
admitted, a registered nurse:
a. Conducts a
nursing assessment of a patient's medical condition and history;
b. Determines whether the:
i. Patient requires immediate physical health
services, and
ii. Patient's
behavioral health issue may be related to the patient's medical condition and
history;
c. Determines
the acuity of the patient's medical condition;
d. Documents the patient's nursing assessment
and the determinations required in subsection (A)(13)(b) and (c) in the
patient's medical record; and
e.
Signs the patient's medical record;
14. A behavioral
health assessment:
a. Documents the patient's:
i. Presenting issue, including the acuity of
the patient's presenting issue;
ii.
Substance abuse history;
iii.
Co-occurring disorder;
iv. Legal
history, including:
(1) Custody,
(2) Guardianship, and
(3) Pending litigation;
v. Court-ordered evaluation;
vi. Court-ordered treatment;
vii. Criminal justice record;
viii. Family history;
ix. Behavioral health treatment
history;
x. Symptoms reported by
the patient; and
xi. Referrals
needed by the patient, if any; and
b. Includes:
i. Recommendations for further assessment or
examination of the patient's needs;
ii. Recommendations for staffing levels or
personnel member qualifications related to the patient's treatment to ensure
patient health and safety;
iii. For
a patient who:
(1) Is admitted to receive
crisis services, the behavioral health services and physical health services
that will be provided to the patient; or
(2) Does not need crisis services, the
behavioral health services or physical health services that will be provided to
the patient until the patient's treatment plan is completed; and
iv. The signature and date signed
of the personnel member conducting the behavioral health assessment;
15. A patient is referred to a medical practitioner if
a determination is made that the patient requires immediate physical health
services or the patient's behavioral health issue may be related to the
patient's medical condition;
16. A request for
participation in a patient's behavioral health assessment is made to the
patient or the patient's representative;
17. An opportunity for participation in the patient's
behavioral health assessment is provided to the patient or the patient's
representative;
18. The request in subsection (A)(16) and the
opportunity in subsection (A)(17) are documented in the patient's medical
record;
19. For a patient who is admitted to receive crisis
services, the patient's behavioral health assessment is documented in the
patient's medical record within eight hours after admission;
20.
Except as provided in subsection (A)(19), a patient's behavioral health
assessment is documented in the patient's medical record within 24 hours after
completing the assessment; and
21. If the information
listed in subsection (A)(14) is obtained about a patient after the patient's
behavioral health assessment is completed, an interval note, including the
information, is documented in the patient's medical record within 48 hours
after the information is obtained.
B. If the results of a suicide assessment required in subsection (A)(11) indicate that the patient could be a danger to self upon discharge, an administrator shall ensure that the information in R9-10-309(B)(2) is made available to the patient or the patient's representative as part of the opportunity for participation in the patient's behavioral health assessment required in subsection (A)(17).
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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