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

Current through Register Vol. 30, No. 28, July 12, 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.