Policies and Procedures
R9-10-113 Tuberculosis Screening and Infection Control ProgramStaff members will provide documentation of negative TB screening annually if required. Generally, if a staff member will have greater than 8 hours of direct client contact weekly then a TB test is mandatory. Staff members have 30 days after the last annual test to document a new test, per AZ Administrative code.
The Centers for Disease Control publication will be the basis for the TB Infection Control program.
Residents will produce negative TB results within 12 months of admission or receive testing following admission. Results will be updated to ensure that a resident has had a negative TB result within the last 12 months throughout their stay. Risk factors will be assessed at intake.
Intake Health Questionnaire will inquire regarding TB symptoms for all client admissions.
R9-10-703.C.1.a Job Descriptions, duties, qualifications, required skills and knowledge for personnel members, employees, volunteers, and students.The Board of Directors will oversee the entire organization.
Administrator
The Administrator is responsible for the operation of the agency overseeing all business, clinical, and any other functions within the agency in accordance with state, local, and federal laws; Arizona Department of Health Services code and guidelines; Board of Behavioral Health Examiners code as applicable, guidelines and standards of practice as applicable; and adherence to principles set forth from the American Counseling Association. The Administrator and/or Clinical Director will oversee, supervise, or provide oversight for contract and consulting professionals.
Chief
Financial OfficerThe Chief Financial Officer will oversee all financial arrangements within the agency ensuring compliance with applicable statues and code as well as federal tax and income laws and guidelines.
Medical Director
The Medical Director will oversee the general medical direction of the entire program. If the Medical Director is a psychiatrist, the Medical Director will oversee the psychiatric care of the clientele. The Medical Director will have authority pertaining to admissions, continued care, and any and all psychiatric recommendations. The Medical Director will have direct input into clinical care, medical care, and all program policies and procedures as they relate to medical guidelines with recommendations and opinions rendered to the Administrator and Clinical Director or directly to the Board of Directors.
Clinical Director
The Clinical Director is responsible for overseeing all clinical behavioral health services in accordance with state, local, and federal laws; Arizona Department of Health Services code and guidelines; Board of Behavioral Health Examiners code as applicable, guidelines and standards of practice as applicable; and adherence to principles set forth from the American Counseling Association. The Clinical Director is responsible for ensuring that staff members receive supervision that addresses the treatment needs of all residents. Administrator and/or Clinical Director will oversee, supervise, or provide oversight for contract and consulting professionals. The Clinical Director must be a Behavioral Health Professional.
Program Manager, BHP:
The Behavioral Health Program Manager is responsible for the following duties in addition to those of a BHP. Clinical Oversight of Behavioral Health Technicians as well as supervision of job performance and compliance with Arizona Department of Health protocols, Arizona Administrative Code, Arizona Revised Statutes, and American Counseling Association Ethics and Standards. Supervision of Behavioral Health Paraprofessionals regarding the job performance and compliance with Arizona Department of Health protocols, Arizona Administrative Code, Arizona Revised Statutes, and American Counseling Association Ethics and Standards. Administrative duties regarding compliance with Arizona Department of Health protocols, Arizona Administrative Code, Arizona Revised Statutes, and American Counseling Association Ethics and Standards. Administrator or Clinical Director duties in the absence of the Executive Director. Program Coordination and development including professional direction, quality improvement, accreditation, and monitoring. All other BHP duties including oversight of admissions and discharges when assigned.
Admissions Director
The Admissions Director is responsible for overseeing the admissions process ensuring that it is conducted within professional and ethical guidelines set forth by the Arizona Department of Health services, Arizona Board of behavioral Health Examiners, the American Counseling Association, and all agency guidelines. The admissions Director will operate under the Administrator.Behavioral Health ProfessionalA behavioral health professional is responsible for a variety of duties including collaboration of care with family members; referral sources; other staff members; physicians, psychiatrists, psychologists, counselors, social workers, and other professionals. This also includes, completion of resident assessment if applicable; implementation of treatment plan; resident documentation and charting; facilitation of therapeutic groups in a an appropriate manner; facilitation of family sessions; being on call several times annually; participation in and facilitation of self-esteem workshops; involvement in the overall therapeutic direction of the therapeutic community and agency; provision of clinical oversight to behavioral health technicians and provision of direct clinical oversight to behavioral health paraprofessionals as applicable; supervision of behavioral health paraprofessionals as applicable; adherence to professional standards and ethics of practice as set forth by the Arizona Department of Health Services, American Counseling Association, and the Arizona Board of Behavioral Health Examiners as applicable; clinical supervision of associate licensees as applicable; oversight of resident self-administration of medication; adherence to policies and procedures; resident adherence to program agreement; overall health and welfare of the therapeutic community including resident rights, local, state, federal laws, physical safety of the property, responding to resident medical or safety emergencies in an appropriate manner; and other duties as assigned by the Clinical Director or Administrator. A BHP is licensed under ARS Title 32 whose scope of practice allows the individual to independently engage in the practice of behavioral health, and except for a substance abuse technician, engage in the practice of behavioral health as defined in ARS 32-3251 under direct supervision as defined in AAC R4-6-101.
R9-10-114
Behavioral Health Technician
BHT’s can provide professional counseling including substance abuse counseling under the clinical oversight of a BHP. BHT’s are responsible for completion of resident assessment if applicable; implementation of treatment plan; resident documentation and charting; facilitation of therapeutic groups in a an appropriate manner; collaboration of care with other professionals, family members, or persons of significance to resident; being on call several times annually; participation in and facilitation of self-esteem workshops; involvement in the overall therapeutic direction of the therapeutic community and agency; adherence to professional standards and ethics of practice as set forth by the Arizona Department of Health Services, American Counseling Association, and the Arizona Board of Behavioral Health Examiners as applicable; oversight of resident self-administration of medication; adherence to policies and procedures; resident adherence to program agreement; overall health and welfare of the therapeutic community including resident rights, local, state, federal laws, physical safety of the property, responding to resident medical or safety emergencies in an appropriate manner; clerical and administrative duties as assigned; and other duties as assigned by the Clinical Director or Administrator. Behavioral health technicians with a primary case load are subject to additional clinical oversight. The minimum requirements for this position are determined on a case by case basis by the Clinical Director or the Administrator.
Case Management Technicians (CMT)
Case Management Technicians are responsible for maintaining the integrity of the therapeutic community by involvement in the overall therapeutic direction of the therapeutic community and agency; adherence to professional standards and ethics of practice as set forth by the Arizona Department of Health Services, American Counseling Association, and the Arizona Board of Behavioral Health Examiners as applicable.
Additional responsibilities include the provision of case management for clients including assistance in accessing or effectively using health, social, or other supportive or similar human services. This can include face-to-face or telephone contact with on or behalf of a client or travel to services with clients. This can include crisis intervention as needed.
Additional responsibilities include oversight of resident self-administration of medication; adherence to policies and procedures; resident adherence to program agreement; overall health and welfare of the therapeutic community including resident rights, local, state, and federal laws, physical safety of the property, responding to resident medical or safety emergencies in an appropriate manner; and other duties as assigned by the Clinical Director or Administrator. The minimum requirements for this position are determined by the Administrator or Clinical Director on a case-by-case basis.
R9-10-114
Behavioral Health ParaprofessionalBHPP’s can facilitate education groups, outings, and similar group activities with residents. BHPP’s can facilitate counseling with direct supervision of a BHP. BHPPs are overseen for standards of practice by the Program Director (a BHP or BHT) if designated, the Clinical Director, and/or the Administrator. There may also be a designated behavioral health residential supervisor (a BHPP or a BHT) that directs BHPPs. BHPP’s may assist a BHT in counseling and receive training in this manner provided they are not responsible for facilitating the counseling directly and are present in a training or a assistance role.
Business Office Manager
The Business Office Manager oversees day to day deposits and withdrawals and account maintenance as well as the Client Expense accounts.
Administrative Assistant
Administrative Assistants are responsible for the clerical and administrative duties as assigned by the Business Manager including answering phones; assisting in communications such as messages, faxing and email; general office clean-up and supplies; adherence to Policies and Procedures; resident adherence to Program Agreement; overall health and welfare of the therapeutic community including resident rights, local, state, and federal laws, physical safety of the property, responding to resident medical or safety emergencies in an appropriate manner; and other duties as assigned by the clinical director or Administrator; and other duties as needed. Minimum qualifications are determined by the Administrator on a case by case basis.
Facilities Supervisor
The Facilities Supervisor is responsible for the overall upkeep of the property including but not limited to conducting quarterly fire drills in accordance with applicable ADHS Code, annual fire department inspection; safety of staff and resident on property; preparations for cold weather including ice on walkways;
Admissions Staff
Admissions staff can consist of a Director of Outreach and Admissions, Admissions Coordinator, or other titles based on their job duties. They can be a BHT, a BHPP, or neither based on the discretion of the Administrator or the Clinical Director depending on their job duties at any given time. Admissions staff are responsible for professional outreach, professional collaboration, preparing admissions, completing intake paperwork including appropriate documentation, and coordination with other staff regarding incoming resident’s needs. All admissions staff are under the direction of the Administrator and/or Clinical Director.
Contract or Consulting Professionals
Independently licensed contracted or consulting clinical professionals will have a job description and will receive an orientation, however they will not be required to meet education requirements herein as they will be meeting their requirements from their licensure board. Non-independently licensed professionals will meet the requirements of either a BHT or BHPP and will be treated as such. Non-clinical contract or consulting professionals will be treated in the same manner as licensed clinical professionals.
Interns/Practicum Students
Intern and Practicum students will meet the requirements of BHT, or BHPP and will be treated as such.
Volunteer
Volunteers will meet the requirements of BHT, or BHPP and will be treated as such. Irregular volunteers will need to be approved by the Clinical Director, Administrator, or a BHP.
Specialized Professionals
Specialized professionals are performing work with clients in a behavioral health setting, however, their work is not necessarily within the realm of behavioral health or counseling and can be performed independently. They are exempt from reviews, and training requirements other than training that is typically gained in their area of specialty. Examples include a spiritual, exercise, nutrition, outdoor recreation, or educational professional. They are not providing services that require a counseling license and would not be considered a BHT.
