Who Can Diagnose R Staff Member and Employee Qualifications and Records

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1 "Behavioral health paraprofessional" means an individual who meets the applicable requirements in R and has: a. An associate's degree, b. A high school diploma, or c. A high school equivalency diploma. "Behavioral health professional" means an individual who meets the applicable requirements in R and is a: a. Psychiatrist, b. Behavioral health medical practitioner, c. Psychologist, d. Social worker, e. Counselor, f. Marriage and family therapist, g. Substance abuse counselor, or h. Registered nurse with at least one year of full-time behavioral health work experience. "Behavioral health technician" means an individual who meets the applicable requirements in R and: a. Has a master's degree or bachelor's degree in a field related to behavioral health; b. Is a registered nurse; c. Is a physician assistant who is not working as a medical practitioner; d. Has a bachelor's degree and at least one year of full-time behavioral health work experience; e. Has an associate's degree and at least two years of full-time behavioral health work experience; f. Has a high school diploma or high school equivalency diploma and: i. 18 credit hours of post-high school education in a field related to behavioral health completed no more than four years before the date the individual begins providing behavioral health services and two years of full-time behavioral health work experience; or ii. Four years of full-time behavioral health work experience; or g. Is licensed as a practical nurse, according to A.R.S. Title 32, Chapter 15, with at least two years of full-time behavioral health work experience. R Staff Member and Employee Qualifications and Records A. A licensee shall ensure that: 1. A staff member is at least 21 years old; 2. Except as provided in subsection (A)(3), an intern is at least 18 years old; 3. An intern in a Level 1 specialized transitional agency is at least 21 years old; and 4. A volunteer is at least 21 years old. B. A licensee shall ensure that a behavioral health professional has the skills and knowledge necessary to: 1. Provide the behavioral health services that the agency is authorized to provide; and 2. Meet the unique needs of the client populations served by the agency, such as children, adults age 65 or older, individuals with a substance abuse problem, individuals who are seriously mentally ill, individuals who have co-occurring disorders, or individuals who may be victims or perpetrators of domestic violence. C. A licensee shall ensure that an individual who is a baccalaureate social worker, master social worker, associate marriage and family therapist, associate counselor, or substance abuse counselor is under direct supervision as defined in A.A.C. R D. A licensee shall ensure that a behavioral health technician has the skills and knowledge required in subsection (F) and otherwise required in this Chapter.

2 E. A licensee shall ensure that a behavioral health paraprofessional hired after the effective date of this Chapter: 1. Who has six weeks of behavioral health work experience has the skills and knowledge required in subsection (F); and 2. Who does not have six weeks of behavioral health work experience: a. Receives six weeks of continuous onsite direction from a behavioral health professional, a behavioral health technician, or a behavioral health paraprofessional who has at least six months of behavioral health work experience; and b. Has the skills and knowledge required in subsection (F) after the six weeks of continuous onsite direction. F. A licensee shall ensure that a behavioral health technician or behavioral health paraprofessional hired after the effective date of this Chapter has the skills and knowledge necessary to perform the duties consistent with the job description of the behavioral health technician or behavioral health paraprofessional and the services the agency is authorized to provide including, if applicable, the skills and knowledge: 1. Necessary to: a. Protect client rights in R ; b. Provide treatment that promotes client dignity, independence, individuality, strengths, privacy, and choice; c. Recognize obvious symptoms of a mental disorder, personality disorder, or substance abuse; d. Provide the behavioral health services that the agency is authorized to provide and that the staff member is qualified to provide; e. Meet the unique needs of the client populations served by the agency or the staff member, such as children, adults age 65 or older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders; f. Protect and maintain the confidentiality of client records and information; g. Recognize and respect cultural differences; h. Recognize, prevent, and respond to a situation in which a client: i. May be a danger to self or a danger to others, ii. Behaves in an aggressive or destructive manner, iii. May be experiencing a crisis situation, or iv. May be experiencing a medical emergency; i. Read and implement a client's treatment plan; j. Assist a client in accessing community services and resources; k. Record and document client information; l. Demonstrate ethical behavior, such as by respecting staff member and client boundaries and recognizing the inappropriateness of receiving gratuities from a client; m. Identify types of medications commonly prescribed for mental disorders, personality disorders, and substance abuse and the common side effects and adverse reactions of the medications; n. Recognize and respond to a fire, disaster, hazard, and medical emergency; and o. Provide the activities or behavioral health services identified in the staff member's job description or the agency's policy and procedure; and 2. That are verified: a. Except as provided in subsection (E)(2), before the staff member provides behavioral health services to a client; b. By the clinical director, a behavioral health professional, or a behavioral health technician with a combination of at least six years of education in a field related to behavioral health and fulltime behavioral health work experience; and c. Through one or more of the following:

