Ariz. Admin. Code § 9-10-308

Current through Register Vol. 30, No. 45, November 8, 2024

Section R9-10-308 - Treatment Plan

A. Except for a patient admitted to receive crisis services or as provided in R9-10-315(E) or (F), an administrator shall ensure that a treatment plan is developed and implemented for a patient that:

1. Is based on the behavioral health assessment and on-going changes to the behavioral health assessment of the patient;

2. Is completed:

a. By a behavioral health professional or by a behavioral health technician under the clinical oversight of a behavioral health professional, and

b. Before the patient receives treatment;

3. Is documented in the patient's medical record within 24 hours after the patient first receives treatment;

4. Includes:

a. The patient's presenting issue, including the acuity of the patient's presenting issue;

b. The behavioral health services and physical health services to be provided to the patient;

c. If the patient was admitted after a suicide attempt or who exhibits suicidal ideation:

i. The results of the suicide assessment required in R9-10-307(11), and

ii. Information specific to helping prevent a recurrence;

d. The signature of the patient or the patient's representative and date signed, or documentation of the refusal to sign;

e. The date when the patient's treatment plan will be reviewed;

f. If a discharge date has been determined, the treatment needed after discharge; and

g. The signature of the personnel member who developed the treatment plan and the date signed;

5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan identifies the acuity of the patient and meets the patient's treatment needs; and

6. Is reviewed and updated on an on-going basis:

a. According to the review date specified in the treatment plan,

b. When a treatment goal is accomplished or changes,

c. When additional information that affects the patient's behavioral health assessment is identified, and

d. When a patient has a significant change in condition or experiences an event that affects treatment.

B. An administrator shall ensure that:

1. A request for participation in developing a patient's treatment plan is made to the patient or the patient's representative;

2. An opportunity for participation in developing the patient's treatment plan is provided to the patient or the patient's representative; and

3. The request in subsection (B)(1) and the opportunity in subsection (B)(2) are documented in the patient's medical record.

C. If a patient who is admitted to receive crisis services remains admitted as a patient after the patient no longer needs crisis services, an administrator shall ensure that a treatment plan for the patient is:

1. Except for subsection (A)(3), completed according to the requirements in subsection (A); and

2. Documented in the patient's medical record within 24 hours after the patient no longer needs crisis services.

Ariz. Admin. Code § R9-10-308

New Section R9-10-308 made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, effective 7/1/2014. Amended by final rulemaking at 25 A.A.R. 1583, effective 10/1/2019. Amended by exempt rulemaking at 27 A.A.R. 661, effective 5/1/2021.