Director of Food Services (A BHPP or a BHT)
Responsible for consultation with Registered Dietitian as often as necessary to meet the nutritional needs of the residents. Qualifications and specific job duties determined by Clinical Director and Administrator on case by case basis.
Diet and Exercise Coordinator (A BHT or BHPP)
Responsible for assisting client in incorporating diet and exercise routines into their life. Qualifications and specific job duties determined by Clinical Director and Administrator on case by case basis.
Clinical Oversight R9-10-114.2.d-I (Including Direct Clinical Oversight and Clinical Supervision)
Clinical oversight will be delivered to BHT’s in a group or individual setting and pertains to direction, advice, counsel, or discussion of any clinical matter relevant to resident care or to counseling and related topics. Oversight may be delivered in a group (where two or more persons are receiving oversight simultaneously) or individually where only one person is receiving oversight. Oversight may include direct observation of clinical skills with residents. Clinical oversight will account for the scope and the extent of services provided, the acuity of the residents and the number of residents receiving services. Clinical oversight will occur bi-monthly or higher except during weeks shortened by holidays, illness, or vacation and be documented monthly in the personnel member’s record. Clinical Oversight will total four hours monthly for primary staff members (those responsible for a case load) and 2+ hours monthly for BHT’s who do not have a caseload but perform some amount of job duties that require licensure. BHT’s who do not perform duties that require licensure do not need clinical oversight.
BHPP’s will receive direct supervision from a BHP when performing job duties that require licensure; professional counseling including substance abuse counseling. Since oversight must be direct, the amount of oversight monthly would equal the amount of duties the BHPP performed that require licensure.
Clinical Supervision of Associate professionals (BHP’s, LAC, LMSW, LASAC) will be performed by a BHP with appropriate qualifications by the Arizona Board of Behavioral Health Examiners. They will not receive oversight as they are receiving supervision.
Behavioral Health Supervision
Staff members who interact with residents but do not perform job duties that require behavioral health licensure will receive behavioral health supervision. This can be documented or not. This pertains to the verification of training, skills, and knowledge of any relevant information needed for performing job duties, as well as, the training of individuals, and the provision of direction in performing job duties. Individuals receiving behavioral health supervision can be BHPPs or not.
Staff members whose job duties include some responsibilities that require licensure and others that require behavioral health supervision can receive both in a percentage reflective of their job duties (such as half behavioral health supervision and half clinical oversight).
R9-10-703.C.1.b Orientation and in-service education for personnel members, employees, volunteers, and students.
All staff members will receive orientation that will occur during and/or over the first six weeks of employment. The orientation education will focus on the following topics; resident rights; review of policies and procedures manual including job description; evacuation paths, procedures for responding to a fire, disaster, hazard, a medical emergency, or a resident crisis situation; policies regarding suspected or alleged abuse, neglect, or exploitation, or violation of a resident’s rights; and resident confidentiality and records.
Additionally BHT’s and BHPP’s skills and knowledge will be verified by a Behavioral Health Professional for the following topics; resident rights, mental health symptoms and diagnoses, unique resident needs, resident confidentiality, sensitivity to varying resident cultural, religious, ethnic, or linguistic differences; response to resident who may be a danger to himself or others, response to a resident behaving in an aggressive manner, in crisis, or experiencing a medical emergency; treatment planning, community resources, documentation, ethics, medications and assistance in the self-administration of medication; fire, disaster, or hazard response; 12-step and self-help groups, admission, assessment, and discharge procedures.
Behavioral health technician and paraprofessional personnel members will complete 16 hours of continuing education/in-service education annually running from March 1 of each year to March 1 of the following year with appropriate pro-rated amounts for new hires. Half time employees complete 8 hours per year and ¾ time or ¼ time personnel members completing a pro-rated amount appropriately. Continuing education can include the above-mentioned topics or similar mental or behavioral health or psychological topics as approved by the Clinical Director.
Behavioral health professionals will complete the continuing education requirements sufficient for their respective professional license.Orientation, verification of skills and knowledge, and continuing education will be documented in the Personnel member’s employee chart. Orientation can take place over a protracted period.
All personnel members will receive annual reviews confirming the personnel member’s skills and knowledge and areas to expand or improve.
R9-10-703.C.1.c Complaints by Personnel membersPersonnel members who have a complaint relating to services provided to a resident can contact the Clinical Director and/or the Administrator to discuss individually. The Administrator and Clinical Director will determine course of action from that point on.
R9-10-703.C.1.d
A health professional who reasonably believes that an individual has violated professional standards of practice or has violated the law, or a substantial risk to the health, safety, or welfare of a resident, the health professional will report directly to the Clinical Director and/or Administrator who will review the report and render an opinion or action within 7 days or sooner depending upon the situation, or immediately if necessary. Reasonable measures will be made by the Administrator and/or Clinical Director to ensure the confidentiality of the reporting individual.
The Administrator and/or Clinical Director will ensure that no retaliatory action is taken against an individual that makes a report against the agency or individual providing that the report was made in good faith, all in accordance with ARS 36-450, 450.01, 450.02.
R9-10-703.C.f / ARS 36-411
Fingerprint Clearance CardAll employees or contracted individuals who “provide direct care” are required to have valid fingerprint clearance card issued Arizona Department of Public Safety. The agency has defined direct care as counseling, assistance in the self-administration of medication, or social services provided to a client such as a group outing, counseling or psychoeducational services, organized activity, or transportation.
Contract employees who are independently credentialed, certified, licensed, or qualified professionals such as a massage therapist, registered dietitian, nutritionist, yoga instructor, or other professional who is not required to have a fingerprint clearance card in their line of work, and is practicing at this agency within the limits of that line of work, is not required to have a fingerprint clearance card. For example, if a yoga instructor is not required to have a fingerprint clearance card to professionally instruct yoga classes then she/he will not be required to have a fingerprint clearance card provided she/he’s practice within the agency is limited to instructing yoga.
Employees or contracted individuals have 20 days from hiring date to initiate the process of obtaining a fingerprint clearance card.
In the event the individual is denied but applying for a good cause exception, they will be allowed to continue employment providing they are acting in good faith to procure a fingerprint clearance card and are not providing “direct care”.
R9-10-703.C.g
ARS 8-804 Applies to the care of children, not applicable to this agency.
R9-10-703.C.1.e & h CPR and First Aid
All personnel members will have current CPR and First Aid training unless otherwise indicated. CPR/First Aid training will be completed within 30 days of the month of the expiration date on the existing supplied card or within the first two weeks of employment. Verification will be documented in the Personnel or Staff member’s employee chart. At least one staff or personnel member with current CPR/First Aid training will be on property at all times. All Personnel members attending Outings will have current CPR and First Aid training.
R9-10-703.C.1.i Resident Receipt of Physical and Behavioral Health services as ordered.The resident’s assigned Primary Staff under the direction of the Clinical Director is responsible for verifying that residents are receiving physical or behavioral health services as ordered.
R9-10-703.C.1.j/R9-10-711 Resident Rights
Residents will receive a copy of their rights upon admission and a copy will be maintained in their record. The resident rights will be conspicuously posted on the premises.
The Prescott House is unable to serve clients who are not proficient in English to a point where they can adequately maintain a therapeutic relationship. In the event a potential resident is unable to adequately communicate in English at this level, referrals will be made.
Reasonable attempts to accommodate a potential client with a disability will be made, however, if a potential client will be better served in a different facility due to the disability, referrals will be made.
Resident Rights are as follows
1). The resident has the right to be treated with dignity, respect, and consideration.
2). The resident has the right to not be subjected to abuse, neglect, exploitation, coercion, manipulation, sexual abuse, sexual assault, seclusion, restraint if not necessary to prevent harm to self or others, retaliation for submitting a complaint to Behavioral Health or another entity, and misappropriation of personal and private property the facility’s personnel members, employees, volunteers, or students.
3). The resident has the right to not be discharged or transferred or threatened with discharge or transfer for reasons unrelated to the resident’s treatment needs, except as established in a fee agreement signed by the resident or the resident’s representative.
4). The resident has the right to not be denied food, the opportunity to sleep, or the opportunity to use the toilet.
5). The resident has the right to associate with individuals of the residents choice, receive visitors, and make telephone calls during the established hours unless the Clinical Director has determined that a resident’s treatment requires the facility to restrict these activities.
6). The resident has the right to privacy in correspondence, communication, visitation, financial affairs, and personal hygiene unless the Clinical Director has determined that a resident’s treatment requires the facility to restrict these activities.
7). The resident has the right to send and receive uncensored and unopened mail, unless restricted by a court order unless the Clinical Director has determined that a resident’s treatment requires the facility to restrict these activities.
8). The resident has the right to either consent or refuse treatment, except in an emergency.
9). The resident has the right to refuse or withdraw consent to treatment before treatment is initiated, unless the treatment is ordered by a court according to ARS-36-5, or is necessary to save the resident’s life or physical health, or is provided according to ARS 36-512.
10). The resident has the right to be informed of proposed treatment alternatives to the treatment,
associated risks, and possible complications, except in an emergency.
11). The resident is informed that the Prescott House does not support health care directives.
12). The resident has the right to be informed of the complaint process.
13). The resident has the right to privacy of records; records are released when written consent is granted except as permitted by law, including but not limited to situations where personnel are required to report abuse, or threats to self or others.
14). The resident has the right to not be discriminated against based on race, national origin, religion, gender, sexual orientation, age, disability, marital status, diagnosis, or source of payment.
15). The resident has the right to receive treatment that supports and respects the resident’s individuality, choices, strengths, and abilities.
16). The resident has the right to receive treatment that supports the resident’s personal liberty and only restricts the resident’s personal liberty according to a court order, by the resident or resident’s representative general consent, or as determined by the Clinical Director as a necessity.
17). The resident has the right to receive treatment in the least restrictive environment that meets the resident’s treatment needs.
18). The resident has the right to receive privacy in treatment and care for personal needs including the right to not be fingerprinted, photographed, or recorded without consent except;
a. photographing for identification and administrative purposes.
b. for a resident receiving treatment according to ARS 36 or 37.
c. For video recordings used for security purposes that are maintained only on a temporary basis.