3 i. Visual observation of the staff member interacting with another individual, such as through role playing exercises; ii. Verbal interaction with the staff member, such as interviewing, discussion, or question and answer; or iii. A written examination. G. A licensee shall ensure that verification of each of the skills and knowledge required in subsection (F) are documented, including the: 1. Name of the staff member; 2. Date skills and knowledge were verified; 3. Method of verification used, according to subsection (F)(2)(c); and 4. Signature and professional credential or job title of the individual who verified the staff member's skills and knowledge. H. A licensee of a residential agency or an inpatient treatment program shall ensure that: 1. Before providing behavioral health services, a staff member submits documentation of a physical examination or nursing assessment that indicates that the staff member is capable of performing the duties contained in the staff member's job description; 2. At the starting date of employment or before providing behavioral health services and every 12 months thereafter, a staff member submits one of the following as evidence of freedom from infectious pulmonary tuberculosis: a. A report of a negative Mantoux skin test administered within six months before the report is submitted; or b. If the staff member has had a positive skin test for tuberculosis, a written statement from a medical practitioner dated within six months before the statement is submitted indicating that the staff member is free from infectious pulmonary tuberculosis; and 3. If a staff member or employee has a communicable disease listed in R (A) or (B), the staff member or employee provides written authorization from a medical practitioner before returning to work. I. A licensee shall ensure that a personnel record is maintained for each staff member that contains: 1. The staff member's name, date of birth, home address, and home telephone number; 2. The name and telephone number of an individual to be notified in case of an emergency; 3. The starting date of employment or contract service and, if applicable, the ending date; and 4. Documentation of: a. The staff member's compliance with the qualifications required in this Chapter, as applicable; b. The staff member's compliance with the behavioral health work experience requirements in this Section; c. The staff member's compliance with the fingerprinting requirements in R (A)(1)(c) or 9 A.A.C. 20, Article 13, if applicable; d. The performance reviews required in R (D); e. The verification of the staff member's skills and knowledge required in subsection (G), if applicable, and as otherwise required in this Chapter; f. The clinical supervision required in R , if applicable; g. The staff member's completion of the orientation required in R (A); h. The staff member's completion of the training required in R (B), if applicable; i. Any disciplinary action taken against the staff member; j. The staff member's documentation of CPR and first aid training, as required in R (B), if applicable; k. The staff member's review of policies and procedures required in R (B)(4), including the signature of the staff member and the date signed; and l. For a staff member working in a residential agency or an inpatient treatment program: i. The staff member's physical examination or nursing assessment as required in subsection (H)(1), and

