1. A. A provider shall ensure that:

   1. 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;

   2. 2. An entry in a resident’s medical record is:

      1. a. Only recorded by the provider or individual designated by the provider to record an entry;
      2. b. Dated, legible, and authenticated; and
      3. c. Not changed to make the initial entry illegible;

   3. 3. A resident’s medical record is available to an individual:

      1. a. Authorized by policies and procedures to access the resident’s medical record;
      2. b. If the individual is not authorized according to policies and procedures, with the written consent of the resident or the resident’s representative; or
      3. c. As permitted by law; and
   4. 4. A resident’s medical record is protected from loss, damage, or unauthorized use.
2. B. If a provider maintains residents’ medical records electronically, the provider shall ensure that safeguards exist to prevent unauthorized access.

3. C. A provider shall ensure that a resident’s medical record contains:

   1. 1. Resident information that includes:

      1. a. The resident’s name,
      2. b. The resident’s date of birth,
      3. c. Any known allergies, and
      4. d. Medication information for the resident;

   2. 2. The names, addresses, and telephone numbers of:

      1. a. The resident’s medical practitioner;
      2. b. The resident’s case manager, if applicable;
      3. c. The behavioral health professional assigned to the resident by the adult behavioral health therapeutic home’s collaborating health care institution; and
      4. d. An individual to be contacted in the event of an emergency;
   3. 3. The date of the resident’s acceptance by the adult behavioral health therapeutic home and, if applicable, the date of the resident’s release from the adult behavioral health therapeutic home;

   4. 4. If applicable, the name and contact information of the resident’s representative and:

      1. a. The document signed by the resident consenting for the resident’s representative to act on the resident’s behalf; or

      2. b. If the resident’s representative:

         1. i. Has a health care power of attorney established under A.R.S. § 36-3221 or a mental health care power of attorney executed under A.R.S. § 36-3282, a copy of the health care power of attorney or mental health care power of attorney; or
         2. ii. Is a legal guardian, a copy of the court order establishing guardianship;
   5. 5. A copy of the resident’s treatment plan and any updates to the resident’s treatment plan, obtained from the adult behavioral health therapeutic home’s collaborating health care institution;

   6. 6. For a resident receiving assistance in the self-administration of medication, documentation that includes for each medication:

      1. a. The date and time of assistance;
      2. b. The name, strength, dosage, and route of administration;
      3. c. The provider’s signature or first and last initials; and
      4. d. Any adverse reaction the resident has to the medication;
   7. 7. Documentation of the resident’s refusal of a medication, if applicable;
   8. 8. Documentation of any significant change in a resident’s behavior or physical, cognitive, or functional condition and the action taken by a provider to address the resident’s changing needs;
   9. 9. If applicable, documentation of any actions taken to control the resident’s sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual; and
   10. 10. If applicable, a written notice of termination of residency.

Historical Note

New Section made by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).