19). The resident has the right to not be prevented or impeded from exercising the resident’s civil rights unless has been adjudicated incompetent or a court of competent jurisdiction has found that the resident is unable to exercise a specific right or category of rights.
20). The resident has the right to review upon written request the resident’s own medical record, in accordance with ARS 12-2293, 12-2294, and 12-2294.01 which includes provisions for when the agency can deny this request.
21). The resident has the right to be provided locked storage space for the resident’s belongings while the resident receives treatment.
22). The resident has the right to have opportunities for social contact and daily social, recreational, or rehabilitative activities.
23). The resident has the right to be informed of the requirements necessary for the resident’s discharge or transfer to a less restrictive physical environment.
24). The resident has the right to receive a referral to another health care institution if the behavioral health residential facility is unable to provide physical or behavioral health services for resident.
25). The resident has the right to participate in the development of or decisions concerning treatment.
26). The resident has the right to participate or refuse to participate in research or experimental treatment.
27). The resident has the right to receive assistance from a family member, representative, or other individual in understanding, protecting, or exercising the resident’s rights.
In the event that the Clinical Director has determined that a resident’s rights should be restricted as discussed in rights #5, 6, and 7, the specific treatment purpose for this restriction will documented, the resident will be informed of the reason why the right is restricted. These issues are addressed in the Program Agreement at treatment onset and can be further addressed as needed.
R9-10-703.C.k Resident Complaints
In the event a resident has concerns regarding any issue related to his treatment or termination, he may seek a resolution through the following steps:
1). The resident should first discuss his concerns with his Primary Therapist. The resident’s Primary Therapist will respond to the resident about his concerns as soon as possible, which will not exceed one week from the date of this conversation.
2). If the matter is not resolved through discussion with the resident’s Primary Therapist, the resident may then discuss the issue at the next staff meeting, held generally Tuesday and Thursday. In cases where further discussion or additional research might be appropriate, the staff and resident will agree on a reasonable time frame within which to complete the discussion and/or research. This time period will not exceed two weeks from the date of the staff meeting at which the issue is first discussed.
3). If the matter is not resolved through discussion at staff meetings, the resident may then discuss the issue with the Clinical Director and/or the Administrator. The resident will receive a response to this conversation as soon as possible, which will not exceed two weeks from the date of the conversation.
4). If after discussion with the Administrator and/or Clinical Director, the matter has not been resolved to the resident’s satisfaction, the resident may directly express his concerns to:Arizona Department of Health Services – Arizona Department of Health Services 150 N 18th Avenue, Suite 410 Phoenix, Arizona (602) 364-2595
All residents will sign and receive a copy of the Grievance Procedures which will be stored in the resident record. Each resident will receive a copy of this grievance procedure policy upon admission into Prescott House. He, his parent/guardian, or his designated representative must sign a form to indicate his understanding of the grievance policies and procedures established at Prescott House. This signed and dated form will be kept in the resident’s records.
R9-10-703.C.l
Health Care DirectivesThe Prescott House does not honor advanced directives.
R9-10-703.C.1.m / R9-10-712 Medical Records
The Administrator shall ensure that:
1). A Medical Record is established for each resident according to ARS Title 12, Chapter 13, Article 7.1.
2). Medical record entries can be recorded by any staff member as needed.
3). The medical record will be dated, legible, authenticated, and not changed to make the initial entry illegible.
4). A resident’s medical record is available to personnel members as needed.
5). Medical records or information contained within a medical record are not disclosed unless the resident has provided written authorization unless otherwise authorized by law such as threats to self.
6). The maximum time-frame to retrieve a resident’s medical record for a medical practitioner or a BHP, or authorized personnel member within an hour.
7). Medical records will be protected from loss, damage, or unauthorized use. Medical Records will be stored in a locked container inside a locked room and in either the Primary staff member’s office or in central records.
8). A resident’s medical record will maintain:
The resident’s name and address
The resident’s date of birth
The name and contact information of the resident’s representative if applicable
Any known biological or medical allergies
The name of the admitting medical practitioner or BHP
An admitting diagnosis or presenting behavioral health issue.
Documentation of general or informed consent
Documentation of medical history and results of a physical examination
Orders
Assessment
Treatment Plans
Interval note
Progress notes
Documentation of behavioral health residential services provided to the resident
Documentation of the resident’s follow-up instructions provided (Discharge Plan)
Discharge Summary
Lab, radiologic, sleep disorder, diagnostic, and consultation reports if applicable
R9-10-703.C.1.n/ R9-10-704 Quality Assurance and Compliance
The Quality Assurance and Compliance Officer will oversee risk management; infection control; outcomes and statistics; record keeping including documentation and information release; compliance with Arizona Department of Health, and Arizona Board of Behavioral Health Examiners including applicable statutes and code; as well as compliance with the Joint Commission for Accreditation of Healthcare Organizations regulations.
A personnel member will be designated to continually monitor or conceive a quality management program that includes:
1). Evaluation of identified and documented incidents. Incidents will be discussed by the Administrator, Clinical Director, Program Director, and any other relevant personnel at each incident.
2). A method to collect data to evaluate services provided to residents including contracted services. The Program Director, Clinical Director, or Administrator will present relevant data annually for incorporation into overall plan and action.
3). A method to evaluate data collected to identify a concern about the delivery of services related to resident care. See #2.
4). A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care. See #2.
5
). Quality management will be presented at least annually with the Board of Directors.
The Quality Assurance Officer is Jeff Martin
Assistance in the Self-Administration of Medication Quality Management R9-10-718.A.2
All medication count discrepancies, and medication errors including those resulting in incident report or simple transcription errors will be reported the Program Manager, Clinical Director and/or the Administrator for quality management purposes.
R9-10-703.C.1.o/R9-10-705
Contracted ServicesThe Administrator and or Clinical Director are responsible to oversee that contracted services are carried out in a professional manner. Contract employees will maintain all requirements that other BHP’s, BHT’s, BHPP’s, or other employees are subject with modifications made at the discretion of the Administrator or Clinical Director such as education or training requirements.
R9-10-703.C.1.p
VisitationResident’s may receive visitation upon approval by the resident’s primary staff, Clinical Director, or the Administrator at times or days that are consistent with the therapeutic schedule. Approval of visitation is a therapeutic issue and decisions regarding the appropriateness of visitations will reflect the therapeutic need or lack thereof of a particular visitor. Visitation is approved for the main building common area, or private areas as approved with respect to the confidentiality of other residents.
R9-10-703.C.2.a
ScreeningInquiries will be screened for admission appropriateness. Screening may include questions and discussion regarding; medical issues and medications; prior treatment history; resident mental health stability including harm to self or others; resident insight into mental health issues; resident behavioral health issues and treatment needs; facility’s scope of services as needed; resident’s known mental health diagnoses; options for transport to agency and appropriateness therein; general discussion of Program Agreement and program characteristics; financial appropriateness; and therapeutic modalities.
R9-10-703.C.2.a / R9-10-707 Admission
The resident will sign an Informed Consent for Treatment at or before admission. At admission, the resident will sign acknowledgement of Resident Rights; Grievance Procedures; mandated contact information; confidentiality requirements; Program Agreement; Initial/Interim Treatment Plan; and Orientation will be verified and documented. An Assessment will be conducted at admission and is considered part of the admission process, a resident is not considered “admitted” until completion, see below for policies regarding assessment. A Behavioral Health Professional will authorize a resident for admission based on the data collected through the screening and admission process including the assessment. A resident may be provisionally admitted by a BHP despite concerns regarding the admission, when refusal of admission is determined to cause significant stressors on the part of the potential resident, and while a referral is prepared or discussed.
It is presumed that residents accepted for admission are appropriate for the agency including being appropriate to be in a facility that has daily chores, access to household cleaning materials (such as all-purpose cleaner, bleach, window cleaner, and bath cleaner), access to cutlery for food preparation, does not require shatter-proof mirrors (as indicated on their treatment plan), use of gas appliances including a propane grill, can navigate the slope of the property, can function adequately to complete functions such as filling prescriptions, or attending physician appointments, can maintain personal hygiene such as bathing or completing laundry, can remain safe and are responsible enough for a property/program with open ingress/egress, and can safely store and prepare food consistent with Department of Health guidelines and common knowledge. If the client requires additional assistance to meet some of these requirements, such education can be incorporated into his treatment plan. Presenting issues of danger to self or others are not appropriate for admission given potential hazards present on the property.
R9-10-703.C.2.a / R9-10-707 Assessment
An assessment will be an analysis of a resident’s need for physical health services or behavioral health services to determine which services a health care institution will provide to a patient. Assessment’s completed by another provider that are compliant with these policies are considered valid assessment’s provided that information is reviewed and updated at admission and the review or update is documented in the resident’s record within 48 hours of the review.
The assessment shall document at a minimum a resident’s presenting issue; substance abuse history, co-occurring disorder, medical condition and history, legal history including Custody, Guardianship, and pending litigation (as applicable); criminal justice record; family history; behavioral health treatment history; symptoms reported by the resident; any referrals. The assessment will also include recommendations for further assessment or examination of the resident’s needs, services provided until master treatment plan is completed, signature and date of the personnel member completing the assessment.
If during the assessment it becomes apparent that the resident requires immediate physical health services a referral to a medical practitioner will be made. If it is determinable at assessment that the resident’s behavioral health issue may be as a result of a medical condition, a referral will be made to a medical practitioner, though the acuity of the medical condition will be taken into consideration.
The resident or resident’s representative (if applicable) will participate in the assessment as demonstrated in the documentation of the assessment. Assessments will be documented in the resident records within 48 hours of completion. Assessment information is continually reviewed through scheduled staff meetings.
Resident’s will receive a referral for a medical practitioner and be seen within 7 calendar days of admission unless a medical practitioner has performed a medical history and physical examination or a registered nurse has performed a nursing assessment on the resident within 30 calendar days prior to admission.
R9-10-703.C.2.a / R910-708 Treatment Planning
The treatment plan will be completed by a BHP or a BHT under the clinical oversight of a BHP. It will be reviewed at least monthly to reflect on-going changes in the resident’s treatment.