4 ii. The staff member's freedom from infectious pulmonary tuberculosis as required in subsection (H)(2). J. A licensee shall ensure that a personnel record is maintained for each volunteer, intern, or employee that contains: 1. The individual's name, date of birth, home address, and home telephone number; 2. The name and telephone number of an individual to be notified in case of an emergency; 3. The starting date of employment, contract service, or volunteer service and, if applicable, the ending date; 4. For an individual working or providing volunteer services in a residential agency or an inpatient treatment program, documentation of the individual's freedom from infectious pulmonary tuberculosis as required in subsection (H)(2); and 5. Documentation of the individual's compliance with the fingerprinting requirements in R (A)(1)(c) or 9 A.A.C. 20, Article 13, if applicable. K. A licensee shall ensure that personnel records required in this Section are maintained: 1. On the premises or at the administrative office; 2. Throughout an individual's period of employment, contract service, volunteer service, or internship; and 3. For at least two years after the last date of the individual's employment, contract service, volunteer service, or internship. Historical Note New Section made by exempt rulemaking at 7 A.A.R. 4439, effective October 3, 2001 (Supp. 01-3). Amended by exempt rulemaking at 9 A.A.R. 3214, effective June 30, 2003 (Supp. 03-2). R Assessment and Treatment Plan A. A licensee shall develop, implement, and comply with policies and procedures for conducting an assessment that ensure that a behavioral health professional or a behavioral health technician under the supervision of a behavioral health professional, conducting an assessment: 1. Refers the client to a medical practitioner if there is evidence that the client's behavioral health issue may be related to a medical condition; and 2. Addresses a client's: a. Presenting issue; b. Substance abuse history; c. Co-occurring disorder; d. Medical condition and history; e. Legal history, including: i. Custody, ii. Guardianship, iii. Pending litigation, iv. Court-ordered evaluation, v. Court-ordered treatment, and vi. Criminal justice record; f. Family history; and g. Behavioral health treatment history. B. A licensee shall ensure that: 1. A behavioral health professional or a behavioral health technician, under the supervision of a behavioral health professional, initiates an assessment of a client before treatment is initiated, and 2. If an assessment is conducted and documented by a behavioral health technician, a behavioral health professional reviews the assessment information documented by the behavioral health technician to ensure that the assessment information identifies the behavioral health services needed by the client and whether the client needs medical services.

5 C. A licensee shall ensure that a client's assessment is completed with the participation of: 1. The client or the client's guardian or agent, if applicable; 2. If the client is a child, the client's parent, guardian, or custodian; 3. An individual requested by the client or the client's guardian or agent or, if the client is a child, by the client's parent, guardian, or custodian; and 4. Any individual required by federal or state law. D. A licensee may use a documented assessment completed by a behavioral health professional or a behavioral health technician not affiliated with the licensee's agency if: 1. The assessment was completed in compliance with this Section; 2. The assessment was completed within 12 months before the date of the client's admission to the licensee's agency; and 3. The behavioral health professional or the behavioral health technician at the licensee's agency updates the documented assessment to include any changes to the client's condition since the assessment was completed. E. A licensee shall ensure that, except for a client receiving behavioral health services in a crisis situation, a client's assessment information is documented in the client record within seven days after initiating or updating the assessment, to include: 1. A description of the client's presenting issue; 2. An identification of the client's behavioral health symptoms and of each behavioral health issue that requires treatment; 3. A description of the medical symptoms reported by the client and medical referrals needed by the client, if any; 4. Recommendations for further assessment or examination of the client's needs; 5. Recommendations for treatment needed by the client; 6. Recommendations for ancillary services or other services needed by the client; and 7. The signature, professional credential or job title, and date signed of: a. The staff member conducting the assessment; and b. If the assessment information was documented by a behavioral health technician, the behavioral health professional who reviewed the assessment information. F. A licensee shall ensure that: 1. A client's assessment information is reviewed and updated: a. When additional information that affects the client's assessment is identified, and b. At least once every 12 months; and 2. A review and update of a client's assessment information is documented in the client record within seven days after the review is completed. G. A licensee shall ensure that the assessment information of a client receiving behavioral health services in a crisis situation is documented in the client record: 1. Before the individual's or client's: a. Admission, b. Transfer, or c. Referral; and 2. To include the requirements in subsections (E)(1) through (6), the name of each behavioral health professional who reviewed the assessment information according to subsection (B)(2), and the date of the review. H. A licensee shall ensure that policies and procedures for developing, implementing, monitoring, and updating a treatment plan are developed, implemented, and complied with. I. A licensee shall ensure that an initial treatment plan is developed for each client that: 1. Is based upon the initial assessment of the client and, if applicable, the client's physical examination required in R (E); 2. Is completed and documented: a. Before a client:

6 i. Receives counseling; ii. Is admitted to an inpatient facility or residential agency, unless a client's presenting issue requires immediate admission; iii. Receives treatment of the client's behavioral health issue with medication; or iv. Receives opioid treatment according to Article 10; b. No later than 30 days after the client's first visit with a behavioral health professional or a behavioral health technician under the supervision of a behavioral health professional; c. By a behavioral health professional or a behavioral health technician under the supervision of a behavioral health professional; d. With the participation of the client or the client's guardian or agent or, if the client is a child, the client's parent, guardian, or custodian; 3. Includes: a. The client's presenting issue; b. The behavioral health services or ancillary services to be provided to the client until completion of the treatment plan in subsection (J); c. Identification of individuals or entities to provide behavioral health services or ancillary services in subsection (I)(3)(b); d. The information in subsection (J) for a client: i. Receiving DUI treatment, ii. Receiving misdemeanor domestic violence offender treatment, iii. Receiving counseling, iv. Receiving treatment of the client's behavioral health issue with medication, v. Admitted to an inpatient facility or residential agency, or vi. Receiving opioid treatment according to Article 10; e. The signature and date signed, or documentation of the refusal to sign, of the client or the client's guardian or agent or, if the client is a child, the client's parent, guardian, or custodian; and f. The signature, professional credential or job title and date signed of: i. The staff member developing the treatment plan; and ii. If the treatment plan was completed by a behavioral health technician, the behavioral health professional who reviewed the treatment plan; 4. If the initial treatment plan was completed by a behavioral health technician, is reviewed by a behavioral health professional to ensure that the initial treatment plan is complete and accurate and meets the client's treatment needs; and 5. Is entered in the client record within seven days of completion. J. A licensee shall ensure that a treatment plan is developed for each client and that the treatment plan: 1. Is based upon the initial assessment and ongoing assessment of the client; 2. Is completed and documented no later than 90 days after the client's first visit with a behavioral health professional or behavioral health technician under supervision of a behavioral health professional; 3. Is developed by a behavioral health professional or a behavioral health technician under the supervision of a behavioral health professional; 4. Is developed with the participation of the client or the client's guardian or agent or, if the client is a child, the client's parent, guardian, or custodian; 5. If the treatment plan was completed by a behavioral health technician, is reviewed by a behavioral health professional to ensure that the treatment plan is complete and accurate and meets the client's treatment needs; 6. Includes: a. The client's presenting issue; b. One or more treatment goals; c. One or more treatment methods and the frequency of each treatment method;

7 d. The date when the client's treatment plan shall be reviewed; e. If a discharge date has been determined, the treatment needed after discharge; f. The signature and date signed, or documentation of the refusal to sign, of the client or the client's guardian or agent or, if the client is a child, the client's parent, guardian, or custodian; and g. The signature, professional credential or job title and date signed of: i. The staff member developing the treatment plan; and ii. If the treatment plan was completed by a behavioral health technician, the behavioral health professional approving the treatment plan; 7. Is reviewed and updated on an on-going basis: a. According to the review date specified in the treatment plan and at least annually; b. When a treatment goal is accomplished or changes; c. When additional information that affects the client's assessment is identified; d. When a client has a significant change in condition or experiences an event that affects treatment; and e. If the client is receiving opioid treatment according to Article 10, at least once every three months during the client's first year of opioid treatment and at least once every six months after the client's first year of opioid treatment; and 8. Is entered in the client record within seven days of completion. K. A licensee shall ensure that the treatment plan to resolve or address a crisis situation is documented at the agency: 1. Before the date of the individual's or client's: a. Admission, b. Transfer, or c. Referral; and 2. To include the name of the behavioral health professional who reviewed the treatment plan and the date and time of the review. L. A licensee shall ensure that: 1. A client's treatment is based upon the client's treatment plan; 2. When a client's treatment plan is reviewed under subsection (J)(7), a behavioral health professional or behavioral health technician reviews the client's progress in treatment and determines whether the client needs to continue with treatment or to be transferred or discharged; and 3. If a client's progress is reviewed by a behavioral health technician, the behavioral health technician's review and determinations are approved by a behavioral health professional. M. A licensee shall ensure that a client's initial treatment plan and treatment plan are implemented. Historical Note New Section made by exempt rulemaking at 7 A.A.R. 4439, effective October 3, 2001 (Supp. 01-3). Amended by exempt rulemaking at 9 A.A.R. 3214, effective June 30, 2003 (Supp. 03-2).

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