At a minimum, all treatment plans will include; the resident’s presenting issue; the physical or behavioral health services to be provided; signature of resident or representative and date signed, or documentation of refusal to sign; review date; discharge date and treatment needed after discharge as applicable; personnel member signature and date.If the treatment plan was completed by a BHT it will be reviewed and signed by a BHP within 24 hours after the completion of a treatment plan to ensure that the treatment plan is complete and accurate and meets the resident’s treatment needs.
The treatment plan will be continually reviewed and updated according as applicable particularly when a treatment goal is accomplished; a review date is set to expire; additional information of clinical relevance is identified; when the resident experiences a significant change that affects treatment. Residents will participate in the treatment planning process and this will br documented in the resident’s record.
R9-10-703.C.2.a/ R9-10-710 Transport and TransferTransport
In the event of a transport (sending a resident to a receiving licensed health care institution for outpatient services with the intent of the patient returning to this agency), the following apply;
1). A personnel member coordinates the transport
2). An evaluation of the resident is conducted before and after the transport
3). Information from the resident’s medical record is provided to the receiving institution
4). A personnel member explains the risk and benefits of the transport to the resident or representative
5). Communication with individual at receiving HCI will be documented
6). The date and time of the transport will be documented
7). The mode of transportation will be documented
8). The name of the personnel member accompanying the resident will be documented
TransferIn the event of a transfer (discharging a “patient” and sending the “patient” to another licensed health care institution as an inpatient or resident without intending that the patient be returned to the sending health care institution), the following policies will apply:
1). A personnel member coordinates the transfer.
2). An evaluation of the resident is conducted before the transfer.
3). Information from the resident’s medical record is provided to the receiving institution.
4). A personnel member explains the risk and benefits of the transfer to the resident or representative.
5). Communication with individual at receiving HCI will be documented.
6). The date and time of the transfer will be documented.
7). The mode of transportation will be documented.
8). The name of the personnel member accompanying the resident will be documented.
The Administrator and/or Clinical Director will determine if any discharge is a “transport”, “transfer”, or a “discharge” and “referral” as necessary.
R9-10-703.C.2.a / R9-10-709 Discharge Planning and Discharge
A discharge plan including discharge instructions will identify specific needs of the resident after discharge, will be completed before the discharge occurs, and will include a description of the level of care that may meet the resident’s assessed and anticipated needs after discharge. The discharge plan will be documented in the resident record within 48 hours after the plan is completed and will be provided to the resident before the discharge occurs. Residents will be given the opportunity to participate in their discharge plan and this will be documented in the resident record. This applies to scheduled discharges, and does not apply to unscheduled, against staff advice (ASA), involuntary, or non-compliant discharges.
Discharge will occur when a resident meets all treatment plan goals and program goals are adequately met or when the resident’s needs are not consistent with the services the Prescott house is authorized to provide. Resident will receive referrals for treatment or ancillary services needed at the time of discharge. This applies to scheduled discharges, and does not apply to unscheduled, against staff advice (ASA), involuntary, or non-compliant discharges.
A discharge summary will be completed by a medical practitioner or a behavioral health professional and will be entered in the resident record within 10 days after discharge and will include:
1). The resident’s presenting issue and other physical health and behavioral health issues identified in the resident’s treatment plan.
2). A summary of the treatment provided to the resident.
3). The resident’s progress in meeting treatment goals, including treatment goals that were not achieved.
4). The name, dosage, and frequency of each medication for the resident ordered at the time of the resident’s discharge.
5). A description of the disposition of the resident’s possessions, funds, or medications brought to the facility which may be completed by any personnel member or employee as applicable.
Unscheduled Discharges/Termination of Services without notice
In the event a resident terminates services with minimal notice, a discharge plan will be prepared and discharge instructions will be given reflective of the time available to prepare these documents. A more comprehensive plan and instructions can be prepared and communicated to the former resident, or family member/friend post-discharge if indicated. A referral may be given if , given the logistical limitations.
In the event a resident terminates services with limited or no notice due to unauthorized absence or a similar type situation a discharge plan and instructions will be prepared in the absence of the former resident and communicated in the best way possible. A referral may be given to family/friend and communicated to them or the client post-discharge.
Involuntary or Non-Compliant Discharges
Resident’s may be involuntarily discharged for threatening or intimidating employees or peers; expression of intolerant beliefs potentially violating the receipt of services by other individuals; use, possession, or knowledge of peers’ use or possession of illegal substances, or any abusable substance, or misuse of prescribed medication; possession of weapons; any type of gambling; any type of sexual reference with staff or peers (sexual harassment); violation of state, local, or federal law; possession of or viewing of pornography or similar material; continued pattern of Program Agreement violation; continued behaviors that present an obstacle to the appropriate receipt of services of peers; and overall lack of pursuit of treatment plan goals, objectives, or program goals. All residents are provided a written notice of the resident’s right to submit a grievance and the agency’s grievance policy and procedure. A discharge plan will be prepared and discharge instructions will be provided reflective of the time available to do so and will be weighed against the need for the resident to leave the property. A more comprehensive plan and instructions can be prepared and communicated to the former resident post-discharge if indicated.
R9-10-703.C.2.b
Provision of Behavioral Health and Physical Health ServiceThe Prescott House is a Behavioral Health provider no physical health services are provided.
R9-10-703.C.2.c
General Consent and Informed ConsentInformed consent is completed prior to the completion of intake. General consent is acceptable verbally prior to intake as part of the screening process. General consent can be given verbally through the course of treatment for more specific therapeutic interventions.
R9-10-703.C.2.d
Emergency Safety ResponseThe Prescott House does not utilize emergency safety responses. Staff are instructed to contact law enforcement if a client has become out of control, aggressive, or threatening. Extenuating circumstances will be reflected in staff member’s prudent judgement.
Policy on Aggressive, Destructive, or Threatening Behavior
The Prescott House does not utilize any take-down, or other physical interventions to clients who are acting in an aggressive, destructive, or threatening behavior. Verbal intervention is advised when appropriate. Staff can judge if a client is appropriate for verbal intervention. If verbal intervention is inappropriate or unsuccessful, then 911 should be called. Staff should make every attempt to protect the safety of other clients such as advising clients to leave the area of the aggressive client. Threats are violation of law and police can be contacted. At times if it appears prudent verbal de-escalation may result in retraction of the threat and agreement of one or more persons to act civilly with respect. In the event that the staff is in danger he may need to seek safety while police are on their way. Firearms or other weapons are forbidden on the property. Staff are encouraged to utilize non-threatening and supportive language to communicate with the client. Additionally, staff members are encouraged to utilize non-threatening and supportive non-verbal communication skills as well.
R9-10-703 C.2.e / R9-10-703.P
Expense Account and Personal Funds AccountIf the agency is receiving and managing a client’s personal funds the following apply;
The client has voluntarily decided to open the personal funds account.
The account may be closed at any time.
A ledger will be kept by the Business Office Manager detailing all deposits and withdrawals, and ledger will be part of the client’s record.
A client can make a complaint regarding the personal funds account directly to the Program Manager or Administrator who will jointly investigate the concern.
R9-10-703.C.2.f,g/ R9-10-718.
A&C-F Medication ServicesThe Prescott House Medication Services Policy has been reviewed and approved by;Michael Frost, FNPAssistance in the Self-Administration of Medication
Residents will discuss the following with their prescribing professional:
1). The prescribed medication’s anticipated results.
2). The prescribed medication’s potential adverse reactions.
3). The prescribed medication’s potential side-effects.
4). Potential adverse reactions that could result from not taking the medication as prescribed.
Medication errors, adverse responses, and overdoses will be discussed by a personnel member, the resident and with the prescribing physician. The pharmacist, or poison control, or emergency response professionals will be contacted as deemed necessary. Errors, adverse responses, and overdoses will be reviewed by the Administrator and/or Clinical Director for agency response to prevent further incidents. Errors, adverse response, and overdoses may be subject to an Incident Report as applicable.
Medical Practitioner’s will review the appropriateness of a resident’s medication regime when seeing a resident, records will be provided to the medical practitioner. Assistance in the self-administration of medication will be documented in the resident’s medication record, a subsection of the resident record.Off premises assistance in the self-administration of medication
In the event that the resident will need to take the medication off premises without personnel member present, a notation will be made in the medication records indicating that the resident took the medication with him off-site and there is no verification that is was administered appropriately. An over the counter pill container is an acceptable means to store the medications when taken off site. Staff members do not prepare the medication storage container. In the event a client is having difficulty obtaining his medication, he can work with his primary staff or a designated personnel member with whatever assistance is needed, with respect to allowing the client to develop self-sufficiency.
The following assistance is provided to the resident defining assistance in the self-administration
of medication:
1). A reminder when it is time to take the medication.
2). Opening the medication container for the resident as needed.
3). Observing the resident while the resident removes the medication from the container.
4). Verifying that the medication is taken as ordered by the resident’s medical practitioner by confirming that:
a). the resident taking the medication is the individual stated on the medication container label.
b), The dosage of the medication is the same as stated on the medication container label.
c). The medication is being taken by the resident at the time stated on the medication label.
5). Observing the resident while the resident takes the medication.
Observation may include asking the resident to open his mouth to verify ingestion or asking the resident to remain with personnel for a pre-determined length of time following ingestion when therapeutically indicated for the particular resident.
Assistance with self-administration of medication will be in compliance with the resident’s
medical practitioner’s order and will be documented in the resident’s medication records, a
subsection of the resident record. A current drug reference guide is available for all personnel members. A current toxicology reference guide is available for all personnel members.
Training
Training on the self-administration of medication for personnel members who are not medical
practitioners or a registered nurse will include a demonstration of the personnel member’s skills and knowledge necessary to provide assistance in the self-administration of medication, identification of medication errors and medical emergencies related to medication that require emergency medical intervention, and the process for notifying the appropriate entities when an emergency medical intervention is needed.
Personnel members other than a medical practitioner or a registered nurse will complete training
prior to providing assistance in the self-administration of medication and each staff member who conducts the self–administration of medication will be trained on doing so at least once every two years.
Medication Storage
Medication is stored in the following conditions:
1). Medications will be stored in a separate room used for medication storage that includes a lockable door.
2). Medication will be stored in a locked cabinet or container.
3). Medication will be stored according to the manufacturer’s recommendations.
4). Medication will be brought by residents unopened to the personnel member on duty. The personnel member on duty will inventory the medications and record in the resident’s medication chart. When the resident takes his medication the both the personnel member and the resident will initial the medication sheet with any discrepancies noted in the resident’s medication chart. Controlled substances will be stored in an additional locked container within the locked cabinet. Controlled substances will be charted on a different color paper and a count will be made following each dosage and recorded. Expired, unused or abandoned medication will be inventoried and destroyed in a timely manner by two personnel members with appropriate documentation of the destruction.
5). In the event of a medication recall, a personnel member will contact the prescribing practitioner for advisement and direction.
6). Controlled substances will be inventoried at drop off by two personnel members. Controlled substances will be stored in an additional locked container within the locked cabinet in the locked room. Controlled substances will be charted on a different color paper and a count will be made following each dosage and recorded.
7). All medication count discrepancies, and medication errors including those resulting in incident report or simple transcription errors will be reported the Clinical Director and/or the Administrator for quality management purposes (R9-10-718.A.2).
Prescribing physician will determine appropriateness of allowing a resident to take their medications with them at discharge. Discharging personnel member can exercise good judgment by withholding medication disbursement until a recommendation can be made by the prescribing physician. If there is sufficient concern to warrant action a staff member can disburse a discharging resident sufficient doses to make it to the following business day when the prescribing physician can be more readily contacted.
Controlled SubstancesControlled substances will be handled in the same manner as other medications with the following exceptions;
1). Controlled substances will be charted on a different color of paper.
2). Controlled substances will be counted at each use.
3). Controlled substances will be locked in a separate container within the locked medication storage area, (triple locked).
4). Staff discretion will be used when determining if residents or staff will pick up controlled substances from the pharmacy.
5). Medications with abuse potential but not technically controlled can be treated as controlled substances.
R9-10-703.C.2.g Prescription of Controlled Substances
Controlled substances will be prescribed in accordance with professional standards by the appropriate professional with consideration for abuse potential by the client.
R9-10-703.C.2.h Respite Services
The Prescott House does not provide Respite Services.
R9-10-703.C.2.i Services provided by an outdoor behavioral health care program
Not Applicable
R9-10-703.C.2.j Infection Control
The Quality Assurance and Compliance officer will oversee infection Control utilizing the Medical Director and NP for consultation. The Infection Control Program will include annual reports to discuss ongoing infection control procedures. The infection control reports will discuss methods to identify infections including types, causes, and spread of infections and communicable diseases and preventative measures to minimize or prevent them. Infection Control reports are maintained for at least two years.
R9-10-703.C.2.k Time Out
The Prescott House does not utilize Time Out.
R9-10-703.C.2.l/ R9-10-713 Transportation and Resident Outings
Client organized and approved social or recreational activities are not considered outings.
Transportation
A. A licensee of an agency that uses a vehicle owned or leased by the licensee to transport a resident shall ensure that:
1. The vehicle:
a. Is safe and in good repair;
b. Contains a first aid kit.
c. Contains drinking water sufficient to meet the needs of each resident present;
d. Contains a working heating and air conditioning system; and
e. Is insured according to A.R.S. Title 28, Chapter 9;
2. Documentation of vehicle insurance and a record of each maintenance or repair of the vehicle are maintained on the premises or at the administrative office;
3. A driver of the vehicle:
a. Is 21 years of age or older;
b. Has a valid driver license;
c. Does not wear headphones or operate a cellular telephone while operating the vehicle;
d. Removes the keys from the vehicle and engages the emergency brake before exiting the vehicle or, if the vehicle locks in the park position, places the gear in the park position;
e. Does not leave in the vehicle an unattended:
i. Child;
ii. Resident who may be a threat to the health, safety, or welfare of the resident or another individual; or
iii. Resident who is incapable of independent exit from the vehicle;
f. Operates the vehicle safely; and
g. Ensures the safe and hazard-free loading and unloading of residents;
4. Transportation safety is maintained as follows:
a. Each individual in the vehicle wears a working seat belt while the vehicle is in motion;
b. Each seat in a vehicle is securely fastened to the vehicle and provides sufficient space for a resident’s body; and
c. Each individual in the vehicle is sitting in a seat while the vehicle is in motion; and
5. There is a sufficient number of staff members present to ensure each resident’s health, safety, and welfare.
Outings
Per R9-10-101.138, an outing is an event that occurs away from the premises, is not part of the daily routine, and lasts longer than four hours.
A. 1. An outing is consistent with the age, developmental level, physical ability, medical condition, and treatment needs of each resident participating in the outing; and
2. Probable hazards, such as weather conditions, adverse resident behavior, or medical situations that may occur during the outing are identified and staff members participating in the outing are prepared and have the supplies necessary to prevent or respond to each probable hazard.
B. The Administrator and/or the Clinical Director will ensure:
1. There is a sufficient number of staff members present to ensure each resident’s health, safety, and welfare on an outing;
2. There are at least two staff members present on an outing;
3. All personnel on outings have current CPR/First Aid certifications.
4. Documentation is developed before an outing that includes:
a. The name of each resident participating in the outing;
b. A description of the outing;
c. The date of the outing;
d. The anticipated departure and return times;
e. The name, address, and, if available, telephone number of the outing destination; and
f. The license plate number of each vehicle used to transport a resident;
5. The documentation is updated to include the actual departure and return times and is maintained on the premises for at least 12 months after the date of the outing;
6. Emergency information for each resident participating in the outing is maintained in the vehicle used to transport the resident and includes:
a. The resident’s name;
b. Medication information, including the name, dosage, route of administration, and directions for each medication needed by the resident during the anticipated duration of the outing;
c. The resident’s allergies; and
d. The name and telephone number of the individual to notify at the agency in case of medical emergency or other emergency;
R9-10-703.C.2.m
Environmental ServicesSee later in this document under R9-10 721 & 722.
R9-10-703.C.2.n
Pets and AnimalsResident’s cannot keep or care for pets or animals while a resident.
R9-10-703.C.2.o Therapeutic animals
Therapeutic pets are not routinely used at the Prescott House. In the unusual circumstance that one is used, current vaccinations are required and the Clinical Director and/or Administrator will utilize sound judgment regarding the temperament of the animal with sensitivity to resident concerns.
R9-10-703.C.2.p Receiving and Refunding Fees
Financial contract initiated at the onset of treatment with the paying party and/or client with terms set therein.
R9-10-703.C.2.q Social, Recreational, rehabilitative activities, meals and snacks
The residents arrange their own social and recreational activities which are approved by staff. The appropriateness of the social and recreational activity is weighed against the resident’s therapeutic need. Residents prepare their own meals and snacks.
R9-10-703.C.2.r Security of Resident’s Possessions
Resident units are to be locked when staff is not providing oversight of the property and no residents are present. A safe is available for small valuables that are necessary for the resident to keep such as a credit card or checkbook. Residents are asked to mail other valuables to a family member or friend for safekeeping.
R9-10-703.C.2.s / R9-10-721.B.1 & 2 Smoking and Tobacco use
Smoking and tobacco use are allowed in the designated areas only and this area will be designated by signs. Smoking is not permitted anywhere near where combustible materials are stored or in use.
R9-10-703.C.2.t Sudden, intense, or out-of-control behavior
Personnel and all employees are instructed to contact the police if a resident’s behavior becomes out of control and there is no foreseeable de-escalation. A verbal attempt at de-escalation is advised though left to the personnel or employee’s judgment whether police should be contacted. Prescott house does not utilize any physical intervention of any type and all employees are advised of this. Unforeseen circumstances that resulted in unavoidable physical contact will be addressed by the Clinical Director and/or Administrator. Such instances should be unique and rare.
R9-10-703.C.3 Policies and Procedures Review and Update
The Policies and Procedures will be continually reviewed and updated as needed by the Clinical Director and/or Administrator at the minimum of at least once every three years.
R9-10-703.C.4 Policies and Procedures Availability
Policies and Procedures are available in the office of the Administrator, Clinical Director, or Program Manager, and made available to personnel and resident upon request.
R9-10-703.C.5 Provision of Documentation
Agency will provide documentation required within two hours after an AZDHS request in accordance with AAC.
R9-10-703.D Clinical Director
The Administrator will appoint a Clinical Director responsible for the direction of behavioral health services at the facility and is a behavioral health professional.
R9-10-703.
EAll services are provided to residents with the expectation that they will be in services for more than 24 hours.
R9-10-703.F
This code applies to services for children and is not applicable to this agency.
R9-10-703.G
Incident ReportsAdministrator will notify AZFHS within one working of a client’s death, and within 2 working days after a client inflicts self-injury, or has an accident, that requires immediate intervention by an emergency medical services provider.
R9-10-703.H & I Abuse, Neglect, Exploitation of Resident
If abuse, neglect, or exploitation of a resident is alleged or suspected to have occurred before the resident was admitted or while the resident is not on the premises and not receiving services from the agency’s employee or personnel member, the Administrator shall immediately report the alleged or suspected abuse, neglect, or exploitation of the resident according to ARS 46-454.
In the event of abuse, neglect, or exploitation of a resident is alleged or suspected and Administrator and/or the Clinical Director will;
1), Take immediate action to stop the alleged or suspected abuse, neglect, or exploitation.
2). Report said alleged or suspected abuse, neglect, or exploitation to local law enforcement or to Adult Protective Services in the Department of Economic Security.
3/4). Document the suspected abuse, neglect, or exploitation including any action taken and the initial report.
5). Investigate the alleged or suspected abuse, neglect, or exploitation and develop a written report of the investigation within 5 working days after the report in;
a). Dates, times and description of the alleged or suspected abuse, neglect, or exploitation.
b). Description of any injury to the resident and any change to the resident’s physical, cognitive, functional, or emotional condition.
c). Documents the names of witnesses to the alleged or suspected abuse, neglect, or exploitation.
d). Documents the actions taken by the Administrator to prevent the alleged or suspected abuse, neglect, or exploitation from occurring in the future.
6). Maintain a copy of the investigative report for at least 12 months.
R9-10-703.K.1
Entering and Exiting PremisesResidents are required to sign and sign out when entering or exiting the premises. Visitors must check in with the staff on duty when entering or exiting the premises. Employees and personnel members have no requirements regarding entering or exiting the premises though it is recommended that they alert other employees or personnel members to their presence or impending absence.
R9-10-702.K.2
Not applicable, court-ordered treatment.
R9-10-703.K.3
Individuals residing with Residents Such as a ChildOnly admitted residents reside on the property.
R9-10-703.K.4
Not applicable, no child-care on property.
R9-10-703.K.5
Immediate and Unscheduled Behavioral Health or Physical Health ServicesImmediate need for behavioral health services can be provided by the personnel member on duty as qualified if nobody else is available, the resident’s primary staff or other BHT staff when on property, the BHP on-call, or the personnel member on-call. Personnel members are required to contact on-call personnel for discussion or direction of this service. This is presuming that the situation does not involve a crisis, or similar threat-to-self type situation in which emergency procedures are indicated.
In the event of an immediate or unscheduled physical health need the personnel member on-duty may contact the Medical Director’s office or other medical practitioner as applicable or facilitate transport to the emergency room as needed.
R9-10-703.K.6-9 Unauthorized Resident Absence
Residents who are unaccounted for any length of time can be considered having terminated services. This includes not returning to the property before curfew; not being present at the location signed out for in consideration of the time spent in transport; lack of notification of staff of alterations of the sign out location or expected time away. Such terminations of services can be considered a termination without notice which is accounted for in the resident’s discharge documentation. It is at the discretion of the on-call BHP or BHP on duty to determination if a resident should be classified as a termination of services or if a resident should be re-authorized for services if the termination has been already classified.
The Clinical Director will maintain a written log of unauthorized absences for 2 years after the date of a resident’s absence that includes resident name, person absence reported if applicable, date of report, and quality management actions taken into account as a result of the absence.
R9-10-703.L
A staff member able to read, write, communicate, and understand English will be on site at all times.
R9-10-703.M Postings
A copy of the resident rights will be posted conspicuously on the property. The agency’s current license will be posted conspicuously on the property. Notice that OBHL inspection reports are stored and are available for review in the Clinical Director or Administrator’s office will be posted conspicuously on the property. Additionally, the calendar days and times when a resident may accept visitors or make telephone calls will be conspicuously posted on the property.
R9-10-703.N.1 Labor
Labor performed by residents for the facility is consistent with ARS 36-510. Residents are only allowed to provide occasional labor (helping out) and their participation is consensual, and not obligatory in any fashion, and does not impact their treatment. Labor must be consistent with the resident’s needs and abilities.
R9-10-703.N.2-3
Not applicable, applies to children
R9-10-703.N.4 Gravely Disabled or Incapacitated Client
If the Clinical Director or a BHP has determined that a resident is gravely disabled, or is an incapacitated person according to ARS 14-5101, the Clinical Director and/or Administrator will assist in obtaining a resident’s representative to act on the resident’s behalf. This may include collaborating with the resident’s family members or seeking a professional who can manage these responsibilities.
R9-10-703.O Residents incapable of handling financial affairs
If it is abundantly clear that a resident is incapable of handling his own financial affairs the Program Manager, Clinical Director, or Primary Staff will notify the resident’s representative or contact a public fiduciary or a trust officer to take responsibility of the resident’s financial affairs and document this in the resident’s record. The agency will also discuss with family members of the resident who may opt to handle this process.
R9-10-706 Personnel
Personnel members must be 21 years or older. Employees and students must be 18 years or older.
The Administrator shall ensure the following
The qualifications, skills, and knowledge for each type of personnel member are based on the type of behavioral health service provided by the personnel member according to the established job description and the acuity of the residents receiving behavioral health services from the personnel member according to the established job description.
This includes the specific skills and knowledge necessary for the personnel member to provide the expected behavioral health services listed in the established job description. This also includes the type and duration of educations that may allow the personnel member to acquire the specific skills and knowledge for the personnel member to provide the expected behavioral health listed in the established job description. This also includes the type and duration of experience that may allow the personnel member to acquire the specific skills and knowledge for the personnel member to provide the expected behavioral health services listed in the established job description.
A personnel member’s skills and knowledge are verified and documented before the personnel member provides behavioral health services alone. A personnel member may be in a training tract in which he or she is undergoing a prolonged orientation and training prior to skills and knowledge verification.
The facility has personnel members with the qualifications, experience, skills, and knowledge necessary to provide the behavioral health services within the agency’s scope of services, and that meet the needs of a resident, and to ensure to health and safety of a resident.A written plan is implemented to provide orientation specific to the duties of the personnel member, employee, volunteer, or student.
Personnel members must complete orientation prior to providing services related to client care. Orientation may occur over a protracted period, such as 6 weeks, during which time the personnel member is not alone on duty, and primarily observing, being observed, or performing clerical tasks. Orientation documentation includes the individual’s name, date of orientation, and topics covered, see elsewhere in this Manual for topics covered. A written plan is implemented to provide personnel member in-service education specific to the duties of the personnel member and documented to include the personnel member’s name, the date of the training and the topics covered.
A personnel member or employee record is maintained that contains
Individual’s name, date of birth, home address, and contact telephone number.
Individual’s starting date of employment or volunteer services and the ending date if applicable.
Documentation of the individual’s qualifications including skills and knowledge applicable to the individual’s job duties (Behavioral Health Technicians and Paraprofessionals)
Documentation of the individual’s education and experience applicable to the individual’s job duties.
The individual’s completed orientation and in-service education.
The individual’s license or certification.
Fingerprint clearance cards if applicable.
Clinical oversight of Behavioral Health Technicians and paraprofessionals as applicable.
CPR and First Aid training completion documentation as applicable.
Documentation of freedom from infectious Tuberculosis as applicable.
The Administrator shall ensure that personnel records are maintained throughout the individual’s period of providing services for the facility and for at least two years after the last date the individual provided services.
The Administrator will ensure that at least one personnel member who is present at the facility and each personnel member on an outing have CPR and First Aid completed and up to date.
The Administrator will ensure that there is at least one person awake at the facility when a resident is on the premises.
The Administrator will ensure that there is at least one personnel member and available to come to the facility if needed.
The resident to staff ration should not exceed 39 residents to 1 staff member on evenings (5-11pm), weekends, holidays, or any non-business hour times, and is not exceed 39 to 1 on overnight shifts (11pm to 7am)
The Administrator will ensure that the facility has sufficient personnel members to provide general resident supervision and treatment and sufficient personnel members or employees to provide ancillary services to meet the scheduled and unscheduled needs of each resident.
The Administrator shall ensure that there is a daily staffing schedule that indicates the dates, scheduled work hours, and name of each employee assigned to work including on-call personnel members, and includes documentation of the employees who work each calendar day and the hours worked by each employee, and is maintained for 12 months after the last date of the documentation.
The Administrator will ensure that there is a BHP present or on-call at all times.
The Administrator will ensure that there is a Registered Nurse or Medical Practitioner present or on-call at all times.
The Administrator will ensure that if a resident requires services that the facility is not licensed to or able to provide, that a personnel member arranges for the resident to be transported to a hospital or another health care institution where the services can be provided.
R9-10-716 Behavioral Health Services
Residents admitted need behavioral health services to maintain or enhance ability to function independently and residents will have opportunities to participate in activities designed to maintain or enhance independence. If residents are unable to function independently then their appropriateness for the program should be evaluated on a case-by-case basis as continuous protective oversight is not a component of the program.
The treatment program is designed to enhance independent resident functioning through purchase and preparation of food, laundry completion, transportation planning, and securing and maintaining employment or similar activity.
The scope of services is counseling and assistance in the self-administration of medication, see R9-10-703.A.2.a, earlier in this document.
In settings or activities with more than one resident participating services are provided to residents having similar diagnoses, treatment needs, developmental levels, social skills, verbal skills, a personal histories including history of physical or sexual abuse to ensure the health and safety of each resident and that treatment needs are being met.
Residents do not have access to any materials, furnishings, equipment, or participate in any activity or treatment that may present a threat to the residents’ health or safety based on the resident’s documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, or personal space. Admission criteria described previously exclude individuals who are not appropriate for the facility or program.
Residents do not share space, participate in any activity or treatment, or verbally or physically interact with any other resident that may pose a threat to the residents’, health or safety based on the residents’ documented diagnosis, treatment needs, developmental levels, social skills, verbal skills, and personal history.
Counseling will be provided within the scope of services, again see scope of services documented earlier in this document. Counseling will be provided according to the frequency and number of hours identified in the resident’s treatment plan, and will be provided by a BHP or a BHT. The Administrator will ensure that personnel members have the skills and knowledge to address a specific behavioral health issue.
Documentation
Counseling sessions will be documented in the resident record to include:
1). Date of the counseling session
2). Duration of the counseling session.
3). Designation of individual, family, or group counseling.
4). Treatment goals addressed during the counseling session.
5). Signature of the personnel member who provided the counseling and the date signed.
The Prescott House does not utilize Emergency Safety Response. Staff members are advised to contact police in the event of violence or threats particularly if attempts at verbal de-escalation are not indicated or have failed.
R9-10-717 Outdoor Behavioral Health Programs
Not Applicable
R9-10-719 Food Services
Residents purchase and prepare their own meals in an effort to promote independent living. To ensure that nutritional needs are being met, all residents will participate in a nutrition education / food safety program with individualized services as needed. Food safety guidelines will be posted in every living quarter. Living quarters will be inspected daily to ensure food safety requirements are being met. All living quarters will be equipped with meat thermometers. All refrigerators will be equipped with thermometers which will be checked daily.
R9-10-720 Emergency and Safety Standards including Disaster Plan
Disaster Plan
In the event of a disaster, all employee and personnel members have a vested interest in the safety and delivery of resident care. Resident care in the event of a disaster will be assigned to the Administrator and/or Clinical Director. In the event that these persons are unavailable, the chain of command as detailed in the employee flow chart will designate the responsibility of resident care. Resident care will include first housing, then medications, then physical and behavioral health services. It is the duty of the Administrator and Clinical Director to have some preparedness for foreseeable disasters prior to occurrence. In the event of Disaster specific to the property, several of the clients can reside at 710 E Willis. Additional clients can be housed at local hotels and with other agencies known to the provider. In the event of a city-wide or regional disaster, the Administrator, Clinical Director, or individual granted responsibility will seek housing, likely a hotel, in the Phoenix or Flagstaff areas first depending on the circumstances and considering the availability of services in the area. Referrals to other programs will be considered along with the possibility of residents residing with family or trusted friends in out of state situations as deemed necessary. The Administrator will assume responsibility that there is prudent reserves within the bank account to allow for emergency action within reason.
This Disaster Plan has been reviewed April 2017 and remains adequate. It will be re-evaluated annually.
R9-10-721 Environmental Standards
The Administrator will ensure that the physical environment meets the following standards and that staff are ensuring the same.
A.1.c
Staff will ensure that the premises and equipment are free from conditions or situations that may cause a resident or other individual to suffer physical injury.
A.2
The agency will have regularly scheduled pest control services.
A.3
Any bio hazardous medical waste will be disposed in accordance with AAC 13, Article 14 and sharps container will be maintained by staff.
A.4 & 5
Any equipment will be tested and maintained according to the manufacturer’s specifications and documentation of the testing or calibration will be maintained for at least one year and are used in accordance with the manufacturer’s specifications.
A.6
Staff will ensure that garbage and refuse are stored in containers lined with plastic bags and are removed greater than once weekly, preferably daily during chores.
A.7 & 8
Heating and cooling systems within the facility will keep the temperature between 70 and 84 degrees and space heaters will not be used.
A.9
Common areas will be lighted sufficiently to assure the safety of residents and to monitor residents.
A.10 & 11
Hot water temperatures are maintained between 95 and 120 degrees, and the supply of hot and cold water will be sufficient to meet the hygiene needs of the residents.
A.12
Soiled linens and clothing will be stored separately from clean ones and in closed containers away from food storage, kitchen, and dining areas.
A.13
Oxygen containers will be secured in an upright position.
A.14-15
Poisonous or toxic materials, and combustible or flammable liquids are stored by the agency will be stored in the original labeled containers or safety containers in a storage area outside the facility, or in an attached garage, that is locked and inaccessible to residents, except in where they access the locked storage area for the purposes of utilizing said materials for basic household cleaning purposes applicable to program requirements. Toxic or poisonous materials and combustible or flammable liquids that are not typical to common household use will be locked and entirely inaccessible to residents. At admission it is determined that residents are appropriate to be in the vicinity of and to utilize typical household cleaners and related materials.Residents will be appropriate to be in a facility that contains common household cleaners.Staff handless the propane tank including filling them, they are to be stored as described above.
A.16
Pets or animals are not allowed.
A.17-18
Not Applicable
B.1-2
Smoking, or any tobacco usage is not permitted in the facility. A tobacco use area will be designated, no combustible materials will be stored in or near this area. See Program Agreement.
C
Not ApplicableR9-10-722 Physical Plant Standards
The premises and equipment will be sufficient to accommodate the services provided within the agency scope of services.
B.1
Rooms will be available for a resident to receive treatment or visitors and there will be a common area and a dining area that are not converted, partitioned, or otherwise used as sleeping areas, and furniture and materials to accommodate recreational and socialization needs of the residents will be provided.
B.2
A visitor bathroom will be available during hours of operation that provides privacy, and contains; a working sink and running water; a working toilet that flushes and has a seat; toilet paper; soap for hand washing; paper towels; lighting and a window or other means of ventilation.
B.3
For every six residents who stay overnight there will be at least 1 working toilet that flushes and one sink with running water.
B.4
For every eight residents who stay overnight there will be at least one working bathtub or shower.
B.5
A resident bathroom will consist of a window or other means of ventilation, and a nonporous surface for the shower enclosure and slip resistant surfaces in tubs and showers.Resident should be appropriate for a facility that does not have shatter proof mirrors.
B.6
Bathroom doors are not locked, or if locked staff has a key accessible.
B.7 & 8.a – h
Every resident is assigned to a bedroom that is not used for a common area; is not used as a passageway to another bedroom or bathroom unless the bathroom is for the exclusive use of an individual occupying the bedroom; contains a door that opens to a hallway, common area, or outdoors; is constructed and furnished to provide unimpeded access to the door,; has a window or door covers that provide resident privacy; has floor to ceiling walls, has at least 60 square feet per person not including closets; shared by no more than 8 residents; and provides at least 3 feet of space between beds. Beds will be at least 36 inches wide and 72 inches long and all residents will have individual storage space for personal effects and clothing such as a dresser or chest of drawers.
B.8.i
Residents will be provided clean linens upon arrival including mattress pad sheets large enough to tuck under the mattress, a pillow and pillow case, bedspread, a blanket(s) and waterproof mattress covers as needed.
B.j
Rooms will be lighted sufficient to read.
B.k
Clothing rods or hooks will be designed to minimize the opportunity for a resident to cause self-injury.
C & D
Not Applicable
Urinalysis
All staff members are subject to urinalysis at the discretion of the Administrator or Clinical Director including time, means, and method. Failure to adhere to specified time, means, or method can be result in termination.
Social Media and Boundaries
Employees acknowledge that reference to work issues in any way publically outside of work such as facebook posts any other manner could be considered unethical at the discretion of the Administrator or Clinical Director. Employees should consult with the Administrator or Clinical Director if they are unsure of a situation.
All employees will exercise ethical boundaries with residents, clients, former clients or residents in accordance with professional guidelines as interpreted by the Administrator or Clinical Director. Employees should consult with the Administrator or Clinical Director if they are unsure of a situation.
There is not policy stated length of time regarding boundaries, and it is expected that all employees will consult with professional peers and the Administrator or Clinical Director before making decisions that may be a boundary violation.
Dress Code
Dress code is determined by the Administrator and/or Clinical Director on a case-by-case basis. It is assumed that all employees (excluding maintenance) will wear long pants (or dresses) unless involved in a therapeutic outing. It is assumed that all employees will refrain from wearing clothing with drug, sex, violence, gambling, or similar type references.
Professional Behaviors
All employees will conduct themselves in a professional manner in accordance with generally accepted professional guidelines as interpreted by the Administrator or the Clinical Director.
All employees acknowledge that by working in behavioral health, it is assumed that all employees will conduct themselves in an appropriate manner on property or off whether clients are present or not. “Appropriate” is determined by the Administrator and/or Clinical Director. Inappropriate behaviors can include lack of adherence to local, state, or federal law; engaging in behaviors that are in conflict with the employees past clinical issues such as addictive disorders; behaving in ways that shed a negative light on the agency, or residents, or clients thereof; or engaging in behaviors that are inconsistent with those of a person who is engaged in a helping profession, as determined by the Administrator and/or Clinical Director. Failure to remain “appropriate” in all affairs can result in restrictions, warnings, or termination.
Confidentiality
All employees are expected to guard resident or former resident confidentiality with utmost importance, both in professional settings and outside of work in the community in accordance with professional standards, and state or federal law.
Electronic Devices
Employees utilizing portable electronic devices for work-related matters are expected to diligently safeguard confidentiality and exercise good judgment such as deleting emails forwarded to mobile device frequently, exercising caution when referring to residents in text or email such as avoiding sensitive discussions.
On Call Procedures
The Administrator and/or the Clinical Director are continuously on-call 24/7/36, except as designated otherwise.
The on-call personnel and bhp designated sheet will be produced monthly throughout the year.
A staff member on-call agrees to remain available for phone call throughout their on-call period or make accommodations. On call person can arrive on property within an hour throughout their on-call period or will make accommodations.
All on-call persons are expected to make reasonable efforts to assist in emergencies or in routine matters when needed whether they are the designated on-call person or not.
2nd Shift, Weekend Day Shift, and Holiday Day Shift Duties, not limited to the following:
Defined as close of business hours until arrival of the third shift person at approximately 11pm.
Maintain professional attitudes, conduct, attire, and job performance.
Ensure the health, safety and welfare of the community including adherence with policies and procedures, code and law.Inspect entire property on more than one occasion.
Verify whereabouts and safety of all residents.
Adequately inform oncoming staff members of all concerns.
Refrain from personal use of phone or internet that in any way interferes with job performance.
3rd Shift (overnight) Duties, not limited to the following:
Defined as approximately 11pm through begin of business hours the following morning or the arrival of the day shift person, approximately 8am.
Remain awake and available to respond to residents thought the shift.
Not attempt to stay awake for time periods that are not prudent or healthy, and inform supervisors of these concerns.
Maintain professional attitudes, conduct, attire, and job performance.
Ensure the health, safety and welfare of the community including adherence with policies and procedures, code and law.Inspect entire property on more than one occasion.
Verify whereabouts and safety of all residents.
Adequately inform oncoming staff members of all concerns.
Refrain from personal use of phone or internet that in any way interferes with job performance, though the overnight shift is encouraged to use appropriate media, including on-line education as approved, in order to remain awake and alert.
Vehicle Use Agreement
I have provided a valid driver’s license to the Prescott House. I will not drive a company vehicle until I am approved by the Executive Director, Program Manager, or Business Manager to drive vehicles.
I will notify the Prescott House of any changes to my driving records prior to driving a company vehicle and will not drive until my driving privileges have been reviewed following the release of new information.
I will not wear headphones or operate any hand-held wireless communication devices or hand-held electronic entertainment devices while operating the vehicle.
I will not leave a child, person who may be threat to himself or others, or person incapable of independent exit from the vehicle unattended in the vehicle.
I will ensure the safe and hazard free loading and unloading of residents.
I will confirm that each passenger has utilized a functioning seat belt prior to departure, and that each seat is securely fastened to the vehicle with ample room for each passenger.
I will prudently obey all traffic laws and drive responsibly utilizing good judgement to ensure passenger safety. This includes but is not limited to route pre-planning for safety; consideration of the needs of passengers; avoiding difficult maneuvers such as left-turns when visibility is impaired, or across multiple lanes of traffic during higher traffic periods; awareness of the vehicle condition such as allowing windshield ice to melt prior to use, or checking tire pressure if needed, or examining the condition of wiper blades; consideration of impending weather changes; placing safety ahead of timeliness; awareness when driving such as not driving when sleepy or suffering physical or emotional problems, or paying attention to the road and associated conditions rather than adjusting the radio or similar devices.
I will not utilize the company vehicle for personal endeavors unless this has been approved by the Executive Director, Program Manager, Business Manager, or Behavioral Health Residential Supervisor.
I will ensure that a first aid kit and water are in the vehicle per guidelines.
On-Call
If a staff member is designated as the on-call personnel or the on-call BHP it is presumed that the staff member can respond to the property within an hour or has made reasonable accommodations with another qualified staff member to take their place as necessary.
Peer Mentor Position
The peer mentor fits into the overall Prescott House treatment philosophy of staff being an extension of client and provides an opportunity for the mentor to demonstrate leadership and develop helping profession experience. Peer Mentors receive pay or compensation of some kind, in accordance with minimum wage or similar requirements, and are not volunteers.
A peer mentor is a client or resident who will both be receiving services and providing support, limited services, and various responsibilities to other clients or residents. The peer mentor is a quasi-staff position. A Peer Mentor will not have staff designations, will not be privy to medical records or confidential information of any kind, will not perform counseling, and will not have access to or participate in assistance in the self-administration of medication.
A Peer Mentor will be able to complete a wide range of activities based on the individual’s strengths. This can include assisting staff in group or activity facilitation, facilitating an therapeutic activity group, providing emotional support to other clients or residents, being of assistance to staff in emergency or crisis situations, possibly providing transportation as appropriate, light office work, maintenance and facilities jobs and responsibilities, therapeutic community activities such as room checks or meeting attendance verification, or other responsibilities as assigned.
Utilization Review Policy and ProcedureUtilization Review (UR) will be completed by a BHP or a BHT. Designated UR representative for the Prescott House will manage the client insurance billing from the initial clinical review through concurrent reviews until discharge. All reviews will be conducted in a timely manner to ensure smooth transition between levels of care. The UR designate will consistently collaborate with all clinical and behavioral staff to have a comprehensive clinical picture of the client. The UR designate will be supervised by the Clinical Director (BHP and a designated BHP if he/she is a BHT. The UR designate will conduct all affairs with full ethical consideration to Arizona Department of Health Services, Arizona Board of Behavioral Health Examiners, American Counseling Association, and generally accepted professional guidelines.
Payroll Policy
Employees are expected to accurately report their hours worked on their weekly time sheet. Time sheets are due in the Business Office prior to Noon on the first Monday after the pay period.
Hourly employees do not record hours outside of their scheduled shift without a noted approval from their supervisor. Overtime must be similarly approved and noted.
Salary employees work a 40-hour week, at the end of the week (Sunday) the 40-hour period resets regardless of the hours worked. Salary employees do not record hours in excess of 40 in one week of a pay period in order to work less hours in the next week. Failure to work to work 40 hours in week can result in either vacation hours being deducted or pay being deducted accordingly.
Requested vacation days are recorded on the timesheet as either a 4-hour half day off or 8 -our full day off. Employees cannot take a half or full day off and work hours on another day to offset having to use vacation hours.
There is a 2 week notice for vacation time. Vacation time can be denied by the Administrator based on agency needs. Vacation days must be designated as half or full day at request.
Employees will have vacation time designated by the Administrator annually. Employees can roll over no more than 40 hours of vacation time from one year to another. The vacation time will accrue throughout the year.
New employees will begin accruing vacation time after 90 days of employment.
Sick time will accrue throughout the year and will be no more than 40 hours and will be used in accordance with state law.
Suicide/ Self-Harm Protocols
Primary staff will triage each of their clients for suicidal ideation at their weekly scheduled individual sessions and document the event. This will provide continuous monitoring of danger to self or others through the course of treatment.
Every situation is unique and it is difficult to have blanket policy that is universally applicable. Therefore, the protocols will be applied based on the prudent judgement of the staff member engaged in the discussion. It is required that a staff member who engages in the following discussion verbally discuss this with at least one other individual prior to their shift ending in order to gain perspective and feedback. Additionally, the staff member is required to pass the information along to the clinical representative such as the on-call BHT, BHP, or the client’s primary staff prior to the end of his shift.When a client reports hopelessness, suicidal thoughts, or seems as though he may be suffering from these, the staff member(s) on duty are encouraged to verbally engage a client to determine answers to the following questions. Staff members are advised to find a safe, and private place for this discussion.Staff members are encouraged to understand prudent judgement throughout the process which effectively means understanding the potential unique characteristics to each situation. For example, if the client is clearly agitated approaching them safely, supportively, with respect, and establishing rapport would be more advisable then immediately launching into questions about suicidality. Similarly, if the situation seems alarmingly imminent such as the client has a knife then the staff would proceed to calling 911 rather than launching a series of questions. Additionally, a staff member may feel that the client is minimizing his intent and plan and needs to be taken to the emergency room despite not specifically endorsing a plan or intent. In this scenario a client would have to voluntarily agree to be transported. Moreover, a staff member may engage in rapport building for quite some time before launching into questions.
The Suicide protocols are based upon the Columbia-Suicide Severity Rating Scale. The Scale itself can be used at intake to evaluate potential severity in clients. The policy on use is as follows
Question 1; Desire to not be AliveDoes the client have thoughts such as wishing to be dead, not be alive anymore, wanting to go to sleep and not wake up, or any similar type of description proceed to question 2.
Question 2; Non-specific Active Suicidal ThoughtsDoes the client have general non-specific thoughts of wanting to end his life or commit suicide such as thinking “I’ve thought about killing myself? If this is true proceed to
Question 3.If you do not proceed past Question 2 then the situation can generally be handled by supportive conversation, verbal safety plans, and follow-up with primary staff and clinical team. The staff should pass this information along to other staff for continued monitoring, further evaluation, and clinical follow-up.
Question 3; Active Suicidal Ideation with Any Methods, but no Plan and without Intent to ActDoes the client endorse thoughts of suicide and has thought of at least one method to complete a suicide. There is a lack of a specific plan or intent. For example, the client has stated that he has thought of overdosing on pills but has not identified a time, place, or type of pill. If this is true then proceed to
Question 4.If you do not proceed past Question 3 then the situation can generally be handled by supportive conversation, verbal safety plans, and follow-up with primary staff and clinical team. The staff should pass this information along to other staff for continued monitoring, further evaluation, and clinical follow-up. In this instance a written safety plan should be considered.
Question 4: Active Suicidal Ideation with Some Intent to Act, Without Specific PlanThe client endorses active suicidal thoughts of killing himself with some intent to act on thoughts. For example, the client has thoughts but reports, “I will not do anything about them”.If you do not proceed past Question 4 then the situation can generally be handled by supportive conversation, verbal safety plans, and follow-up with primary staff and clinical team. The staff should pass this information along to other staff for continued monitoring, further evaluation, and clinical follow-up. In this instance a written safety plan should be considered, and follow-up checks should occur with the client over the next 4-24 hours to evaluate if the client’s situation has worsened.
Question 5: Active Suicidal Ideation with Specific Plan and Intent.The client has thoughts of killing himself with details and a plan fully or partially worked out and has some intent to carry it out. For example, the client states that he wants to die, and is considering going to a place where he can purchase a gun and then using that gun to kill himself.If the answer to 5 is yes then the client will be transported to the emergency room or crisis stabilization unit for evaluation. If the client refuses to go to the emergency room then 911 will be called, though some verbal intervention coaxing the client to go is recommended if it seems prudent. If the situation is exceptionally imminent such as a plan to shoot himself with a gun in his car in the parking lot, or cut himself with intent to die with a knife that is in his hand, then 911 should be called. The staff member should have visual awareness of the client’s location at all times until he walks into the emergency room or emergency personnel have arrived.
Clinical ConsiderationsSome suicide plans may not be realistic at present. Such as a client who plans on killing himself when he turns 50 next year, or with a gun that he has in storage in another state, or jumping off the golden gate bridge. In the event this occurs the staff member should discuss these scenarios with the clinical team for the proper course of action as the situation may not require imminent action such as a ‘yes” to question 5, but may need strong follow-up and monitoring as the situation could worsen quickly and the client has altered his plan to a more viable one.If the client feels that he should be taken to the hospital for evaluation then that should occur.If the client’s ideation, plan, and intent are imminent such as the client stating that he plans to hang himself of the deck rail then the client should be immediately transported to the hospital or 911 should be called.
In the event that the client has intent but no plan, transport to the emergency room should be considered as a plan could quickly be arranged. The timing of the intent may be crucial such as the client reporting that he intends to kill himself today but has not worked out a plan as of yet.
At times, verbal engagement causes a client to reduce the severity of his suicidality. A client may get to question 4, though with some supportive conversation may reduce back to question 2. However, if a client does endorse to question 5 but later reneges, it is protocol to transport the client except in the most unique of clinical situation, such as the client will have consistent monitoring over the next 24 hours, and multiple clinicians have agreed that this course of action is most prudent.
Self-Harm Behaviors
Differentiation between self-harm and suicidal behaviors can be difficult to determine. If the client cut on himself with no intent of killing himself then this is considered self-harm. Medical attention may be needed for the injury however psychiatric intervention is not indicated.However, if the client is behaving recklessly and indulging in self-harm behaviors that could result in death despite not intending to die, such as cutting vertically along his arm, then psychiatric intervention is advisable and the client will likely be transported to the emergency room.
Psychotic and Delusional BehaviorsIf the client is actively psychotic and/or delusional the he may not be truly suicidal. However, his lack of awareness to reality suggests that he will likely need evaluation for hospitalization. For example a client feels that the voices are commanding him to die.Psychotic or delusional behavior alone would not trigger an evaluation. For example, a client may hear voices, see people that others do not, or believe that the FBI is following him. However, his behaviors may necessitate an evaluation as they endanger himself or others. For example, he sees people that are following him and has armed himself with a knife and is prepared for combat.
Summary
The process can be summarized as Ideation; Plan; Intent. If the client has all 3 the he should be transported to the emergency room or 911 should be called.The most important protocol is to discuss any interactions of this nature with as many other staff members as possible to gain perspective. For example, an individual situation may not be particularly alarming and may not proceed past question 4, however, other staff members may have a more thorough understanding of the client’s past including such dynamics as past attempts and other warning signs that necessitate further review with this client.
